|
SPACER ELEOS TIBIAL POLY 10MM
|
Facility
|
OP
|
$13,176.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,713.00 |
| Max. Negotiated Rate |
$12,649.82 |
| Rate for Payer: Aetna Commercial |
$10,146.21
|
| Rate for Payer: Anthem Medicaid |
$4,531.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,277.98
|
| Rate for Payer: Cash Price |
$6,588.45
|
| Rate for Payer: Cigna Commercial |
$10,936.83
|
| Rate for Payer: First Health Commercial |
$12,518.06
|
| Rate for Payer: Humana Commercial |
$11,200.36
|
| Rate for Payer: Humana KY Medicaid |
$4,531.54
|
| Rate for Payer: Kentucky WC Medicaid |
$4,577.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,805.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,724.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,953.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,622.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,595.67
|
| Rate for Payer: Ohio Health Group HMO |
$9,882.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,635.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,713.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,084.84
|
| Rate for Payer: PHCS Commercial |
$12,649.82
|
| Rate for Payer: United Healthcare All Payer |
$11,595.67
|
|
|
SPACER ELEOS TIBIAL POLY 12MM
|
Facility
|
OP
|
$13,176.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,713.00 |
| Max. Negotiated Rate |
$12,649.82 |
| Rate for Payer: Aetna Commercial |
$10,146.21
|
| Rate for Payer: Anthem Medicaid |
$4,531.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,277.98
|
| Rate for Payer: Cash Price |
$6,588.45
|
| Rate for Payer: Cigna Commercial |
$10,936.83
|
| Rate for Payer: First Health Commercial |
$12,518.06
|
| Rate for Payer: Humana Commercial |
$11,200.36
|
| Rate for Payer: Humana KY Medicaid |
$4,531.54
|
| Rate for Payer: Kentucky WC Medicaid |
$4,577.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,805.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,724.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,953.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,622.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,595.67
|
| Rate for Payer: Ohio Health Group HMO |
$9,882.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,635.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,713.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,084.84
|
| Rate for Payer: PHCS Commercial |
$12,649.82
|
| Rate for Payer: United Healthcare All Payer |
$11,595.67
|
|
|
SPACER ELEOS TIBIAL POLY 12MM
|
Facility
|
IP
|
$13,176.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,713.00 |
| Max. Negotiated Rate |
$12,649.82 |
| Rate for Payer: Aetna Commercial |
$10,146.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,277.98
|
| Rate for Payer: Cash Price |
$6,588.45
|
| Rate for Payer: Cigna Commercial |
$10,936.83
|
| Rate for Payer: First Health Commercial |
$12,518.06
|
| Rate for Payer: Humana Commercial |
$11,200.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,805.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,724.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,953.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,595.67
|
| Rate for Payer: Ohio Health Group HMO |
$9,882.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,635.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,713.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,084.84
|
| Rate for Payer: PHCS Commercial |
$12,649.82
|
| Rate for Payer: United Healthcare All Payer |
$11,595.67
|
|
|
SPACER ELEOS TIBIAL POLY 16MM
|
Facility
|
IP
|
$13,176.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,713.00 |
| Max. Negotiated Rate |
$12,649.82 |
| Rate for Payer: Aetna Commercial |
$10,146.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,277.98
|
| Rate for Payer: Cash Price |
$6,588.45
|
| Rate for Payer: Cigna Commercial |
$10,936.83
|
| Rate for Payer: First Health Commercial |
$12,518.06
|
| Rate for Payer: Humana Commercial |
$11,200.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,805.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,724.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,953.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,595.67
|
| Rate for Payer: Ohio Health Group HMO |
$9,882.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,635.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,713.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,084.84
|
| Rate for Payer: PHCS Commercial |
$12,649.82
|
| Rate for Payer: United Healthcare All Payer |
$11,595.67
|
|
|
SPACER ELEOS TIBIAL POLY 16MM
|
Facility
|
OP
|
$13,176.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,713.00 |
| Max. Negotiated Rate |
$12,649.82 |
| Rate for Payer: Aetna Commercial |
$10,146.21
|
| Rate for Payer: Anthem Medicaid |
$4,531.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,277.98
|
| Rate for Payer: Cash Price |
$6,588.45
|
| Rate for Payer: Cigna Commercial |
$10,936.83
|
| Rate for Payer: First Health Commercial |
$12,518.06
|
| Rate for Payer: Humana Commercial |
$11,200.36
|
| Rate for Payer: Humana KY Medicaid |
$4,531.54
|
| Rate for Payer: Kentucky WC Medicaid |
$4,577.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,805.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,724.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,953.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,622.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,595.67
|
| Rate for Payer: Ohio Health Group HMO |
$9,882.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,635.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,713.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,084.84
|
| Rate for Payer: PHCS Commercial |
$12,649.82
|
| Rate for Payer: United Healthcare All Payer |
$11,595.67
|
|
|
SPACER ELEOS TIBIAL POLY 8MM
|
Facility
|
OP
|
$13,176.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,713.00 |
| Max. Negotiated Rate |
$12,649.82 |
| Rate for Payer: Aetna Commercial |
$10,146.21
|
| Rate for Payer: Anthem Medicaid |
$4,531.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,277.98
|
| Rate for Payer: Cash Price |
$6,588.45
|
| Rate for Payer: Cigna Commercial |
$10,936.83
|
| Rate for Payer: First Health Commercial |
$12,518.06
|
| Rate for Payer: Humana Commercial |
$11,200.36
|
| Rate for Payer: Humana KY Medicaid |
$4,531.54
|
| Rate for Payer: Kentucky WC Medicaid |
$4,577.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,805.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,724.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,953.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,622.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,595.67
|
| Rate for Payer: Ohio Health Group HMO |
$9,882.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,635.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,713.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,084.84
|
| Rate for Payer: PHCS Commercial |
$12,649.82
|
| Rate for Payer: United Healthcare All Payer |
$11,595.67
|
|
|
SPACER ELEOS TIBIAL POLY 8MM
|
Facility
|
IP
|
$13,176.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,713.00 |
| Max. Negotiated Rate |
$12,649.82 |
| Rate for Payer: Aetna Commercial |
$10,146.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,277.98
|
| Rate for Payer: Cash Price |
$6,588.45
|
| Rate for Payer: Cigna Commercial |
$10,936.83
|
| Rate for Payer: First Health Commercial |
$12,518.06
|
| Rate for Payer: Humana Commercial |
$11,200.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,805.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,724.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,953.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,595.67
|
| Rate for Payer: Ohio Health Group HMO |
$9,882.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,635.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,713.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,084.84
|
| Rate for Payer: PHCS Commercial |
$12,649.82
|
| Rate for Payer: United Healthcare All Payer |
$11,595.67
|
|
|
SPACER MOD CATHCART TPR 12/14
|
Facility
|
IP
|
$3,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$468.00 |
| Max. Negotiated Rate |
$3,456.00 |
| Rate for Payer: Aetna Commercial |
$2,772.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,808.00
|
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Cigna Commercial |
$2,988.00
|
| Rate for Payer: First Health Commercial |
$3,420.00
|
| Rate for Payer: Humana Commercial |
$3,060.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,952.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,656.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,080.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,168.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,700.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$720.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$468.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,116.00
|
| Rate for Payer: PHCS Commercial |
$3,456.00
|
| Rate for Payer: United Healthcare All Payer |
$3,168.00
|
|
|
SPACER MOD CATHCART TPR 12/14
|
Facility
|
OP
|
$3,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$468.00 |
| Max. Negotiated Rate |
$3,456.00 |
| Rate for Payer: Aetna Commercial |
$2,772.00
|
| Rate for Payer: Anthem Medicaid |
$1,238.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,808.00
|
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Cigna Commercial |
$2,988.00
|
| Rate for Payer: First Health Commercial |
$3,420.00
|
| Rate for Payer: Humana Commercial |
$3,060.00
|
| Rate for Payer: Humana KY Medicaid |
$1,238.04
|
| Rate for Payer: Kentucky WC Medicaid |
$1,250.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,952.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,656.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,080.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,262.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,168.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,700.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$720.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$468.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,116.00
|
| Rate for Payer: PHCS Commercial |
$3,456.00
|
| Rate for Payer: United Healthcare All Payer |
$3,168.00
|
|
|
SPACER NCB 1MM
|
Facility
|
OP
|
$1,882.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$244.66 |
| Max. Negotiated Rate |
$1,806.72 |
| Rate for Payer: Aetna Commercial |
$1,449.14
|
| Rate for Payer: Anthem Medicaid |
$647.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,467.96
|
| Rate for Payer: Cash Price |
$941.00
|
| Rate for Payer: Cigna Commercial |
$1,562.06
|
| Rate for Payer: First Health Commercial |
$1,787.90
|
| Rate for Payer: Humana Commercial |
$1,599.70
|
| Rate for Payer: Humana KY Medicaid |
$647.22
|
| Rate for Payer: Kentucky WC Medicaid |
$653.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,543.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,388.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$660.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,656.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,411.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$376.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$244.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$583.42
|
| Rate for Payer: PHCS Commercial |
$1,806.72
|
| Rate for Payer: United Healthcare All Payer |
$1,656.16
|
|
|
SPACER NCB 1MM
|
Facility
|
IP
|
$1,882.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$244.66 |
| Max. Negotiated Rate |
$1,806.72 |
| Rate for Payer: Aetna Commercial |
$1,449.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,467.96
|
| Rate for Payer: Cash Price |
$941.00
|
| Rate for Payer: Cigna Commercial |
$1,562.06
|
| Rate for Payer: First Health Commercial |
$1,787.90
|
| Rate for Payer: Humana Commercial |
$1,599.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,543.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,388.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,656.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,411.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$376.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$244.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$583.42
|
| Rate for Payer: PHCS Commercial |
$1,806.72
|
| Rate for Payer: United Healthcare All Payer |
$1,656.16
|
|
|
SPACER NCB 2MM
|
Facility
|
IP
|
$1,882.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$244.66 |
| Max. Negotiated Rate |
$1,806.72 |
| Rate for Payer: Aetna Commercial |
$1,449.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,467.96
|
| Rate for Payer: Cash Price |
$941.00
|
| Rate for Payer: Cigna Commercial |
$1,562.06
|
| Rate for Payer: First Health Commercial |
$1,787.90
|
| Rate for Payer: Humana Commercial |
$1,599.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,543.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,388.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,656.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,411.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$376.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$244.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$583.42
|
| Rate for Payer: PHCS Commercial |
$1,806.72
|
| Rate for Payer: United Healthcare All Payer |
$1,656.16
|
|
|
SPACER NCB 2MM
|
Facility
|
OP
|
$1,882.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$244.66 |
| Max. Negotiated Rate |
$1,806.72 |
| Rate for Payer: Aetna Commercial |
$1,449.14
|
| Rate for Payer: Anthem Medicaid |
$647.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,467.96
|
| Rate for Payer: Cash Price |
$941.00
|
| Rate for Payer: Cigna Commercial |
$1,562.06
|
| Rate for Payer: First Health Commercial |
$1,787.90
|
| Rate for Payer: Humana Commercial |
$1,599.70
|
| Rate for Payer: Humana KY Medicaid |
$647.22
|
| Rate for Payer: Kentucky WC Medicaid |
$653.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,543.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,388.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$660.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,656.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,411.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$376.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$244.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$583.42
|
| Rate for Payer: PHCS Commercial |
$1,806.72
|
| Rate for Payer: United Healthcare All Payer |
$1,656.16
|
|
|
SPACER NCB 3MM
|
Facility
|
IP
|
$1,882.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$244.66 |
| Max. Negotiated Rate |
$1,806.72 |
| Rate for Payer: Aetna Commercial |
$1,449.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,467.96
|
| Rate for Payer: Cash Price |
$941.00
|
| Rate for Payer: Cigna Commercial |
$1,562.06
|
| Rate for Payer: First Health Commercial |
$1,787.90
|
| Rate for Payer: Humana Commercial |
$1,599.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,543.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,388.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,656.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,411.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$376.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$244.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$583.42
|
| Rate for Payer: PHCS Commercial |
$1,806.72
|
| Rate for Payer: United Healthcare All Payer |
$1,656.16
|
|
|
SPACER NCB 3MM
|
Facility
|
OP
|
$1,882.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$244.66 |
| Max. Negotiated Rate |
$1,806.72 |
| Rate for Payer: Aetna Commercial |
$1,449.14
|
| Rate for Payer: Anthem Medicaid |
$647.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,467.96
|
| Rate for Payer: Cash Price |
$941.00
|
| Rate for Payer: Cigna Commercial |
$1,562.06
|
| Rate for Payer: First Health Commercial |
$1,787.90
|
| Rate for Payer: Humana Commercial |
$1,599.70
|
| Rate for Payer: Humana KY Medicaid |
$647.22
|
| Rate for Payer: Kentucky WC Medicaid |
$653.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,543.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,388.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$660.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,656.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,411.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$376.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$244.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$583.42
|
| Rate for Payer: PHCS Commercial |
$1,806.72
|
| Rate for Payer: United Healthcare All Payer |
$1,656.16
|
|
|
SPACR MOD CATHCRT TPR 12/14 -3
|
Facility
|
OP
|
$3,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$468.00 |
| Max. Negotiated Rate |
$3,456.00 |
| Rate for Payer: Aetna Commercial |
$2,772.00
|
| Rate for Payer: Anthem Medicaid |
$1,238.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,808.00
|
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Cigna Commercial |
$2,988.00
|
| Rate for Payer: First Health Commercial |
$3,420.00
|
| Rate for Payer: Humana Commercial |
$3,060.00
|
| Rate for Payer: Humana KY Medicaid |
$1,238.04
|
| Rate for Payer: Kentucky WC Medicaid |
$1,250.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,952.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,656.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,080.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,262.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,168.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,700.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$720.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$468.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,116.00
|
| Rate for Payer: PHCS Commercial |
$3,456.00
|
| Rate for Payer: United Healthcare All Payer |
$3,168.00
|
|
|
SPACR MOD CATHCRT TPR 12/14 -3
|
Facility
|
IP
|
$3,600.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$468.00 |
| Max. Negotiated Rate |
$3,456.00 |
| Rate for Payer: Aetna Commercial |
$2,772.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,808.00
|
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Cigna Commercial |
$2,988.00
|
| Rate for Payer: First Health Commercial |
$3,420.00
|
| Rate for Payer: Humana Commercial |
$3,060.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,952.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,656.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,080.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,168.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,700.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$720.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$468.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,116.00
|
| Rate for Payer: PHCS Commercial |
$3,456.00
|
| Rate for Payer: United Healthcare All Payer |
$3,168.00
|
|
|
SPATIAL FRAME IDENT BAND KIT
|
Facility
|
OP
|
$3,100.90
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$403.12 |
| Max. Negotiated Rate |
$2,976.86 |
| Rate for Payer: Aetna Commercial |
$2,387.69
|
| Rate for Payer: Anthem Medicaid |
$1,066.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,418.70
|
| Rate for Payer: Cash Price |
$1,550.45
|
| Rate for Payer: Cigna Commercial |
$2,573.75
|
| Rate for Payer: First Health Commercial |
$2,945.86
|
| Rate for Payer: Humana Commercial |
$2,635.76
|
| Rate for Payer: Humana KY Medicaid |
$1,066.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,077.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,542.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,288.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$930.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,087.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,728.79
|
| Rate for Payer: Ohio Health Group HMO |
$2,325.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$620.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$403.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$961.28
|
| Rate for Payer: PHCS Commercial |
$2,976.86
|
| Rate for Payer: United Healthcare All Payer |
$2,728.79
|
|
|
SPATIAL FRAME IDENT BAND KIT
|
Facility
|
IP
|
$3,100.90
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$403.12 |
| Max. Negotiated Rate |
$2,976.86 |
| Rate for Payer: Aetna Commercial |
$2,387.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,418.70
|
| Rate for Payer: Cash Price |
$1,550.45
|
| Rate for Payer: Cigna Commercial |
$2,573.75
|
| Rate for Payer: First Health Commercial |
$2,945.86
|
| Rate for Payer: Humana Commercial |
$2,635.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,542.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,288.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$930.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,728.79
|
| Rate for Payer: Ohio Health Group HMO |
$2,325.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$620.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$403.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$961.28
|
| Rate for Payer: PHCS Commercial |
$2,976.86
|
| Rate for Payer: United Healthcare All Payer |
$2,728.79
|
|
|
SPATIAL FRAME SHOULDER BOLT
|
Facility
|
OP
|
$1,071.92
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$139.35 |
| Max. Negotiated Rate |
$1,029.04 |
| Rate for Payer: Aetna Commercial |
$825.38
|
| Rate for Payer: Anthem Medicaid |
$368.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$836.10
|
| Rate for Payer: Cash Price |
$535.96
|
| Rate for Payer: Cigna Commercial |
$889.69
|
| Rate for Payer: First Health Commercial |
$1,018.32
|
| Rate for Payer: Humana Commercial |
$911.13
|
| Rate for Payer: Humana KY Medicaid |
$368.63
|
| Rate for Payer: Kentucky WC Medicaid |
$372.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$878.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$791.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$321.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$376.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$943.29
|
| Rate for Payer: Ohio Health Group HMO |
$803.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$214.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$139.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$332.30
|
| Rate for Payer: PHCS Commercial |
$1,029.04
|
| Rate for Payer: United Healthcare All Payer |
$943.29
|
|
|
SPATIAL FRAME SHOULDER BOLT
|
Facility
|
IP
|
$1,071.92
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$139.35 |
| Max. Negotiated Rate |
$1,029.04 |
| Rate for Payer: Aetna Commercial |
$825.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$836.10
|
| Rate for Payer: Cash Price |
$535.96
|
| Rate for Payer: Cigna Commercial |
$889.69
|
| Rate for Payer: First Health Commercial |
$1,018.32
|
| Rate for Payer: Humana Commercial |
$911.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$878.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$791.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$321.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$943.29
|
| Rate for Payer: Ohio Health Group HMO |
$803.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$214.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$139.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$332.30
|
| Rate for Payer: PHCS Commercial |
$1,029.04
|
| Rate for Payer: United Healthcare All Payer |
$943.29
|
|
|
SP COGNITION RETRAINING
|
Facility
|
IP
|
$205.00
|
|
|
Service Code
|
HCPCS 92507
|
| Hospital Charge Code |
44000001
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$26.65 |
| Max. Negotiated Rate |
$196.80 |
| Rate for Payer: Aetna Commercial |
$157.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$159.90
|
| Rate for Payer: Cash Price |
$102.50
|
| Rate for Payer: Cigna Commercial |
$170.15
|
| Rate for Payer: First Health Commercial |
$194.75
|
| Rate for Payer: Humana Commercial |
$174.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$168.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$151.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$180.40
|
| Rate for Payer: Ohio Health Group HMO |
$153.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$41.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.55
|
| Rate for Payer: PHCS Commercial |
$196.80
|
| Rate for Payer: United Healthcare All Payer |
$180.40
|
|
|
SP COGNITION RETRAINING
|
Facility
|
OP
|
$205.00
|
|
|
Service Code
|
HCPCS 92507
|
| Hospital Charge Code |
44000001
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$26.65 |
| Max. Negotiated Rate |
$196.80 |
| Rate for Payer: Aetna Commercial |
$157.85
|
| Rate for Payer: Anthem Medicaid |
$70.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$159.90
|
| Rate for Payer: Cash Price |
$102.50
|
| Rate for Payer: Cigna Commercial |
$170.15
|
| Rate for Payer: First Health Commercial |
$194.75
|
| Rate for Payer: Humana Commercial |
$174.25
|
| Rate for Payer: Humana KY Medicaid |
$70.50
|
| Rate for Payer: Kentucky WC Medicaid |
$71.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$168.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$151.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$71.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$180.40
|
| Rate for Payer: Ohio Health Group HMO |
$153.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$41.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.55
|
| Rate for Payer: PHCS Commercial |
$196.80
|
| Rate for Payer: United Healthcare All Payer |
$180.40
|
|
|
S P CONSULT PREPARED AT SOMC
|
Facility
|
OP
|
$457.00
|
|
|
Service Code
|
HCPCS 88323
|
| Hospital Charge Code |
30001518
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$46.86 |
| Max. Negotiated Rate |
$438.72 |
| Rate for Payer: Aetna Commercial |
$351.89
|
| Rate for Payer: Anthem Medicaid |
$157.16
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$46.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$366.97
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$65.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$63.26
|
| Rate for Payer: Cash Price |
$228.50
|
| Rate for Payer: Cash Price |
$228.50
|
| Rate for Payer: Cigna Commercial |
$379.31
|
| Rate for Payer: First Health Commercial |
$434.15
|
| Rate for Payer: Humana Commercial |
$388.45
|
| Rate for Payer: Humana KY Medicaid |
$157.16
|
| Rate for Payer: Humana Medicare Advantage |
$46.86
|
| Rate for Payer: Kentucky WC Medicaid |
$158.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$374.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$337.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$160.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$402.16
|
| Rate for Payer: Ohio Health Group HMO |
$342.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$141.67
|
| Rate for Payer: PHCS Commercial |
$438.72
|
| Rate for Payer: United Healthcare All Payer |
$402.16
|
|
|
S P CONSULT PREPARED AT SOMC
|
Facility
|
IP
|
$457.00
|
|
|
Service Code
|
HCPCS 88323
|
| Hospital Charge Code |
30001518
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$59.41 |
| Max. Negotiated Rate |
$438.72 |
| Rate for Payer: Aetna Commercial |
$351.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$366.97
|
| Rate for Payer: Cash Price |
$228.50
|
| Rate for Payer: Cigna Commercial |
$379.31
|
| Rate for Payer: First Health Commercial |
$434.15
|
| Rate for Payer: Humana Commercial |
$388.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$374.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$337.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$402.16
|
| Rate for Payer: Ohio Health Group HMO |
$342.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$141.67
|
| Rate for Payer: PHCS Commercial |
$438.72
|
| Rate for Payer: United Healthcare All Payer |
$402.16
|
|
