|
TIBIAL BASE JRNY UNI SZ4 LM/RL
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
TIBIAL BASE JRNY UNI SZ4 LM/RL
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
TIBIAL BASE JRNY UNI SZ4 RM/LL
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
TIBIAL BASE JRNY UNI SZ4 RM/LL
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
TIBIAL BASE JRNY UNI SZ5 LM/RL
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
TIBIAL BASE JRNY UNI SZ5 LM/RL
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
TIBIAL BASE JRNY UNI SZ5 RM/LL
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
TIBIAL BASE JRNY UNI SZ5 RM/LL
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
TIBIAL BASE JRNY UNI SZ6 LM/RL
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
TIBIAL BASE JRNY UNI SZ6 LM/RL
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
TIBIAL BASE JRNY UNI SZ6 RM/LL
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
TIBIAL BASE JRNY UNI SZ6 RM/LL
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
TIBIAL BASE LEG HK SZ 2 RT
|
Facility
|
OP
|
$24,230.78
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,150.00 |
| Max. Negotiated Rate |
$23,261.55 |
| Rate for Payer: Aetna Commercial |
$18,657.70
|
| Rate for Payer: Anthem Medicaid |
$8,332.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,900.01
|
| Rate for Payer: Cash Price |
$12,115.39
|
| Rate for Payer: Cigna Commercial |
$20,111.55
|
| Rate for Payer: First Health Commercial |
$23,019.24
|
| Rate for Payer: Humana Commercial |
$20,596.16
|
| Rate for Payer: Humana KY Medicaid |
$8,332.97
|
| Rate for Payer: Kentucky WC Medicaid |
$8,417.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,869.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,882.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,269.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,500.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,323.09
|
| Rate for Payer: Ohio Health Group HMO |
$18,173.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,846.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,150.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,511.54
|
| Rate for Payer: PHCS Commercial |
$23,261.55
|
| Rate for Payer: United Healthcare All Payer |
$21,323.09
|
|
|
TIBIAL BASE LEG HK SZ 2 RT
|
Facility
|
IP
|
$24,230.78
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,150.00 |
| Max. Negotiated Rate |
$23,261.55 |
| Rate for Payer: Aetna Commercial |
$18,657.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,900.01
|
| Rate for Payer: Cash Price |
$12,115.39
|
| Rate for Payer: Cigna Commercial |
$20,111.55
|
| Rate for Payer: First Health Commercial |
$23,019.24
|
| Rate for Payer: Humana Commercial |
$20,596.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,869.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,882.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,269.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,323.09
|
| Rate for Payer: Ohio Health Group HMO |
$18,173.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,846.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,150.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,511.54
|
| Rate for Payer: PHCS Commercial |
$23,261.55
|
| Rate for Payer: United Healthcare All Payer |
$21,323.09
|
|
|
TIBIAL BASE LEG HK SZ 3 RT
|
Facility
|
OP
|
$24,230.78
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,150.00 |
| Max. Negotiated Rate |
$23,261.55 |
| Rate for Payer: Aetna Commercial |
$18,657.70
|
| Rate for Payer: Anthem Medicaid |
$8,332.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,900.01
|
| Rate for Payer: Cash Price |
$12,115.39
|
| Rate for Payer: Cigna Commercial |
$20,111.55
|
| Rate for Payer: First Health Commercial |
$23,019.24
|
| Rate for Payer: Humana Commercial |
$20,596.16
|
| Rate for Payer: Humana KY Medicaid |
$8,332.97
|
| Rate for Payer: Kentucky WC Medicaid |
$8,417.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,869.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,882.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,269.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,500.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,323.09
|
| Rate for Payer: Ohio Health Group HMO |
$18,173.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,846.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,150.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,511.54
|
| Rate for Payer: PHCS Commercial |
$23,261.55
|
| Rate for Payer: United Healthcare All Payer |
$21,323.09
|
|
|
TIBIAL BASE LEG HK SZ 3 RT
|
Facility
|
IP
|
$24,230.78
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,150.00 |
| Max. Negotiated Rate |
$23,261.55 |
| Rate for Payer: Aetna Commercial |
$18,657.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,900.01
|
| Rate for Payer: Cash Price |
$12,115.39
|
| Rate for Payer: Cigna Commercial |
$20,111.55
|
| Rate for Payer: First Health Commercial |
$23,019.24
|
| Rate for Payer: Humana Commercial |
$20,596.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,869.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,882.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,269.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,323.09
|
| Rate for Payer: Ohio Health Group HMO |
$18,173.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,846.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,150.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,511.54
|
| Rate for Payer: PHCS Commercial |
$23,261.55
|
| Rate for Payer: United Healthcare All Payer |
$21,323.09
|
|
|
TIBIAL BASE LEG HK SZ 4 RT
|
Facility
|
IP
|
$24,230.78
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,150.00 |
| Max. Negotiated Rate |
$23,261.55 |
| Rate for Payer: Aetna Commercial |
$18,657.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,900.01
|
| Rate for Payer: Cash Price |
$12,115.39
|
| Rate for Payer: Cigna Commercial |
$20,111.55
|
| Rate for Payer: First Health Commercial |
$23,019.24
|
| Rate for Payer: Humana Commercial |
$20,596.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,869.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,882.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,269.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,323.09
|
| Rate for Payer: Ohio Health Group HMO |
$18,173.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,846.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,150.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,511.54
|
| Rate for Payer: PHCS Commercial |
$23,261.55
|
| Rate for Payer: United Healthcare All Payer |
$21,323.09
|
|
|
TIBIAL BASE LEG HK SZ 4 RT
|
Facility
|
OP
|
$24,230.78
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,150.00 |
| Max. Negotiated Rate |
$23,261.55 |
| Rate for Payer: Aetna Commercial |
$18,657.70
|
| Rate for Payer: Anthem Medicaid |
$8,332.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,900.01
|
| Rate for Payer: Cash Price |
$12,115.39
|
| Rate for Payer: Cigna Commercial |
$20,111.55
|
| Rate for Payer: First Health Commercial |
$23,019.24
|
| Rate for Payer: Humana Commercial |
$20,596.16
|
| Rate for Payer: Humana KY Medicaid |
$8,332.97
|
| Rate for Payer: Kentucky WC Medicaid |
$8,417.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,869.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,882.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,269.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,500.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,323.09
|
| Rate for Payer: Ohio Health Group HMO |
$18,173.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,846.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,150.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,511.54
|
| Rate for Payer: PHCS Commercial |
$23,261.55
|
| Rate for Payer: United Healthcare All Payer |
$21,323.09
|
|
|
TIBIAL BASE LEG HK SZ 5 RT
|
Facility
|
OP
|
$24,230.78
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,150.00 |
| Max. Negotiated Rate |
$23,261.55 |
| Rate for Payer: Aetna Commercial |
$18,657.70
|
| Rate for Payer: Anthem Medicaid |
$8,332.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,900.01
|
| Rate for Payer: Cash Price |
$12,115.39
|
| Rate for Payer: Cigna Commercial |
$20,111.55
|
| Rate for Payer: First Health Commercial |
$23,019.24
|
| Rate for Payer: Humana Commercial |
$20,596.16
|
| Rate for Payer: Humana KY Medicaid |
$8,332.97
|
| Rate for Payer: Kentucky WC Medicaid |
$8,417.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,869.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,882.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,269.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,500.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,323.09
|
| Rate for Payer: Ohio Health Group HMO |
$18,173.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,846.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,150.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,511.54
|
| Rate for Payer: PHCS Commercial |
$23,261.55
|
| Rate for Payer: United Healthcare All Payer |
$21,323.09
|
|
|
TIBIAL BASE LEG HK SZ 5 RT
|
Facility
|
IP
|
$24,230.78
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,150.00 |
| Max. Negotiated Rate |
$23,261.55 |
| Rate for Payer: Aetna Commercial |
$18,657.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,900.01
|
| Rate for Payer: Cash Price |
$12,115.39
|
| Rate for Payer: Cigna Commercial |
$20,111.55
|
| Rate for Payer: First Health Commercial |
$23,019.24
|
| Rate for Payer: Humana Commercial |
$20,596.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,869.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,882.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,269.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,323.09
|
| Rate for Payer: Ohio Health Group HMO |
$18,173.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,846.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,150.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,511.54
|
| Rate for Payer: PHCS Commercial |
$23,261.55
|
| Rate for Payer: United Healthcare All Payer |
$21,323.09
|
|
|
TIBIAL BASE LEG HK SZ 7 RT
|
Facility
|
OP
|
$21,995.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,859.37 |
| Max. Negotiated Rate |
$21,115.34 |
| Rate for Payer: Aetna Commercial |
$16,936.27
|
| Rate for Payer: Anthem Medicaid |
$7,564.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,156.22
|
| Rate for Payer: Cash Price |
$10,997.58
|
| Rate for Payer: Cigna Commercial |
$18,255.97
|
| Rate for Payer: First Health Commercial |
$20,895.39
|
| Rate for Payer: Humana Commercial |
$18,695.88
|
| Rate for Payer: Humana KY Medicaid |
$7,564.13
|
| Rate for Payer: Kentucky WC Medicaid |
$7,641.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,036.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,232.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,598.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,715.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,355.73
|
| Rate for Payer: Ohio Health Group HMO |
$16,496.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,399.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,859.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,818.50
|
| Rate for Payer: PHCS Commercial |
$21,115.34
|
| Rate for Payer: United Healthcare All Payer |
$19,355.73
|
|
|
TIBIAL BASE LEG HK SZ 7 RT
|
Facility
|
IP
|
$21,995.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,859.37 |
| Max. Negotiated Rate |
$21,115.34 |
| Rate for Payer: Aetna Commercial |
$16,936.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,156.22
|
| Rate for Payer: Cash Price |
$10,997.58
|
| Rate for Payer: Cigna Commercial |
$18,255.97
|
| Rate for Payer: First Health Commercial |
$20,895.39
|
| Rate for Payer: Humana Commercial |
$18,695.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,036.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,232.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,598.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,355.73
|
| Rate for Payer: Ohio Health Group HMO |
$16,496.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,399.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,859.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,818.50
|
| Rate for Payer: PHCS Commercial |
$21,115.34
|
| Rate for Payer: United Healthcare All Payer |
$19,355.73
|
|
|
TIBIAL BASE PLATE OSS LONG 63
|
Facility
|
OP
|
$23,293.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,028.17 |
| Max. Negotiated Rate |
$22,361.89 |
| Rate for Payer: Aetna Commercial |
$17,936.10
|
| Rate for Payer: Anthem Medicaid |
$8,010.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,169.04
|
| Rate for Payer: Cash Price |
$11,646.82
|
| Rate for Payer: Cigna Commercial |
$19,333.72
|
| Rate for Payer: First Health Commercial |
$22,128.96
|
| Rate for Payer: Humana Commercial |
$19,799.59
|
| Rate for Payer: Humana KY Medicaid |
$8,010.68
|
| Rate for Payer: Kentucky WC Medicaid |
$8,092.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,100.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,190.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,988.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,171.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,498.40
|
| Rate for Payer: Ohio Health Group HMO |
$17,470.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,658.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,028.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,221.03
|
| Rate for Payer: PHCS Commercial |
$22,361.89
|
| Rate for Payer: United Healthcare All Payer |
$20,498.40
|
|
|
TIBIAL BASE PLATE OSS LONG 63
|
Facility
|
IP
|
$23,293.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,028.17 |
| Max. Negotiated Rate |
$22,361.89 |
| Rate for Payer: Aetna Commercial |
$17,936.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,169.04
|
| Rate for Payer: Cash Price |
$11,646.82
|
| Rate for Payer: Cigna Commercial |
$19,333.72
|
| Rate for Payer: First Health Commercial |
$22,128.96
|
| Rate for Payer: Humana Commercial |
$19,799.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,100.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,190.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,988.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,498.40
|
| Rate for Payer: Ohio Health Group HMO |
$17,470.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,658.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,028.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,221.03
|
| Rate for Payer: PHCS Commercial |
$22,361.89
|
| Rate for Payer: United Healthcare All Payer |
$20,498.40
|
|
|
TIBIAL BASE PLATE OSS LONG 67
|
Facility
|
IP
|
$23,293.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,028.17 |
| Max. Negotiated Rate |
$22,361.89 |
| Rate for Payer: Aetna Commercial |
$17,936.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,169.04
|
| Rate for Payer: Cash Price |
$11,646.82
|
| Rate for Payer: Cigna Commercial |
$19,333.72
|
| Rate for Payer: First Health Commercial |
$22,128.96
|
| Rate for Payer: Humana Commercial |
$19,799.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,100.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,190.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,988.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,498.40
|
| Rate for Payer: Ohio Health Group HMO |
$17,470.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,658.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,028.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,221.03
|
| Rate for Payer: PHCS Commercial |
$22,361.89
|
| Rate for Payer: United Healthcare All Payer |
$20,498.40
|
|
