|
TM REVERSE 36MM POLY LNR +3
|
Facility
|
OP
|
$8,185.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,064.17 |
| Max. Negotiated Rate |
$7,858.50 |
| Rate for Payer: Aetna Commercial |
$6,303.17
|
| Rate for Payer: Anthem Medicaid |
$2,815.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,385.03
|
| Rate for Payer: Cash Price |
$4,092.97
|
| Rate for Payer: Cigna Commercial |
$6,794.33
|
| Rate for Payer: First Health Commercial |
$7,776.64
|
| Rate for Payer: Humana Commercial |
$6,958.05
|
| Rate for Payer: Humana KY Medicaid |
$2,815.14
|
| Rate for Payer: Kentucky WC Medicaid |
$2,843.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,712.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,041.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,455.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,871.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,203.63
|
| Rate for Payer: Ohio Health Group HMO |
$6,139.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,637.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,064.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,537.64
|
| Rate for Payer: PHCS Commercial |
$7,858.50
|
| Rate for Payer: United Healthcare All Payer |
$7,203.63
|
|
|
TM REVERSE 36MM POLY LNR +3
|
Facility
|
IP
|
$8,185.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,064.17 |
| Max. Negotiated Rate |
$7,858.50 |
| Rate for Payer: Aetna Commercial |
$6,303.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,385.03
|
| Rate for Payer: Cash Price |
$4,092.97
|
| Rate for Payer: Cigna Commercial |
$6,794.33
|
| Rate for Payer: First Health Commercial |
$7,776.64
|
| Rate for Payer: Humana Commercial |
$6,958.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,712.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,041.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,455.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,203.63
|
| Rate for Payer: Ohio Health Group HMO |
$6,139.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,637.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,064.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,537.64
|
| Rate for Payer: PHCS Commercial |
$7,858.50
|
| Rate for Payer: United Healthcare All Payer |
$7,203.63
|
|
|
TM REVERSE 36MM POLY LNR +6
|
Facility
|
IP
|
$8,185.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,064.17 |
| Max. Negotiated Rate |
$7,858.50 |
| Rate for Payer: Aetna Commercial |
$6,303.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,385.03
|
| Rate for Payer: Cash Price |
$4,092.97
|
| Rate for Payer: Cigna Commercial |
$6,794.33
|
| Rate for Payer: First Health Commercial |
$7,776.64
|
| Rate for Payer: Humana Commercial |
$6,958.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,712.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,041.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,455.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,203.63
|
| Rate for Payer: Ohio Health Group HMO |
$6,139.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,637.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,064.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,537.64
|
| Rate for Payer: PHCS Commercial |
$7,858.50
|
| Rate for Payer: United Healthcare All Payer |
$7,203.63
|
|
|
TM REVERSE 36MM POLY LNR +6
|
Facility
|
OP
|
$8,185.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,064.17 |
| Max. Negotiated Rate |
$7,858.50 |
| Rate for Payer: Aetna Commercial |
$6,303.17
|
| Rate for Payer: Anthem Medicaid |
$2,815.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,385.03
|
| Rate for Payer: Cash Price |
$4,092.97
|
| Rate for Payer: Cigna Commercial |
$6,794.33
|
| Rate for Payer: First Health Commercial |
$7,776.64
|
| Rate for Payer: Humana Commercial |
$6,958.05
|
| Rate for Payer: Humana KY Medicaid |
$2,815.14
|
| Rate for Payer: Kentucky WC Medicaid |
$2,843.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,712.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,041.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,455.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,871.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,203.63
|
| Rate for Payer: Ohio Health Group HMO |
$6,139.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,637.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,064.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,537.64
|
| Rate for Payer: PHCS Commercial |
$7,858.50
|
| Rate for Payer: United Healthcare All Payer |
$7,203.63
|
|
|
TM REVERSE 40MM GLENOSPHERE
|
Facility
|
OP
|
$8,902.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,157.36 |
| Max. Negotiated Rate |
$8,546.69 |
| Rate for Payer: Aetna Commercial |
$6,855.16
|
| Rate for Payer: Anthem Medicaid |
$3,061.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,944.18
|
| Rate for Payer: Cash Price |
$4,451.40
|
| Rate for Payer: Cigna Commercial |
$7,389.32
|
| Rate for Payer: First Health Commercial |
$8,457.66
|
| Rate for Payer: Humana Commercial |
$7,567.38
|
| Rate for Payer: Humana KY Medicaid |
$3,061.67
|
| Rate for Payer: Kentucky WC Medicaid |
$3,092.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,300.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,570.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,670.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,123.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,834.46
|
| Rate for Payer: Ohio Health Group HMO |
$6,677.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,780.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,157.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,759.87
|
| Rate for Payer: PHCS Commercial |
$8,546.69
|
| Rate for Payer: United Healthcare All Payer |
$7,834.46
|
|
|
TM REVERSE 40MM GLENOSPHERE
|
Facility
|
IP
|
$8,902.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,157.36 |
| Max. Negotiated Rate |
$8,546.69 |
| Rate for Payer: Aetna Commercial |
$6,855.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,944.18
|
| Rate for Payer: Cash Price |
$4,451.40
|
| Rate for Payer: Cigna Commercial |
$7,389.32
|
| Rate for Payer: First Health Commercial |
$8,457.66
|
| Rate for Payer: Humana Commercial |
$7,567.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,300.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,570.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,670.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,834.46
|
| Rate for Payer: Ohio Health Group HMO |
$6,677.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,780.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,157.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,759.87
|
| Rate for Payer: PHCS Commercial |
$8,546.69
|
| Rate for Payer: United Healthcare All Payer |
$7,834.46
|
|
|
TM REVERSE 40MM POLY LINER +0
|
Facility
|
IP
|
$7,716.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,003.15 |
| Max. Negotiated Rate |
$7,407.89 |
| Rate for Payer: Aetna Commercial |
$5,941.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,018.91
|
| Rate for Payer: Cash Price |
$3,858.28
|
| Rate for Payer: Cigna Commercial |
$6,404.74
|
| Rate for Payer: First Health Commercial |
$7,330.72
|
| Rate for Payer: Humana Commercial |
$6,559.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,327.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,694.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,314.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,790.56
|
| Rate for Payer: Ohio Health Group HMO |
$5,787.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,543.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,003.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,392.13
|
| Rate for Payer: PHCS Commercial |
$7,407.89
|
| Rate for Payer: United Healthcare All Payer |
$6,790.56
|
|
|
TM REVERSE 40MM POLY LINER +0
|
Facility
|
OP
|
$7,716.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,003.15 |
| Max. Negotiated Rate |
$7,407.89 |
| Rate for Payer: Aetna Commercial |
$5,941.74
|
| Rate for Payer: Anthem Medicaid |
$2,653.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,018.91
|
| Rate for Payer: Cash Price |
$3,858.28
|
| Rate for Payer: Cigna Commercial |
$6,404.74
|
| Rate for Payer: First Health Commercial |
$7,330.72
|
| Rate for Payer: Humana Commercial |
$6,559.07
|
| Rate for Payer: Humana KY Medicaid |
$2,653.72
|
| Rate for Payer: Kentucky WC Medicaid |
$2,680.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,327.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,694.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,314.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,706.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,790.56
|
| Rate for Payer: Ohio Health Group HMO |
$5,787.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,543.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,003.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,392.13
|
| Rate for Payer: PHCS Commercial |
$7,407.89
|
| Rate for Payer: United Healthcare All Payer |
$6,790.56
|
|
|
TM REVERSE 40MM POLY LINER +3
|
Facility
|
IP
|
$7,716.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,003.15 |
| Max. Negotiated Rate |
$7,407.89 |
| Rate for Payer: Aetna Commercial |
$5,941.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,018.91
|
| Rate for Payer: Cash Price |
$3,858.28
|
| Rate for Payer: Cigna Commercial |
$6,404.74
|
| Rate for Payer: First Health Commercial |
$7,330.72
|
| Rate for Payer: Humana Commercial |
$6,559.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,327.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,694.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,314.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,790.56
|
| Rate for Payer: Ohio Health Group HMO |
$5,787.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,543.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,003.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,392.13
|
| Rate for Payer: PHCS Commercial |
$7,407.89
|
| Rate for Payer: United Healthcare All Payer |
$6,790.56
|
|
|
TM REVERSE 40MM POLY LINER +3
|
Facility
|
OP
|
$7,716.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,003.15 |
| Max. Negotiated Rate |
$7,407.89 |
| Rate for Payer: Aetna Commercial |
$5,941.74
|
| Rate for Payer: Anthem Medicaid |
$2,653.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,018.91
|
| Rate for Payer: Cash Price |
$3,858.28
|
| Rate for Payer: Cigna Commercial |
$6,404.74
|
| Rate for Payer: First Health Commercial |
$7,330.72
|
| Rate for Payer: Humana Commercial |
$6,559.07
|
| Rate for Payer: Humana KY Medicaid |
$2,653.72
|
| Rate for Payer: Kentucky WC Medicaid |
$2,680.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,327.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,694.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,314.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,706.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,790.56
|
| Rate for Payer: Ohio Health Group HMO |
$5,787.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,543.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,003.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,392.13
|
| Rate for Payer: PHCS Commercial |
$7,407.89
|
| Rate for Payer: United Healthcare All Payer |
$6,790.56
|
|
|
TM REVERSE 40MM POLY LINER +6
|
Facility
|
IP
|
$7,716.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,003.15 |
| Max. Negotiated Rate |
$7,407.89 |
| Rate for Payer: Aetna Commercial |
$5,941.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,018.91
|
| Rate for Payer: Cash Price |
$3,858.28
|
| Rate for Payer: Cigna Commercial |
$6,404.74
|
| Rate for Payer: First Health Commercial |
$7,330.72
|
| Rate for Payer: Humana Commercial |
$6,559.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,327.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,694.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,314.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,790.56
|
| Rate for Payer: Ohio Health Group HMO |
$5,787.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,543.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,003.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,392.13
|
| Rate for Payer: PHCS Commercial |
$7,407.89
|
| Rate for Payer: United Healthcare All Payer |
$6,790.56
|
|
|
TM REVERSE 40MM POLY LINER +6
|
Facility
|
OP
|
$7,716.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,003.15 |
| Max. Negotiated Rate |
$7,407.89 |
| Rate for Payer: Aetna Commercial |
$5,941.74
|
| Rate for Payer: Anthem Medicaid |
$2,653.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,018.91
|
| Rate for Payer: Cash Price |
$3,858.28
|
| Rate for Payer: Cigna Commercial |
$6,404.74
|
| Rate for Payer: First Health Commercial |
$7,330.72
|
| Rate for Payer: Humana Commercial |
$6,559.07
|
| Rate for Payer: Humana KY Medicaid |
$2,653.72
|
| Rate for Payer: Kentucky WC Medicaid |
$2,680.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,327.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,694.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,314.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,706.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,790.56
|
| Rate for Payer: Ohio Health Group HMO |
$5,787.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,543.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,003.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,392.13
|
| Rate for Payer: PHCS Commercial |
$7,407.89
|
| Rate for Payer: United Healthcare All Payer |
$6,790.56
|
|
|
TM REVERSE 40MM POLY LNR +0
|
Facility
|
IP
|
$8,185.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,064.17 |
| Max. Negotiated Rate |
$7,858.50 |
| Rate for Payer: Aetna Commercial |
$6,303.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,385.03
|
| Rate for Payer: Cash Price |
$4,092.97
|
| Rate for Payer: Cigna Commercial |
$6,794.33
|
| Rate for Payer: First Health Commercial |
$7,776.64
|
| Rate for Payer: Humana Commercial |
$6,958.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,712.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,041.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,455.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,203.63
|
| Rate for Payer: Ohio Health Group HMO |
$6,139.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,637.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,064.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,537.64
|
| Rate for Payer: PHCS Commercial |
$7,858.50
|
| Rate for Payer: United Healthcare All Payer |
$7,203.63
|
|
|
TM REVERSE 40MM POLY LNR +0
|
Facility
|
OP
|
$8,185.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,064.17 |
| Max. Negotiated Rate |
$7,858.50 |
| Rate for Payer: Aetna Commercial |
$6,303.17
|
| Rate for Payer: Anthem Medicaid |
$2,815.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,385.03
|
| Rate for Payer: Cash Price |
$4,092.97
|
| Rate for Payer: Cigna Commercial |
$6,794.33
|
| Rate for Payer: First Health Commercial |
$7,776.64
|
| Rate for Payer: Humana Commercial |
$6,958.05
|
| Rate for Payer: Humana KY Medicaid |
$2,815.14
|
| Rate for Payer: Kentucky WC Medicaid |
$2,843.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,712.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,041.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,455.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,871.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,203.63
|
| Rate for Payer: Ohio Health Group HMO |
$6,139.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,637.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,064.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,537.64
|
| Rate for Payer: PHCS Commercial |
$7,858.50
|
| Rate for Payer: United Healthcare All Payer |
$7,203.63
|
|
|
TM REVERSE 40MM POLY LNR +3
|
Facility
|
OP
|
$8,185.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,064.17 |
| Max. Negotiated Rate |
$7,858.50 |
| Rate for Payer: Aetna Commercial |
$6,303.17
|
| Rate for Payer: Anthem Medicaid |
$2,815.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,385.03
|
| Rate for Payer: Cash Price |
$4,092.97
|
| Rate for Payer: Cigna Commercial |
$6,794.33
|
| Rate for Payer: First Health Commercial |
$7,776.64
|
| Rate for Payer: Humana Commercial |
$6,958.05
|
| Rate for Payer: Humana KY Medicaid |
$2,815.14
|
| Rate for Payer: Kentucky WC Medicaid |
$2,843.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,712.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,041.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,455.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,871.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,203.63
|
| Rate for Payer: Ohio Health Group HMO |
$6,139.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,637.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,064.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,537.64
|
| Rate for Payer: PHCS Commercial |
$7,858.50
|
| Rate for Payer: United Healthcare All Payer |
$7,203.63
|
|
|
TM REVERSE 40MM POLY LNR +3
|
Facility
|
IP
|
$8,185.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,064.17 |
| Max. Negotiated Rate |
$7,858.50 |
| Rate for Payer: Aetna Commercial |
$6,303.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,385.03
|
| Rate for Payer: Cash Price |
$4,092.97
|
| Rate for Payer: Cigna Commercial |
$6,794.33
|
| Rate for Payer: First Health Commercial |
$7,776.64
|
| Rate for Payer: Humana Commercial |
$6,958.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,712.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,041.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,455.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,203.63
|
| Rate for Payer: Ohio Health Group HMO |
$6,139.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,637.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,064.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,537.64
|
| Rate for Payer: PHCS Commercial |
$7,858.50
|
| Rate for Payer: United Healthcare All Payer |
$7,203.63
|
|
|
TM REVERSE 40MM POLY LNR +6
|
Facility
|
OP
|
$8,185.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,064.17 |
| Max. Negotiated Rate |
$7,858.50 |
| Rate for Payer: Aetna Commercial |
$6,303.17
|
| Rate for Payer: Anthem Medicaid |
$2,815.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,385.03
|
| Rate for Payer: Cash Price |
$4,092.97
|
| Rate for Payer: Cigna Commercial |
$6,794.33
|
| Rate for Payer: First Health Commercial |
$7,776.64
|
| Rate for Payer: Humana Commercial |
$6,958.05
|
| Rate for Payer: Humana KY Medicaid |
$2,815.14
|
| Rate for Payer: Kentucky WC Medicaid |
$2,843.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,712.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,041.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,455.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,871.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,203.63
|
| Rate for Payer: Ohio Health Group HMO |
$6,139.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,637.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,064.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,537.64
|
| Rate for Payer: PHCS Commercial |
$7,858.50
|
| Rate for Payer: United Healthcare All Payer |
$7,203.63
|
|
|
TM REVERSE 40MM POLY LNR +6
|
Facility
|
IP
|
$8,185.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,064.17 |
| Max. Negotiated Rate |
$7,858.50 |
| Rate for Payer: Aetna Commercial |
$6,303.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,385.03
|
| Rate for Payer: Cash Price |
$4,092.97
|
| Rate for Payer: Cigna Commercial |
$6,794.33
|
| Rate for Payer: First Health Commercial |
$7,776.64
|
| Rate for Payer: Humana Commercial |
$6,958.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,712.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,041.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,455.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,203.63
|
| Rate for Payer: Ohio Health Group HMO |
$6,139.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,637.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,064.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,537.64
|
| Rate for Payer: PHCS Commercial |
$7,858.50
|
| Rate for Payer: United Healthcare All Payer |
$7,203.63
|
|
|
TM REVERSE BASE PLATE
|
Facility
|
OP
|
$13,064.48
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,698.38 |
| Max. Negotiated Rate |
$12,541.90 |
| Rate for Payer: Aetna Commercial |
$10,059.65
|
| Rate for Payer: Anthem Medicaid |
$4,492.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,190.29
|
| Rate for Payer: Cash Price |
$6,532.24
|
| Rate for Payer: Cigna Commercial |
$10,843.52
|
| Rate for Payer: First Health Commercial |
$12,411.26
|
| Rate for Payer: Humana Commercial |
$11,104.81
|
| Rate for Payer: Humana KY Medicaid |
$4,492.87
|
| Rate for Payer: Kentucky WC Medicaid |
$4,538.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,712.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,641.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,919.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,583.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,496.74
|
| Rate for Payer: Ohio Health Group HMO |
$9,798.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,612.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,698.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,049.99
|
| Rate for Payer: PHCS Commercial |
$12,541.90
|
| Rate for Payer: United Healthcare All Payer |
$11,496.74
|
|
|
TM REVERSE BASE PLATE
|
Facility
|
IP
|
$13,064.48
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,698.38 |
| Max. Negotiated Rate |
$12,541.90 |
| Rate for Payer: Aetna Commercial |
$10,059.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,190.29
|
| Rate for Payer: Cash Price |
$6,532.24
|
| Rate for Payer: Cigna Commercial |
$10,843.52
|
| Rate for Payer: First Health Commercial |
$12,411.26
|
| Rate for Payer: Humana Commercial |
$11,104.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,712.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,641.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,919.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,496.74
|
| Rate for Payer: Ohio Health Group HMO |
$9,798.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,612.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,698.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,049.99
|
| Rate for Payer: PHCS Commercial |
$12,541.90
|
| Rate for Payer: United Healthcare All Payer |
$11,496.74
|
|
|
TM REVERSE BASE PLATE 15MM
|
Facility
|
OP
|
$13,064.48
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,698.38 |
| Max. Negotiated Rate |
$12,541.90 |
| Rate for Payer: Aetna Commercial |
$10,059.65
|
| Rate for Payer: Anthem Medicaid |
$4,492.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,190.29
|
| Rate for Payer: Cash Price |
$6,532.24
|
| Rate for Payer: Cigna Commercial |
$10,843.52
|
| Rate for Payer: First Health Commercial |
$12,411.26
|
| Rate for Payer: Humana Commercial |
$11,104.81
|
| Rate for Payer: Humana KY Medicaid |
$4,492.87
|
| Rate for Payer: Kentucky WC Medicaid |
$4,538.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,712.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,641.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,919.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,583.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,496.74
|
| Rate for Payer: Ohio Health Group HMO |
$9,798.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,612.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,698.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,049.99
|
| Rate for Payer: PHCS Commercial |
$12,541.90
|
| Rate for Payer: United Healthcare All Payer |
$11,496.74
|
|
|
TM REVERSE BASE PLATE 15MM
|
Facility
|
IP
|
$13,064.48
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,698.38 |
| Max. Negotiated Rate |
$12,541.90 |
| Rate for Payer: Aetna Commercial |
$10,059.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,190.29
|
| Rate for Payer: Cash Price |
$6,532.24
|
| Rate for Payer: Cigna Commercial |
$10,843.52
|
| Rate for Payer: First Health Commercial |
$12,411.26
|
| Rate for Payer: Humana Commercial |
$11,104.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,712.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,641.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,919.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,496.74
|
| Rate for Payer: Ohio Health Group HMO |
$9,798.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,612.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,698.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,049.99
|
| Rate for Payer: PHCS Commercial |
$12,541.90
|
| Rate for Payer: United Healthcare All Payer |
$11,496.74
|
|
|
TM REVERSE DUAL TAPER INSERT
|
Facility
|
OP
|
$5,341.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$694.41 |
| Max. Negotiated Rate |
$5,127.94 |
| Rate for Payer: Aetna Commercial |
$4,113.03
|
| Rate for Payer: Anthem Medicaid |
$1,836.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,166.45
|
| Rate for Payer: Cash Price |
$2,670.80
|
| Rate for Payer: Cigna Commercial |
$4,433.53
|
| Rate for Payer: First Health Commercial |
$5,074.52
|
| Rate for Payer: Humana Commercial |
$4,540.36
|
| Rate for Payer: Humana KY Medicaid |
$1,836.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,855.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,380.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,942.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,602.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,873.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,700.61
|
| Rate for Payer: Ohio Health Group HMO |
$4,006.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,068.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$694.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,655.90
|
| Rate for Payer: PHCS Commercial |
$5,127.94
|
| Rate for Payer: United Healthcare All Payer |
$4,700.61
|
|
|
TM REVERSE DUAL TAPER INSERT
|
Facility
|
IP
|
$5,341.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$694.41 |
| Max. Negotiated Rate |
$5,127.94 |
| Rate for Payer: Aetna Commercial |
$4,113.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,166.45
|
| Rate for Payer: Cash Price |
$2,670.80
|
| Rate for Payer: Cigna Commercial |
$4,433.53
|
| Rate for Payer: First Health Commercial |
$5,074.52
|
| Rate for Payer: Humana Commercial |
$4,540.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,380.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,942.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,602.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,700.61
|
| Rate for Payer: Ohio Health Group HMO |
$4,006.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,068.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$694.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,655.90
|
| Rate for Payer: PHCS Commercial |
$5,127.94
|
| Rate for Payer: United Healthcare All Payer |
$4,700.61
|
|
|
TM REVERSE DUAL TPR INSERT
|
Facility
|
OP
|
$5,218.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$678.39 |
| Max. Negotiated Rate |
$5,009.66 |
| Rate for Payer: Aetna Commercial |
$4,018.17
|
| Rate for Payer: Anthem Medicaid |
$1,794.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,070.35
|
| Rate for Payer: Cash Price |
$2,609.20
|
| Rate for Payer: Cigna Commercial |
$4,331.27
|
| Rate for Payer: First Health Commercial |
$4,957.48
|
| Rate for Payer: Humana Commercial |
$4,435.64
|
| Rate for Payer: Humana KY Medicaid |
$1,794.61
|
| Rate for Payer: Kentucky WC Medicaid |
$1,812.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,279.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,851.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,565.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,830.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,592.19
|
| Rate for Payer: Ohio Health Group HMO |
$3,913.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,043.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$678.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,617.70
|
| Rate for Payer: PHCS Commercial |
$5,009.66
|
| Rate for Payer: United Healthcare All Payer |
$4,592.19
|
|
