|
TM REVERSE STEM 8MM*130MM
|
Facility
|
OP
|
$33,710.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,113.00 |
| Max. Negotiated Rate |
$32,361.60 |
| Rate for Payer: Aetna Commercial |
$25,956.70
|
| Rate for Payer: Anthem Medicaid |
$11,592.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,293.80
|
| Rate for Payer: Cash Price |
$16,855.00
|
| Rate for Payer: Cigna Commercial |
$27,979.30
|
| Rate for Payer: First Health Commercial |
$32,024.50
|
| Rate for Payer: Humana Commercial |
$28,653.50
|
| Rate for Payer: Humana KY Medicaid |
$11,592.87
|
| Rate for Payer: Kentucky WC Medicaid |
$11,710.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,642.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,877.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,113.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,825.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,664.80
|
| Rate for Payer: Ohio Health Group HMO |
$25,282.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26,968.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29,327.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,259.90
|
| Rate for Payer: PHCS Commercial |
$32,361.60
|
| Rate for Payer: United Healthcare All Payer |
$29,664.80
|
|
|
TM REVERSE STEM 8MM*130MM
|
Facility
|
IP
|
$33,710.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,113.00 |
| Max. Negotiated Rate |
$32,361.60 |
| Rate for Payer: Aetna Commercial |
$25,956.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,293.80
|
| Rate for Payer: Cash Price |
$16,855.00
|
| Rate for Payer: Cigna Commercial |
$27,979.30
|
| Rate for Payer: First Health Commercial |
$32,024.50
|
| Rate for Payer: Humana Commercial |
$28,653.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,642.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,877.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,113.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,664.80
|
| Rate for Payer: Ohio Health Group HMO |
$25,282.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26,968.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29,327.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,259.90
|
| Rate for Payer: PHCS Commercial |
$32,361.60
|
| Rate for Payer: United Healthcare All Payer |
$29,664.80
|
|
|
TM REVERSE STEM 8MM*170MM
|
Facility
|
IP
|
$33,710.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,113.00 |
| Max. Negotiated Rate |
$32,361.60 |
| Rate for Payer: Aetna Commercial |
$25,956.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,293.80
|
| Rate for Payer: Cash Price |
$16,855.00
|
| Rate for Payer: Cigna Commercial |
$27,979.30
|
| Rate for Payer: First Health Commercial |
$32,024.50
|
| Rate for Payer: Humana Commercial |
$28,653.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,642.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,877.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,113.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,664.80
|
| Rate for Payer: Ohio Health Group HMO |
$25,282.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26,968.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29,327.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,259.90
|
| Rate for Payer: PHCS Commercial |
$32,361.60
|
| Rate for Payer: United Healthcare All Payer |
$29,664.80
|
|
|
TM REVERSE STEM 8MM*170MM
|
Facility
|
OP
|
$33,710.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,113.00 |
| Max. Negotiated Rate |
$32,361.60 |
| Rate for Payer: Aetna Commercial |
$25,956.70
|
| Rate for Payer: Anthem Medicaid |
$11,592.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,293.80
|
| Rate for Payer: Cash Price |
$16,855.00
|
| Rate for Payer: Cigna Commercial |
$27,979.30
|
| Rate for Payer: First Health Commercial |
$32,024.50
|
| Rate for Payer: Humana Commercial |
$28,653.50
|
| Rate for Payer: Humana KY Medicaid |
$11,592.87
|
| Rate for Payer: Kentucky WC Medicaid |
$11,710.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,642.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,877.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,113.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,825.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,664.80
|
| Rate for Payer: Ohio Health Group HMO |
$25,282.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26,968.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29,327.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,259.90
|
| Rate for Payer: PHCS Commercial |
$32,361.60
|
| Rate for Payer: United Healthcare All Payer |
$29,664.80
|
|
|
TM REVRSE 36MM POLY LINER +0MM
|
Facility
|
OP
|
$5,682.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,704.77 |
| Max. Negotiated Rate |
$5,455.28 |
| Rate for Payer: Aetna Commercial |
$4,375.59
|
| Rate for Payer: Anthem Medicaid |
$1,954.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.41
|
| Rate for Payer: Cash Price |
$2,841.29
|
| Rate for Payer: Cigna Commercial |
$4,716.54
|
| Rate for Payer: First Health Commercial |
$5,398.45
|
| Rate for Payer: Humana Commercial |
$4,830.19
|
| Rate for Payer: Humana KY Medicaid |
$1,954.24
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.67
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,546.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,943.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,920.98
|
| Rate for Payer: PHCS Commercial |
$5,455.28
|
| Rate for Payer: United Healthcare All Payer |
$5,000.67
|
|
|
TM REVRSE 36MM POLY LINER +0MM
|
Facility
|
IP
|
$5,682.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,704.77 |
| Max. Negotiated Rate |
$5,455.28 |
| Rate for Payer: Aetna Commercial |
$4,375.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.41
|
| Rate for Payer: Cash Price |
$2,841.29
|
| Rate for Payer: Cigna Commercial |
$4,716.54
|
| Rate for Payer: First Health Commercial |
$5,398.45
|
| Rate for Payer: Humana Commercial |
$4,830.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.67
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,546.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,943.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,920.98
|
| Rate for Payer: PHCS Commercial |
$5,455.28
|
| Rate for Payer: United Healthcare All Payer |
$5,000.67
|
|
|
TM RVRSE 2.5MM PIN REV 2.5 PIN
|
Facility
|
OP
|
$1,965.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$589.50 |
| Max. Negotiated Rate |
$1,886.40 |
| Rate for Payer: Aetna Commercial |
$1,513.05
|
| Rate for Payer: Anthem Medicaid |
$675.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,532.70
|
| Rate for Payer: Cash Price |
$982.50
|
| Rate for Payer: Cigna Commercial |
$1,630.95
|
| Rate for Payer: First Health Commercial |
$1,866.75
|
| Rate for Payer: Humana Commercial |
$1,670.25
|
| Rate for Payer: Humana KY Medicaid |
$675.76
|
| Rate for Payer: Kentucky WC Medicaid |
$682.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,611.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,450.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$589.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$689.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,729.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,473.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,572.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,709.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,355.85
|
| Rate for Payer: PHCS Commercial |
$1,886.40
|
| Rate for Payer: United Healthcare All Payer |
$1,729.20
|
|
|
TM RVRSE 2.5MM PIN REV 2.5 PIN
|
Facility
|
IP
|
$1,965.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$589.50 |
| Max. Negotiated Rate |
$1,886.40 |
| Rate for Payer: Aetna Commercial |
$1,513.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,532.70
|
| Rate for Payer: Cash Price |
$982.50
|
| Rate for Payer: Cigna Commercial |
$1,630.95
|
| Rate for Payer: First Health Commercial |
$1,866.75
|
| Rate for Payer: Humana Commercial |
$1,670.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,611.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,450.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$589.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,729.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,473.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,572.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,709.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,355.85
|
| Rate for Payer: PHCS Commercial |
$1,886.40
|
| Rate for Payer: United Healthcare All Payer |
$1,729.20
|
|
|
TM RVRSE 36MM POLY LINER +3MM
|
Facility
|
OP
|
$5,682.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,704.77 |
| Max. Negotiated Rate |
$5,455.28 |
| Rate for Payer: Aetna Commercial |
$4,375.59
|
| Rate for Payer: Anthem Medicaid |
$1,954.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.41
|
| Rate for Payer: Cash Price |
$2,841.29
|
| Rate for Payer: Cigna Commercial |
$4,716.54
|
| Rate for Payer: First Health Commercial |
$5,398.45
|
| Rate for Payer: Humana Commercial |
$4,830.19
|
| Rate for Payer: Humana KY Medicaid |
$1,954.24
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.67
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,546.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,943.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,920.98
|
| Rate for Payer: PHCS Commercial |
$5,455.28
|
| Rate for Payer: United Healthcare All Payer |
$5,000.67
|
|
|
TM RVRSE 36MM POLY LINER +3MM
|
Facility
|
IP
|
$5,682.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,704.77 |
| Max. Negotiated Rate |
$5,455.28 |
| Rate for Payer: Aetna Commercial |
$4,375.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.41
|
| Rate for Payer: Cash Price |
$2,841.29
|
| Rate for Payer: Cigna Commercial |
$4,716.54
|
| Rate for Payer: First Health Commercial |
$5,398.45
|
| Rate for Payer: Humana Commercial |
$4,830.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.67
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,546.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,943.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,920.98
|
| Rate for Payer: PHCS Commercial |
$5,455.28
|
| Rate for Payer: United Healthcare All Payer |
$5,000.67
|
|
|
TM RVRSE 36MM POLY LINER +6MM
|
Facility
|
IP
|
$5,682.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,704.77 |
| Max. Negotiated Rate |
$5,455.28 |
| Rate for Payer: Aetna Commercial |
$4,375.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.41
|
| Rate for Payer: Cash Price |
$2,841.29
|
| Rate for Payer: Cigna Commercial |
$4,716.54
|
| Rate for Payer: First Health Commercial |
$5,398.45
|
| Rate for Payer: Humana Commercial |
$4,830.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.67
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,546.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,943.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,920.98
|
| Rate for Payer: PHCS Commercial |
$5,455.28
|
| Rate for Payer: United Healthcare All Payer |
$5,000.67
|
|
|
TM RVRSE 36MM POLY LINER +6MM
|
Facility
|
OP
|
$5,682.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,704.77 |
| Max. Negotiated Rate |
$5,455.28 |
| Rate for Payer: Aetna Commercial |
$4,375.59
|
| Rate for Payer: Anthem Medicaid |
$1,954.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.41
|
| Rate for Payer: Cash Price |
$2,841.29
|
| Rate for Payer: Cigna Commercial |
$4,716.54
|
| Rate for Payer: First Health Commercial |
$5,398.45
|
| Rate for Payer: Humana Commercial |
$4,830.19
|
| Rate for Payer: Humana KY Medicaid |
$1,954.24
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.67
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,546.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,943.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,920.98
|
| Rate for Payer: PHCS Commercial |
$5,455.28
|
| Rate for Payer: United Healthcare All Payer |
$5,000.67
|
|
|
TM RVRSE 40MM POLY LINER +0MM
|
Facility
|
IP
|
$5,682.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,704.77 |
| Max. Negotiated Rate |
$5,455.28 |
| Rate for Payer: Aetna Commercial |
$4,375.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.41
|
| Rate for Payer: Cash Price |
$2,841.29
|
| Rate for Payer: Cigna Commercial |
$4,716.54
|
| Rate for Payer: First Health Commercial |
$5,398.45
|
| Rate for Payer: Humana Commercial |
$4,830.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.67
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,546.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,943.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,920.98
|
| Rate for Payer: PHCS Commercial |
$5,455.28
|
| Rate for Payer: United Healthcare All Payer |
$5,000.67
|
|
|
TM RVRSE 40MM POLY LINER +0MM
|
Facility
|
OP
|
$5,682.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,704.77 |
| Max. Negotiated Rate |
$5,455.28 |
| Rate for Payer: Aetna Commercial |
$4,375.59
|
| Rate for Payer: Anthem Medicaid |
$1,954.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.41
|
| Rate for Payer: Cash Price |
$2,841.29
|
| Rate for Payer: Cigna Commercial |
$4,716.54
|
| Rate for Payer: First Health Commercial |
$5,398.45
|
| Rate for Payer: Humana Commercial |
$4,830.19
|
| Rate for Payer: Humana KY Medicaid |
$1,954.24
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.67
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,546.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,943.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,920.98
|
| Rate for Payer: PHCS Commercial |
$5,455.28
|
| Rate for Payer: United Healthcare All Payer |
$5,000.67
|
|
|
TM RVRSE 40MM POLY LINER +3MM
|
Facility
|
OP
|
$5,682.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,704.77 |
| Max. Negotiated Rate |
$5,455.28 |
| Rate for Payer: Aetna Commercial |
$4,375.59
|
| Rate for Payer: Anthem Medicaid |
$1,954.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.41
|
| Rate for Payer: Cash Price |
$2,841.29
|
| Rate for Payer: Cigna Commercial |
$4,716.54
|
| Rate for Payer: First Health Commercial |
$5,398.45
|
| Rate for Payer: Humana Commercial |
$4,830.19
|
| Rate for Payer: Humana KY Medicaid |
$1,954.24
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.67
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,546.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,943.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,920.98
|
| Rate for Payer: PHCS Commercial |
$5,455.28
|
| Rate for Payer: United Healthcare All Payer |
$5,000.67
|
|
|
TM RVRSE 40MM POLY LINER +3MM
|
Facility
|
IP
|
$5,682.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,704.77 |
| Max. Negotiated Rate |
$5,455.28 |
| Rate for Payer: Aetna Commercial |
$4,375.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.41
|
| Rate for Payer: Cash Price |
$2,841.29
|
| Rate for Payer: Cigna Commercial |
$4,716.54
|
| Rate for Payer: First Health Commercial |
$5,398.45
|
| Rate for Payer: Humana Commercial |
$4,830.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.67
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,546.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,943.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,920.98
|
| Rate for Payer: PHCS Commercial |
$5,455.28
|
| Rate for Payer: United Healthcare All Payer |
$5,000.67
|
|
|
TM RVRSE 40MM POLY LINER +6MM
|
Facility
|
OP
|
$5,682.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,704.77 |
| Max. Negotiated Rate |
$5,455.28 |
| Rate for Payer: Aetna Commercial |
$4,375.59
|
| Rate for Payer: Anthem Medicaid |
$1,954.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.41
|
| Rate for Payer: Cash Price |
$2,841.29
|
| Rate for Payer: Cigna Commercial |
$4,716.54
|
| Rate for Payer: First Health Commercial |
$5,398.45
|
| Rate for Payer: Humana Commercial |
$4,830.19
|
| Rate for Payer: Humana KY Medicaid |
$1,954.24
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.67
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,546.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,943.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,920.98
|
| Rate for Payer: PHCS Commercial |
$5,455.28
|
| Rate for Payer: United Healthcare All Payer |
$5,000.67
|
|
|
TM RVRSE 40MM POLY LINER +6MM
|
Facility
|
IP
|
$5,682.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,704.77 |
| Max. Negotiated Rate |
$5,455.28 |
| Rate for Payer: Aetna Commercial |
$4,375.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.41
|
| Rate for Payer: Cash Price |
$2,841.29
|
| Rate for Payer: Cigna Commercial |
$4,716.54
|
| Rate for Payer: First Health Commercial |
$5,398.45
|
| Rate for Payer: Humana Commercial |
$4,830.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.67
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,546.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,943.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,920.98
|
| Rate for Payer: PHCS Commercial |
$5,455.28
|
| Rate for Payer: United Healthcare All Payer |
$5,000.67
|
|
|
TM RVRSE SPACER +9 00434903909
|
Facility
|
OP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem Medicaid |
$1,484.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Humana KY Medicaid |
$1,484.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,499.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,513.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
TM RVRSE SPACER +9 00434903909
|
Facility
|
IP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
TM RVRSE SPACR +12 00434903912
|
Facility
|
OP
|
$5,366.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,609.80 |
| Max. Negotiated Rate |
$5,151.36 |
| Rate for Payer: Aetna Commercial |
$4,131.82
|
| Rate for Payer: Anthem Medicaid |
$1,845.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,185.48
|
| Rate for Payer: Cash Price |
$2,683.00
|
| Rate for Payer: Cigna Commercial |
$4,453.78
|
| Rate for Payer: First Health Commercial |
$5,097.70
|
| Rate for Payer: Humana Commercial |
$4,561.10
|
| Rate for Payer: Humana KY Medicaid |
$1,845.37
|
| Rate for Payer: Kentucky WC Medicaid |
$1,864.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,400.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,960.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,609.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,882.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,722.08
|
| Rate for Payer: Ohio Health Group HMO |
$4,024.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,292.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,668.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,702.54
|
| Rate for Payer: PHCS Commercial |
$5,151.36
|
| Rate for Payer: United Healthcare All Payer |
$4,722.08
|
|
|
TM RVRSE SPACR +12 00434903912
|
Facility
|
IP
|
$5,366.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,609.80 |
| Max. Negotiated Rate |
$5,151.36 |
| Rate for Payer: Aetna Commercial |
$4,131.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,185.48
|
| Rate for Payer: Cash Price |
$2,683.00
|
| Rate for Payer: Cigna Commercial |
$4,453.78
|
| Rate for Payer: First Health Commercial |
$5,097.70
|
| Rate for Payer: Humana Commercial |
$4,561.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,400.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,960.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,609.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,722.08
|
| Rate for Payer: Ohio Health Group HMO |
$4,024.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,292.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,668.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,702.54
|
| Rate for Payer: PHCS Commercial |
$5,151.36
|
| Rate for Payer: United Healthcare All Payer |
$4,722.08
|
|
|
TM TIBIAL CONE LARGE 51*34 L
|
Facility
|
IP
|
$22,562.22
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,768.67 |
| Max. Negotiated Rate |
$21,659.73 |
| Rate for Payer: Aetna Commercial |
$17,372.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,598.53
|
| Rate for Payer: Cash Price |
$11,281.11
|
| Rate for Payer: Cigna Commercial |
$18,726.64
|
| Rate for Payer: First Health Commercial |
$21,434.11
|
| Rate for Payer: Humana Commercial |
$19,177.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,501.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,650.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,768.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,854.75
|
| Rate for Payer: Ohio Health Group HMO |
$16,921.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,049.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,629.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,567.93
|
| Rate for Payer: PHCS Commercial |
$21,659.73
|
| Rate for Payer: United Healthcare All Payer |
$19,854.75
|
|
|
TM TIBIAL CONE LARGE 51*34 L
|
Facility
|
OP
|
$22,562.22
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,768.67 |
| Max. Negotiated Rate |
$21,659.73 |
| Rate for Payer: Aetna Commercial |
$17,372.91
|
| Rate for Payer: Anthem Medicaid |
$7,759.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,598.53
|
| Rate for Payer: Cash Price |
$11,281.11
|
| Rate for Payer: Cigna Commercial |
$18,726.64
|
| Rate for Payer: First Health Commercial |
$21,434.11
|
| Rate for Payer: Humana Commercial |
$19,177.89
|
| Rate for Payer: Humana KY Medicaid |
$7,759.15
|
| Rate for Payer: Kentucky WC Medicaid |
$7,838.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,501.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,650.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,768.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,914.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,854.75
|
| Rate for Payer: Ohio Health Group HMO |
$16,921.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,049.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,629.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,567.93
|
| Rate for Payer: PHCS Commercial |
$21,659.73
|
| Rate for Payer: United Healthcare All Payer |
$19,854.75
|
|
|
TM TIBIAL CONE LARGE 51*34 R
|
Facility
|
OP
|
$22,562.22
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,768.67 |
| Max. Negotiated Rate |
$21,659.73 |
| Rate for Payer: Aetna Commercial |
$17,372.91
|
| Rate for Payer: Anthem Medicaid |
$7,759.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,598.53
|
| Rate for Payer: Cash Price |
$11,281.11
|
| Rate for Payer: Cigna Commercial |
$18,726.64
|
| Rate for Payer: First Health Commercial |
$21,434.11
|
| Rate for Payer: Humana Commercial |
$19,177.89
|
| Rate for Payer: Humana KY Medicaid |
$7,759.15
|
| Rate for Payer: Kentucky WC Medicaid |
$7,838.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,501.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,650.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,768.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,914.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,854.75
|
| Rate for Payer: Ohio Health Group HMO |
$16,921.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,049.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,629.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,567.93
|
| Rate for Payer: PHCS Commercial |
$21,659.73
|
| Rate for Payer: United Healthcare All Payer |
$19,854.75
|
|
