|
ECLIPSE HUMERAL HEAD 49/18
|
Facility
|
IP
|
$10,840.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,252.00 |
| Max. Negotiated Rate |
$10,406.40 |
| Rate for Payer: Aetna Commercial |
$8,346.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,455.20
|
| Rate for Payer: Cash Price |
$5,420.00
|
| Rate for Payer: Cigna Commercial |
$8,997.20
|
| Rate for Payer: First Health Commercial |
$10,298.00
|
| Rate for Payer: Humana Commercial |
$9,214.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,888.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,999.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,252.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,539.20
|
| Rate for Payer: Ohio Health Group HMO |
$8,130.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,672.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,430.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,479.60
|
| Rate for Payer: PHCS Commercial |
$10,406.40
|
| Rate for Payer: United Healthcare All Payer |
$9,539.20
|
|
|
ECLIPSE HUMERAL HEAD 49/18
|
Facility
|
OP
|
$10,840.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,252.00 |
| Max. Negotiated Rate |
$10,406.40 |
| Rate for Payer: Aetna Commercial |
$8,346.80
|
| Rate for Payer: Anthem Medicaid |
$3,727.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,455.20
|
| Rate for Payer: Cash Price |
$5,420.00
|
| Rate for Payer: Cigna Commercial |
$8,997.20
|
| Rate for Payer: First Health Commercial |
$10,298.00
|
| Rate for Payer: Humana Commercial |
$9,214.00
|
| Rate for Payer: Humana KY Medicaid |
$3,727.88
|
| Rate for Payer: Kentucky WC Medicaid |
$3,765.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,888.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,999.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,252.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,802.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,539.20
|
| Rate for Payer: Ohio Health Group HMO |
$8,130.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,672.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,430.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,479.60
|
| Rate for Payer: PHCS Commercial |
$10,406.40
|
| Rate for Payer: United Healthcare All Payer |
$9,539.20
|
|
|
ECLIPSE HUMERAL HEAD 49/20
|
Facility
|
OP
|
$9,570.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,871.00 |
| Max. Negotiated Rate |
$9,187.20 |
| Rate for Payer: Aetna Commercial |
$7,368.90
|
| Rate for Payer: Anthem Medicaid |
$3,291.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,464.60
|
| Rate for Payer: Cash Price |
$4,785.00
|
| Rate for Payer: Cigna Commercial |
$7,943.10
|
| Rate for Payer: First Health Commercial |
$9,091.50
|
| Rate for Payer: Humana Commercial |
$8,134.50
|
| Rate for Payer: Humana KY Medicaid |
$3,291.12
|
| Rate for Payer: Kentucky WC Medicaid |
$3,324.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,847.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,062.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,871.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,357.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,421.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,177.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,325.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,603.30
|
| Rate for Payer: PHCS Commercial |
$9,187.20
|
| Rate for Payer: United Healthcare All Payer |
$8,421.60
|
|
|
ECLIPSE HUMERAL HEAD 49/20
|
Facility
|
IP
|
$9,570.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,871.00 |
| Max. Negotiated Rate |
$9,187.20 |
| Rate for Payer: Aetna Commercial |
$7,368.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,464.60
|
| Rate for Payer: Cash Price |
$4,785.00
|
| Rate for Payer: Cigna Commercial |
$7,943.10
|
| Rate for Payer: First Health Commercial |
$9,091.50
|
| Rate for Payer: Humana Commercial |
$8,134.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,847.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,062.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,871.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,421.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,177.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,325.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,603.30
|
| Rate for Payer: PHCS Commercial |
$9,187.20
|
| Rate for Payer: United Healthcare All Payer |
$8,421.60
|
|
|
ECLIPSE HUMERAL HEAD 51/19
|
Facility
|
OP
|
$9,570.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,871.00 |
| Max. Negotiated Rate |
$9,187.20 |
| Rate for Payer: Aetna Commercial |
$7,368.90
|
| Rate for Payer: Anthem Medicaid |
$3,291.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,464.60
|
| Rate for Payer: Cash Price |
$4,785.00
|
| Rate for Payer: Cigna Commercial |
$7,943.10
|
| Rate for Payer: First Health Commercial |
$9,091.50
|
| Rate for Payer: Humana Commercial |
$8,134.50
|
| Rate for Payer: Humana KY Medicaid |
$3,291.12
|
| Rate for Payer: Kentucky WC Medicaid |
$3,324.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,847.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,062.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,871.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,357.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,421.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,177.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,325.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,603.30
|
| Rate for Payer: PHCS Commercial |
$9,187.20
|
| Rate for Payer: United Healthcare All Payer |
$8,421.60
|
|
|
ECLIPSE HUMERAL HEAD 51/19
|
Facility
|
IP
|
$9,570.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,871.00 |
| Max. Negotiated Rate |
$9,187.20 |
| Rate for Payer: Aetna Commercial |
$7,368.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,464.60
|
| Rate for Payer: Cash Price |
$4,785.00
|
| Rate for Payer: Cigna Commercial |
$7,943.10
|
| Rate for Payer: First Health Commercial |
$9,091.50
|
| Rate for Payer: Humana Commercial |
$8,134.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,847.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,062.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,871.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,421.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,177.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,325.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,603.30
|
| Rate for Payer: PHCS Commercial |
$9,187.20
|
| Rate for Payer: United Healthcare All Payer |
$8,421.60
|
|
|
ECLIPSE HUMERAL HEAD 51/21
|
Facility
|
IP
|
$9,570.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,871.00 |
| Max. Negotiated Rate |
$9,187.20 |
| Rate for Payer: Aetna Commercial |
$7,368.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,464.60
|
| Rate for Payer: Cash Price |
$4,785.00
|
| Rate for Payer: Cigna Commercial |
$7,943.10
|
| Rate for Payer: First Health Commercial |
$9,091.50
|
| Rate for Payer: Humana Commercial |
$8,134.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,847.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,062.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,871.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,421.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,177.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,325.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,603.30
|
| Rate for Payer: PHCS Commercial |
$9,187.20
|
| Rate for Payer: United Healthcare All Payer |
$8,421.60
|
|
|
ECLIPSE HUMERAL HEAD 51/21
|
Facility
|
OP
|
$9,570.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,871.00 |
| Max. Negotiated Rate |
$9,187.20 |
| Rate for Payer: Aetna Commercial |
$7,368.90
|
| Rate for Payer: Anthem Medicaid |
$3,291.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,464.60
|
| Rate for Payer: Cash Price |
$4,785.00
|
| Rate for Payer: Cigna Commercial |
$7,943.10
|
| Rate for Payer: First Health Commercial |
$9,091.50
|
| Rate for Payer: Humana Commercial |
$8,134.50
|
| Rate for Payer: Humana KY Medicaid |
$3,291.12
|
| Rate for Payer: Kentucky WC Medicaid |
$3,324.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,847.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,062.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,871.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,357.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,421.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,177.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,325.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,603.30
|
| Rate for Payer: PHCS Commercial |
$9,187.20
|
| Rate for Payer: United Healthcare All Payer |
$8,421.60
|
|
|
ECLIPSE HUMERAL HEAD 53/20
|
Facility
|
OP
|
$9,570.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,871.00 |
| Max. Negotiated Rate |
$9,187.20 |
| Rate for Payer: Aetna Commercial |
$7,368.90
|
| Rate for Payer: Anthem Medicaid |
$3,291.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,464.60
|
| Rate for Payer: Cash Price |
$4,785.00
|
| Rate for Payer: Cigna Commercial |
$7,943.10
|
| Rate for Payer: First Health Commercial |
$9,091.50
|
| Rate for Payer: Humana Commercial |
$8,134.50
|
| Rate for Payer: Humana KY Medicaid |
$3,291.12
|
| Rate for Payer: Kentucky WC Medicaid |
$3,324.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,847.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,062.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,871.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,357.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,421.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,177.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,325.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,603.30
|
| Rate for Payer: PHCS Commercial |
$9,187.20
|
| Rate for Payer: United Healthcare All Payer |
$8,421.60
|
|
|
ECLIPSE HUMERAL HEAD 53/20
|
Facility
|
IP
|
$9,570.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,871.00 |
| Max. Negotiated Rate |
$9,187.20 |
| Rate for Payer: Aetna Commercial |
$7,368.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,464.60
|
| Rate for Payer: Cash Price |
$4,785.00
|
| Rate for Payer: Cigna Commercial |
$7,943.10
|
| Rate for Payer: First Health Commercial |
$9,091.50
|
| Rate for Payer: Humana Commercial |
$8,134.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,847.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,062.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,871.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,421.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,177.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,325.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,603.30
|
| Rate for Payer: PHCS Commercial |
$9,187.20
|
| Rate for Payer: United Healthcare All Payer |
$8,421.60
|
|
|
ECLIPSE HUMERAL HEAD 53/22
|
Facility
|
OP
|
$9,570.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,871.00 |
| Max. Negotiated Rate |
$9,187.20 |
| Rate for Payer: Aetna Commercial |
$7,368.90
|
| Rate for Payer: Anthem Medicaid |
$3,291.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,464.60
|
| Rate for Payer: Cash Price |
$4,785.00
|
| Rate for Payer: Cigna Commercial |
$7,943.10
|
| Rate for Payer: First Health Commercial |
$9,091.50
|
| Rate for Payer: Humana Commercial |
$8,134.50
|
| Rate for Payer: Humana KY Medicaid |
$3,291.12
|
| Rate for Payer: Kentucky WC Medicaid |
$3,324.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,847.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,062.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,871.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,357.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,421.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,177.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,325.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,603.30
|
| Rate for Payer: PHCS Commercial |
$9,187.20
|
| Rate for Payer: United Healthcare All Payer |
$8,421.60
|
|
|
ECLIPSE HUMERAL HEAD 53/22
|
Facility
|
IP
|
$9,570.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,871.00 |
| Max. Negotiated Rate |
$9,187.20 |
| Rate for Payer: Aetna Commercial |
$7,368.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,464.60
|
| Rate for Payer: Cash Price |
$4,785.00
|
| Rate for Payer: Cigna Commercial |
$7,943.10
|
| Rate for Payer: First Health Commercial |
$9,091.50
|
| Rate for Payer: Humana Commercial |
$8,134.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,847.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,062.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,871.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,421.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,177.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,325.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,603.30
|
| Rate for Payer: PHCS Commercial |
$9,187.20
|
| Rate for Payer: United Healthcare All Payer |
$8,421.60
|
|
|
ECLIPSE HUMERAL HEAD 55/21
|
Facility
|
OP
|
$9,570.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,871.00 |
| Max. Negotiated Rate |
$9,187.20 |
| Rate for Payer: Aetna Commercial |
$7,368.90
|
| Rate for Payer: Anthem Medicaid |
$3,291.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,464.60
|
| Rate for Payer: Cash Price |
$4,785.00
|
| Rate for Payer: Cigna Commercial |
$7,943.10
|
| Rate for Payer: First Health Commercial |
$9,091.50
|
| Rate for Payer: Humana Commercial |
$8,134.50
|
| Rate for Payer: Humana KY Medicaid |
$3,291.12
|
| Rate for Payer: Kentucky WC Medicaid |
$3,324.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,847.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,062.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,871.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,357.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,421.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,177.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,325.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,603.30
|
| Rate for Payer: PHCS Commercial |
$9,187.20
|
| Rate for Payer: United Healthcare All Payer |
$8,421.60
|
|
|
ECLIPSE HUMERAL HEAD 55/21
|
Facility
|
IP
|
$9,570.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,871.00 |
| Max. Negotiated Rate |
$9,187.20 |
| Rate for Payer: Aetna Commercial |
$7,368.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,464.60
|
| Rate for Payer: Cash Price |
$4,785.00
|
| Rate for Payer: Cigna Commercial |
$7,943.10
|
| Rate for Payer: First Health Commercial |
$9,091.50
|
| Rate for Payer: Humana Commercial |
$8,134.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,847.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,062.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,871.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,421.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,177.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,325.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,603.30
|
| Rate for Payer: PHCS Commercial |
$9,187.20
|
| Rate for Payer: United Healthcare All Payer |
$8,421.60
|
|
|
ECLIPSE HUMERAL HEAD 55/23
|
Facility
|
OP
|
$9,570.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,871.00 |
| Max. Negotiated Rate |
$9,187.20 |
| Rate for Payer: Aetna Commercial |
$7,368.90
|
| Rate for Payer: Anthem Medicaid |
$3,291.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,464.60
|
| Rate for Payer: Cash Price |
$4,785.00
|
| Rate for Payer: Cigna Commercial |
$7,943.10
|
| Rate for Payer: First Health Commercial |
$9,091.50
|
| Rate for Payer: Humana Commercial |
$8,134.50
|
| Rate for Payer: Humana KY Medicaid |
$3,291.12
|
| Rate for Payer: Kentucky WC Medicaid |
$3,324.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,847.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,062.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,871.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,357.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,421.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,177.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,325.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,603.30
|
| Rate for Payer: PHCS Commercial |
$9,187.20
|
| Rate for Payer: United Healthcare All Payer |
$8,421.60
|
|
|
ECLIPSE HUMERAL HEAD 55/23
|
Facility
|
IP
|
$9,570.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,871.00 |
| Max. Negotiated Rate |
$9,187.20 |
| Rate for Payer: Aetna Commercial |
$7,368.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,464.60
|
| Rate for Payer: Cash Price |
$4,785.00
|
| Rate for Payer: Cigna Commercial |
$7,943.10
|
| Rate for Payer: First Health Commercial |
$9,091.50
|
| Rate for Payer: Humana Commercial |
$8,134.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,847.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,062.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,871.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,421.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,177.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,325.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,603.30
|
| Rate for Payer: PHCS Commercial |
$9,187.20
|
| Rate for Payer: United Healthcare All Payer |
$8,421.60
|
|
|
ECMO/ECLS INITIATION ARTERY
|
Facility
|
IP
|
$555.00
|
|
|
Service Code
|
HCPCS 33947
|
| Hospital Charge Code |
76101321
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$166.50 |
| Max. Negotiated Rate |
$532.80 |
| Rate for Payer: Aetna Commercial |
$427.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$432.90
|
| Rate for Payer: Cash Price |
$277.50
|
| Rate for Payer: Cigna Commercial |
$460.65
|
| Rate for Payer: First Health Commercial |
$527.25
|
| Rate for Payer: Humana Commercial |
$471.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$455.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$409.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$166.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$488.40
|
| Rate for Payer: Ohio Health Group HMO |
$416.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$444.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$482.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$382.95
|
| Rate for Payer: PHCS Commercial |
$532.80
|
| Rate for Payer: United Healthcare All Payer |
$488.40
|
|
|
ECMO/ECLS INITIATION ARTERY
|
Professional
|
Both
|
$555.00
|
|
|
Service Code
|
HCPCS 33947
|
| Hospital Charge Code |
76101321
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$194.25 |
| Max. Negotiated Rate |
$629.30 |
| Rate for Payer: Ambetter Exchange |
$322.14
|
| Rate for Payer: Anthem Medicaid |
$279.23
|
| Rate for Payer: Buckeye Individual/Medicaid |
$322.14
|
| Rate for Payer: Buckeye Medicare Advantage |
$322.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$386.57
|
| Rate for Payer: Cash Price |
$277.50
|
| Rate for Payer: Cash Price |
$277.50
|
| Rate for Payer: Cigna Commercial |
$629.30
|
| Rate for Payer: Humana Medicaid |
$279.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$459.90
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$322.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$322.14
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$284.81
|
| Rate for Payer: Molina Healthcare Passport |
$279.23
|
| Rate for Payer: Multiplan PHCS |
$333.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$418.78
|
| Rate for Payer: UHCCP Medicaid |
$194.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$282.02
|
| Rate for Payer: Wellcare Medicare Advantage |
$322.14
|
|
|
ECMO/ECLS INITIATION ARTERY
|
Facility
|
OP
|
$555.00
|
|
|
Service Code
|
HCPCS 33947
|
| Hospital Charge Code |
76101321
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$166.50 |
| Max. Negotiated Rate |
$532.80 |
| Rate for Payer: Aetna Commercial |
$427.35
|
| Rate for Payer: Anthem Medicaid |
$190.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$432.90
|
| Rate for Payer: Cash Price |
$277.50
|
| Rate for Payer: Cigna Commercial |
$460.65
|
| Rate for Payer: First Health Commercial |
$527.25
|
| Rate for Payer: Humana Commercial |
$471.75
|
| Rate for Payer: Humana KY Medicaid |
$190.86
|
| Rate for Payer: Kentucky WC Medicaid |
$192.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$455.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$409.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$166.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$194.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$488.40
|
| Rate for Payer: Ohio Health Group HMO |
$416.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$444.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$482.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$382.95
|
| Rate for Payer: PHCS Commercial |
$532.80
|
| Rate for Payer: United Healthcare All Payer |
$488.40
|
|
|
ECMO/ECLS INITIATION ARTERY(P
|
Professional
|
Both
|
$555.00
|
|
|
Service Code
|
HCPCS 33947
|
| Hospital Charge Code |
761P1321
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$194.25 |
| Max. Negotiated Rate |
$629.30 |
| Rate for Payer: Ambetter Exchange |
$322.14
|
| Rate for Payer: Anthem Medicaid |
$279.23
|
| Rate for Payer: Buckeye Individual/Medicaid |
$322.14
|
| Rate for Payer: Buckeye Medicare Advantage |
$322.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$386.57
|
| Rate for Payer: Cash Price |
$277.50
|
| Rate for Payer: Cash Price |
$277.50
|
| Rate for Payer: Cigna Commercial |
$629.30
|
| Rate for Payer: Humana Medicaid |
$279.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$459.90
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$322.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$322.14
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$284.81
|
| Rate for Payer: Molina Healthcare Passport |
$279.23
|
| Rate for Payer: Multiplan PHCS |
$333.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$418.78
|
| Rate for Payer: UHCCP Medicaid |
$194.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$282.02
|
| Rate for Payer: Wellcare Medicare Advantage |
$322.14
|
|
|
ECMO/ECLS INITIATION VENOUS
|
Professional
|
Both
|
$520.00
|
|
|
Service Code
|
HCPCS 33946
|
| Hospital Charge Code |
76101320
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$182.00 |
| Max. Negotiated Rate |
$569.72 |
| Rate for Payer: Ambetter Exchange |
$290.44
|
| Rate for Payer: Anthem Medicaid |
$252.80
|
| Rate for Payer: Buckeye Individual/Medicaid |
$290.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$290.44
|
| Rate for Payer: CareSource Just4Me Medicare |
$348.53
|
| Rate for Payer: Cash Price |
$260.00
|
| Rate for Payer: Cash Price |
$260.00
|
| Rate for Payer: Cigna Commercial |
$569.72
|
| Rate for Payer: Humana Medicaid |
$252.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$416.35
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$290.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$290.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$257.86
|
| Rate for Payer: Molina Healthcare Passport |
$252.80
|
| Rate for Payer: Multiplan PHCS |
$312.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$377.57
|
| Rate for Payer: UHCCP Medicaid |
$182.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$255.33
|
| Rate for Payer: Wellcare Medicare Advantage |
$290.44
|
|
|
ECMO/ECLS INITIATION VENOUS
|
Facility
|
OP
|
$520.00
|
|
|
Service Code
|
HCPCS 33946
|
| Hospital Charge Code |
76101320
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$156.00 |
| Max. Negotiated Rate |
$499.20 |
| Rate for Payer: Aetna Commercial |
$400.40
|
| Rate for Payer: Anthem Medicaid |
$178.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$405.60
|
| Rate for Payer: Cash Price |
$260.00
|
| Rate for Payer: Cigna Commercial |
$431.60
|
| Rate for Payer: First Health Commercial |
$494.00
|
| Rate for Payer: Humana Commercial |
$442.00
|
| Rate for Payer: Humana KY Medicaid |
$178.83
|
| Rate for Payer: Kentucky WC Medicaid |
$180.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$426.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$383.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$156.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$182.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$457.60
|
| Rate for Payer: Ohio Health Group HMO |
$390.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$416.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$452.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$358.80
|
| Rate for Payer: PHCS Commercial |
$499.20
|
| Rate for Payer: United Healthcare All Payer |
$457.60
|
|
|
ECMO/ECLS INITIATION VENOUS
|
Facility
|
IP
|
$520.00
|
|
|
Service Code
|
HCPCS 33946
|
| Hospital Charge Code |
76101320
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$156.00 |
| Max. Negotiated Rate |
$499.20 |
| Rate for Payer: Aetna Commercial |
$400.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$405.60
|
| Rate for Payer: Cash Price |
$260.00
|
| Rate for Payer: Cigna Commercial |
$431.60
|
| Rate for Payer: First Health Commercial |
$494.00
|
| Rate for Payer: Humana Commercial |
$442.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$426.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$383.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$156.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$457.60
|
| Rate for Payer: Ohio Health Group HMO |
$390.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$416.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$452.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$358.80
|
| Rate for Payer: PHCS Commercial |
$499.20
|
| Rate for Payer: United Healthcare All Payer |
$457.60
|
|
|
ECMO/ECLS INITIATION VENOUS(P
|
Professional
|
Both
|
$520.00
|
|
|
Service Code
|
HCPCS 33946
|
| Hospital Charge Code |
761P1320
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$182.00 |
| Max. Negotiated Rate |
$569.72 |
| Rate for Payer: Ambetter Exchange |
$290.44
|
| Rate for Payer: Anthem Medicaid |
$252.80
|
| Rate for Payer: Buckeye Individual/Medicaid |
$290.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$290.44
|
| Rate for Payer: CareSource Just4Me Medicare |
$348.53
|
| Rate for Payer: Cash Price |
$260.00
|
| Rate for Payer: Cash Price |
$260.00
|
| Rate for Payer: Cigna Commercial |
$569.72
|
| Rate for Payer: Humana Medicaid |
$252.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$416.35
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$290.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$290.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$257.86
|
| Rate for Payer: Molina Healthcare Passport |
$252.80
|
| Rate for Payer: Multiplan PHCS |
$312.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$377.57
|
| Rate for Payer: UHCCP Medicaid |
$182.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$255.33
|
| Rate for Payer: Wellcare Medicare Advantage |
$290.44
|
|
|
ECMO/ECLS INSJ CTR CANNULA
|
Professional
|
Both
|
$2,180.00
|
|
|
Service Code
|
HCPCS 33956
|
| Hospital Charge Code |
76101323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$688.02 |
| Max. Negotiated Rate |
$1,557.15 |
| Rate for Payer: Ambetter Exchange |
$781.68
|
| Rate for Payer: Anthem Medicaid |
$688.02
|
| Rate for Payer: Buckeye Individual/Medicaid |
$781.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$781.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$938.02
|
| Rate for Payer: Cash Price |
$1,090.00
|
| Rate for Payer: Cash Price |
$1,090.00
|
| Rate for Payer: Cigna Commercial |
$1,557.15
|
| Rate for Payer: Humana Medicaid |
$688.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,139.32
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$781.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$781.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$701.78
|
| Rate for Payer: Molina Healthcare Passport |
$688.02
|
| Rate for Payer: Multiplan PHCS |
$1,308.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,016.18
|
| Rate for Payer: UHCCP Medicaid |
$763.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$694.90
|
| Rate for Payer: Wellcare Medicare Advantage |
$781.68
|
|
