|
ULNAR RIGHT 60MM STD
|
Facility
|
IP
|
$9,406.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,222.84 |
| Max. Negotiated Rate |
$9,030.24 |
| Rate for Payer: Aetna Commercial |
$7,243.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,337.07
|
| Rate for Payer: Cash Price |
$4,703.25
|
| Rate for Payer: Cigna Commercial |
$7,807.40
|
| Rate for Payer: First Health Commercial |
$8,936.18
|
| Rate for Payer: Humana Commercial |
$7,995.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,713.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,942.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,821.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,277.72
|
| Rate for Payer: Ohio Health Group HMO |
$7,054.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,881.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,222.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,916.02
|
| Rate for Payer: PHCS Commercial |
$9,030.24
|
| Rate for Payer: United Healthcare All Payer |
$8,277.72
|
|
|
ULNAR RIGHT 85MM STD
|
Facility
|
OP
|
$9,954.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.02 |
| Max. Negotiated Rate |
$9,555.84 |
| Rate for Payer: Aetna Commercial |
$7,664.58
|
| Rate for Payer: Anthem Medicaid |
$3,423.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,764.12
|
| Rate for Payer: Cash Price |
$4,977.00
|
| Rate for Payer: Cigna Commercial |
$8,261.82
|
| Rate for Payer: First Health Commercial |
$9,456.30
|
| Rate for Payer: Humana Commercial |
$8,460.90
|
| Rate for Payer: Humana KY Medicaid |
$3,423.18
|
| Rate for Payer: Kentucky WC Medicaid |
$3,458.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,162.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,346.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,986.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,491.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,759.52
|
| Rate for Payer: Ohio Health Group HMO |
$7,465.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,990.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,294.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,085.74
|
| Rate for Payer: PHCS Commercial |
$9,555.84
|
| Rate for Payer: United Healthcare All Payer |
$8,759.52
|
|
|
ULNAR RIGHT 85MM STD
|
Facility
|
IP
|
$9,954.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.02 |
| Max. Negotiated Rate |
$9,555.84 |
| Rate for Payer: Aetna Commercial |
$7,664.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,764.12
|
| Rate for Payer: Cash Price |
$4,977.00
|
| Rate for Payer: Cigna Commercial |
$8,261.82
|
| Rate for Payer: First Health Commercial |
$9,456.30
|
| Rate for Payer: Humana Commercial |
$8,460.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,162.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,346.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,986.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,759.52
|
| Rate for Payer: Ohio Health Group HMO |
$7,465.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,990.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,294.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,085.74
|
| Rate for Payer: PHCS Commercial |
$9,555.84
|
| Rate for Payer: United Healthcare All Payer |
$8,759.52
|
|
|
ULORIC 40MG TABLET
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 64764091830
|
| Hospital Charge Code |
25001621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.64 |
| Max. Negotiated Rate |
$26.88 |
| Rate for Payer: Aetna Commercial |
$21.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.84
|
| Rate for Payer: Cash Price |
$14.00
|
| Rate for Payer: Cigna Commercial |
$23.24
|
| Rate for Payer: First Health Commercial |
$26.60
|
| Rate for Payer: Humana Commercial |
$23.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.64
|
| Rate for Payer: Ohio Health Group HMO |
$21.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.68
|
| Rate for Payer: PHCS Commercial |
$26.88
|
| Rate for Payer: United Healthcare All Payer |
$24.64
|
|
|
ULORIC 40MG TABLET
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
NDC 64764091830
|
| Hospital Charge Code |
25001621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.64 |
| Max. Negotiated Rate |
$26.88 |
| Rate for Payer: Aetna Commercial |
$21.56
|
| Rate for Payer: Anthem Medicaid |
$9.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.84
|
| Rate for Payer: Cash Price |
$14.00
|
| Rate for Payer: Cigna Commercial |
$23.24
|
| Rate for Payer: First Health Commercial |
$26.60
|
| Rate for Payer: Humana Commercial |
$23.80
|
| Rate for Payer: Humana KY Medicaid |
$9.63
|
| Rate for Payer: Kentucky WC Medicaid |
$9.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.64
|
| Rate for Payer: Ohio Health Group HMO |
$21.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.68
|
| Rate for Payer: PHCS Commercial |
$26.88
|
| Rate for Payer: United Healthcare All Payer |
$24.64
|
|
|
ULORIC 80MG TABLET
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
NDC 64764067730
|
| Hospital Charge Code |
25001622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.64 |
| Max. Negotiated Rate |
$26.88 |
| Rate for Payer: Aetna Commercial |
$21.56
|
| Rate for Payer: Anthem Medicaid |
$9.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.84
|
| Rate for Payer: Cash Price |
$14.00
|
| Rate for Payer: Cigna Commercial |
$23.24
|
| Rate for Payer: First Health Commercial |
$26.60
|
| Rate for Payer: Humana Commercial |
$23.80
|
| Rate for Payer: Humana KY Medicaid |
$9.63
|
| Rate for Payer: Kentucky WC Medicaid |
$9.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.64
|
| Rate for Payer: Ohio Health Group HMO |
$21.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.68
|
| Rate for Payer: PHCS Commercial |
$26.88
|
| Rate for Payer: United Healthcare All Payer |
$24.64
|
|
|
ULORIC 80MG TABLET
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 64764067730
|
| Hospital Charge Code |
25001622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.64 |
| Max. Negotiated Rate |
$26.88 |
| Rate for Payer: Aetna Commercial |
$21.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.84
|
| Rate for Payer: Cash Price |
$14.00
|
| Rate for Payer: Cigna Commercial |
$23.24
|
| Rate for Payer: First Health Commercial |
$26.60
|
| Rate for Payer: Humana Commercial |
$23.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.64
|
| Rate for Payer: Ohio Health Group HMO |
$21.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.68
|
| Rate for Payer: PHCS Commercial |
$26.88
|
| Rate for Payer: United Healthcare All Payer |
$24.64
|
|
|
ULTANE (SEVOFLURANE) PER 10ML
|
Facility
|
OP
|
$280.00
|
|
|
Service Code
|
NDC 10019065164
|
| Hospital Charge Code |
25003549
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.40 |
| Max. Negotiated Rate |
$268.80 |
| Rate for Payer: Aetna Commercial |
$215.60
|
| Rate for Payer: Anthem Medicaid |
$96.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$218.40
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cigna Commercial |
$232.40
|
| Rate for Payer: First Health Commercial |
$266.00
|
| Rate for Payer: Humana Commercial |
$238.00
|
| Rate for Payer: Humana KY Medicaid |
$96.29
|
| Rate for Payer: Kentucky WC Medicaid |
$97.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$229.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$206.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$84.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$98.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$246.40
|
| Rate for Payer: Ohio Health Group HMO |
$210.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$56.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$86.80
|
| Rate for Payer: PHCS Commercial |
$268.80
|
| Rate for Payer: United Healthcare All Payer |
$246.40
|
|
|
ULTANE (SEVOFLURANE) PER 10ML
|
Facility
|
IP
|
$280.00
|
|
|
Service Code
|
NDC 10019065164
|
| Hospital Charge Code |
25003549
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.40 |
| Max. Negotiated Rate |
$268.80 |
| Rate for Payer: Aetna Commercial |
$215.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$218.40
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cigna Commercial |
$232.40
|
| Rate for Payer: First Health Commercial |
$266.00
|
| Rate for Payer: Humana Commercial |
$238.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$229.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$206.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$84.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$246.40
|
| Rate for Payer: Ohio Health Group HMO |
$210.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$56.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$86.80
|
| Rate for Payer: PHCS Commercial |
$268.80
|
| Rate for Payer: United Healthcare All Payer |
$246.40
|
|
|
ULTIMA ACETABULAR ROOF RING 40
|
Facility
|
IP
|
$8,390.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,090.79 |
| Max. Negotiated Rate |
$8,055.07 |
| Rate for Payer: Aetna Commercial |
$6,460.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,544.75
|
| Rate for Payer: Cash Price |
$4,195.35
|
| Rate for Payer: Cigna Commercial |
$6,964.28
|
| Rate for Payer: First Health Commercial |
$7,971.16
|
| Rate for Payer: Humana Commercial |
$7,132.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,880.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,192.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,517.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,383.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,293.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,678.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,090.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,601.12
|
| Rate for Payer: PHCS Commercial |
$8,055.07
|
| Rate for Payer: United Healthcare All Payer |
$7,383.82
|
|
|
ULTIMA ACETABULAR ROOF RING 40
|
Facility
|
OP
|
$8,390.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,090.79 |
| Max. Negotiated Rate |
$8,055.07 |
| Rate for Payer: Aetna Commercial |
$6,460.84
|
| Rate for Payer: Anthem Medicaid |
$2,885.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,544.75
|
| Rate for Payer: Cash Price |
$4,195.35
|
| Rate for Payer: Cigna Commercial |
$6,964.28
|
| Rate for Payer: First Health Commercial |
$7,971.16
|
| Rate for Payer: Humana Commercial |
$7,132.10
|
| Rate for Payer: Humana KY Medicaid |
$2,885.56
|
| Rate for Payer: Kentucky WC Medicaid |
$2,914.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,880.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,192.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,517.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,943.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,383.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,293.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,678.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,090.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,601.12
|
| Rate for Payer: PHCS Commercial |
$8,055.07
|
| Rate for Payer: United Healthcare All Payer |
$7,383.82
|
|
|
ULTIMA ACETABULAR ROOF RING 42
|
Facility
|
IP
|
$8,390.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,090.79 |
| Max. Negotiated Rate |
$8,055.07 |
| Rate for Payer: Aetna Commercial |
$6,460.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,544.75
|
| Rate for Payer: Cash Price |
$4,195.35
|
| Rate for Payer: Cigna Commercial |
$6,964.28
|
| Rate for Payer: First Health Commercial |
$7,971.16
|
| Rate for Payer: Humana Commercial |
$7,132.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,880.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,192.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,517.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,383.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,293.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,678.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,090.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,601.12
|
| Rate for Payer: PHCS Commercial |
$8,055.07
|
| Rate for Payer: United Healthcare All Payer |
$7,383.82
|
|
|
ULTIMA ACETABULAR ROOF RING 42
|
Facility
|
OP
|
$8,390.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,090.79 |
| Max. Negotiated Rate |
$8,055.07 |
| Rate for Payer: Aetna Commercial |
$6,460.84
|
| Rate for Payer: Anthem Medicaid |
$2,885.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,544.75
|
| Rate for Payer: Cash Price |
$4,195.35
|
| Rate for Payer: Cigna Commercial |
$6,964.28
|
| Rate for Payer: First Health Commercial |
$7,971.16
|
| Rate for Payer: Humana Commercial |
$7,132.10
|
| Rate for Payer: Humana KY Medicaid |
$2,885.56
|
| Rate for Payer: Kentucky WC Medicaid |
$2,914.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,880.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,192.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,517.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,943.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,383.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,293.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,678.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,090.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,601.12
|
| Rate for Payer: PHCS Commercial |
$8,055.07
|
| Rate for Payer: United Healthcare All Payer |
$7,383.82
|
|
|
ULTIMA ACETABULAR ROOF RING 44
|
Facility
|
IP
|
$8,390.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,090.79 |
| Max. Negotiated Rate |
$8,055.07 |
| Rate for Payer: Aetna Commercial |
$6,460.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,544.75
|
| Rate for Payer: Cash Price |
$4,195.35
|
| Rate for Payer: Cigna Commercial |
$6,964.28
|
| Rate for Payer: First Health Commercial |
$7,971.16
|
| Rate for Payer: Humana Commercial |
$7,132.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,880.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,192.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,517.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,383.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,293.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,678.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,090.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,601.12
|
| Rate for Payer: PHCS Commercial |
$8,055.07
|
| Rate for Payer: United Healthcare All Payer |
$7,383.82
|
|
|
ULTIMA ACETABULAR ROOF RING 44
|
Facility
|
OP
|
$8,390.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,090.79 |
| Max. Negotiated Rate |
$8,055.07 |
| Rate for Payer: Aetna Commercial |
$6,460.84
|
| Rate for Payer: Anthem Medicaid |
$2,885.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,544.75
|
| Rate for Payer: Cash Price |
$4,195.35
|
| Rate for Payer: Cigna Commercial |
$6,964.28
|
| Rate for Payer: First Health Commercial |
$7,971.16
|
| Rate for Payer: Humana Commercial |
$7,132.10
|
| Rate for Payer: Humana KY Medicaid |
$2,885.56
|
| Rate for Payer: Kentucky WC Medicaid |
$2,914.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,880.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,192.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,517.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,943.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,383.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,293.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,678.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,090.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,601.12
|
| Rate for Payer: PHCS Commercial |
$8,055.07
|
| Rate for Payer: United Healthcare All Payer |
$7,383.82
|
|
|
ULTIMA ACETABULAR ROOF RING 46
|
Facility
|
OP
|
$8,390.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,090.79 |
| Max. Negotiated Rate |
$8,055.07 |
| Rate for Payer: Aetna Commercial |
$6,460.84
|
| Rate for Payer: Anthem Medicaid |
$2,885.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,544.75
|
| Rate for Payer: Cash Price |
$4,195.35
|
| Rate for Payer: Cigna Commercial |
$6,964.28
|
| Rate for Payer: First Health Commercial |
$7,971.16
|
| Rate for Payer: Humana Commercial |
$7,132.10
|
| Rate for Payer: Humana KY Medicaid |
$2,885.56
|
| Rate for Payer: Kentucky WC Medicaid |
$2,914.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,880.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,192.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,517.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,943.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,383.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,293.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,678.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,090.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,601.12
|
| Rate for Payer: PHCS Commercial |
$8,055.07
|
| Rate for Payer: United Healthcare All Payer |
$7,383.82
|
|
|
ULTIMA ACETABULAR ROOF RING 46
|
Facility
|
IP
|
$8,390.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,090.79 |
| Max. Negotiated Rate |
$8,055.07 |
| Rate for Payer: Aetna Commercial |
$6,460.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,544.75
|
| Rate for Payer: Cash Price |
$4,195.35
|
| Rate for Payer: Cigna Commercial |
$6,964.28
|
| Rate for Payer: First Health Commercial |
$7,971.16
|
| Rate for Payer: Humana Commercial |
$7,132.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,880.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,192.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,517.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,383.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,293.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,678.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,090.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,601.12
|
| Rate for Payer: PHCS Commercial |
$8,055.07
|
| Rate for Payer: United Healthcare All Payer |
$7,383.82
|
|
|
ULTIMA ACETABULAR ROOF RING 48
|
Facility
|
OP
|
$8,390.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,090.79 |
| Max. Negotiated Rate |
$8,055.07 |
| Rate for Payer: Aetna Commercial |
$6,460.84
|
| Rate for Payer: Anthem Medicaid |
$2,885.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,544.75
|
| Rate for Payer: Cash Price |
$4,195.35
|
| Rate for Payer: Cigna Commercial |
$6,964.28
|
| Rate for Payer: First Health Commercial |
$7,971.16
|
| Rate for Payer: Humana Commercial |
$7,132.10
|
| Rate for Payer: Humana KY Medicaid |
$2,885.56
|
| Rate for Payer: Kentucky WC Medicaid |
$2,914.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,880.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,192.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,517.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,943.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,383.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,293.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,678.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,090.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,601.12
|
| Rate for Payer: PHCS Commercial |
$8,055.07
|
| Rate for Payer: United Healthcare All Payer |
$7,383.82
|
|
|
ULTIMA ACETABULAR ROOF RING 48
|
Facility
|
IP
|
$8,390.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,090.79 |
| Max. Negotiated Rate |
$8,055.07 |
| Rate for Payer: Aetna Commercial |
$6,460.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,544.75
|
| Rate for Payer: Cash Price |
$4,195.35
|
| Rate for Payer: Cigna Commercial |
$6,964.28
|
| Rate for Payer: First Health Commercial |
$7,971.16
|
| Rate for Payer: Humana Commercial |
$7,132.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,880.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,192.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,517.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,383.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,293.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,678.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,090.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,601.12
|
| Rate for Payer: PHCS Commercial |
$8,055.07
|
| Rate for Payer: United Healthcare All Payer |
$7,383.82
|
|
|
ULTIMA ACETABULAR ROOF RING 50
|
Facility
|
OP
|
$8,390.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,090.79 |
| Max. Negotiated Rate |
$8,055.07 |
| Rate for Payer: Aetna Commercial |
$6,460.84
|
| Rate for Payer: Anthem Medicaid |
$2,885.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,544.75
|
| Rate for Payer: Cash Price |
$4,195.35
|
| Rate for Payer: Cigna Commercial |
$6,964.28
|
| Rate for Payer: First Health Commercial |
$7,971.16
|
| Rate for Payer: Humana Commercial |
$7,132.10
|
| Rate for Payer: Humana KY Medicaid |
$2,885.56
|
| Rate for Payer: Kentucky WC Medicaid |
$2,914.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,880.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,192.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,517.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,943.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,383.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,293.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,678.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,090.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,601.12
|
| Rate for Payer: PHCS Commercial |
$8,055.07
|
| Rate for Payer: United Healthcare All Payer |
$7,383.82
|
|
|
ULTIMA ACETABULAR ROOF RING 50
|
Facility
|
IP
|
$8,390.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,090.79 |
| Max. Negotiated Rate |
$8,055.07 |
| Rate for Payer: Aetna Commercial |
$6,460.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,544.75
|
| Rate for Payer: Cash Price |
$4,195.35
|
| Rate for Payer: Cigna Commercial |
$6,964.28
|
| Rate for Payer: First Health Commercial |
$7,971.16
|
| Rate for Payer: Humana Commercial |
$7,132.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,880.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,192.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,517.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,383.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,293.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,678.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,090.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,601.12
|
| Rate for Payer: PHCS Commercial |
$8,055.07
|
| Rate for Payer: United Healthcare All Payer |
$7,383.82
|
|
|
ULTIMA ACETABULAR ROOF RING 52
|
Facility
|
IP
|
$8,390.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,090.79 |
| Max. Negotiated Rate |
$8,055.07 |
| Rate for Payer: Aetna Commercial |
$6,460.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,544.75
|
| Rate for Payer: Cash Price |
$4,195.35
|
| Rate for Payer: Cigna Commercial |
$6,964.28
|
| Rate for Payer: First Health Commercial |
$7,971.16
|
| Rate for Payer: Humana Commercial |
$7,132.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,880.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,192.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,517.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,383.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,293.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,678.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,090.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,601.12
|
| Rate for Payer: PHCS Commercial |
$8,055.07
|
| Rate for Payer: United Healthcare All Payer |
$7,383.82
|
|
|
ULTIMA ACETABULAR ROOF RING 52
|
Facility
|
OP
|
$8,390.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,090.79 |
| Max. Negotiated Rate |
$8,055.07 |
| Rate for Payer: Aetna Commercial |
$6,460.84
|
| Rate for Payer: Anthem Medicaid |
$2,885.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,544.75
|
| Rate for Payer: Cash Price |
$4,195.35
|
| Rate for Payer: Cigna Commercial |
$6,964.28
|
| Rate for Payer: First Health Commercial |
$7,971.16
|
| Rate for Payer: Humana Commercial |
$7,132.10
|
| Rate for Payer: Humana KY Medicaid |
$2,885.56
|
| Rate for Payer: Kentucky WC Medicaid |
$2,914.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,880.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,192.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,517.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,943.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,383.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,293.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,678.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,090.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,601.12
|
| Rate for Payer: PHCS Commercial |
$8,055.07
|
| Rate for Payer: United Healthcare All Payer |
$7,383.82
|
|
|
ULTIMA ACETABULAR ROOF RING 54
|
Facility
|
OP
|
$8,390.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,090.79 |
| Max. Negotiated Rate |
$8,055.07 |
| Rate for Payer: Aetna Commercial |
$6,460.84
|
| Rate for Payer: Anthem Medicaid |
$2,885.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,544.75
|
| Rate for Payer: Cash Price |
$4,195.35
|
| Rate for Payer: Cigna Commercial |
$6,964.28
|
| Rate for Payer: First Health Commercial |
$7,971.16
|
| Rate for Payer: Humana Commercial |
$7,132.10
|
| Rate for Payer: Humana KY Medicaid |
$2,885.56
|
| Rate for Payer: Kentucky WC Medicaid |
$2,914.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,880.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,192.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,517.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,943.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,383.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,293.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,678.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,090.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,601.12
|
| Rate for Payer: PHCS Commercial |
$8,055.07
|
| Rate for Payer: United Healthcare All Payer |
$7,383.82
|
|
|
ULTIMA ACETABULAR ROOF RING 54
|
Facility
|
IP
|
$8,390.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,090.79 |
| Max. Negotiated Rate |
$8,055.07 |
| Rate for Payer: Aetna Commercial |
$6,460.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,544.75
|
| Rate for Payer: Cash Price |
$4,195.35
|
| Rate for Payer: Cigna Commercial |
$6,964.28
|
| Rate for Payer: First Health Commercial |
$7,971.16
|
| Rate for Payer: Humana Commercial |
$7,132.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,880.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,192.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,517.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,383.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,293.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,678.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,090.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,601.12
|
| Rate for Payer: PHCS Commercial |
$8,055.07
|
| Rate for Payer: United Healthcare All Payer |
$7,383.82
|
|
