|
ULTIMA ACETABULAR ROOF RING 56
|
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 56
|
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 58
|
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 58
|
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 60
|
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 60
|
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 62
|
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 62
|
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 UNIPOLAR ADAP SLEEV 0MM
|
Facility
|
OP
|
$3,084.84
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$401.03 |
| Max. Negotiated Rate |
$2,961.45 |
| Rate for Payer: Aetna Commercial |
$2,375.33
|
| Rate for Payer: Anthem Medicaid |
$1,060.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,406.18
|
| Rate for Payer: Cash Price |
$1,542.42
|
| Rate for Payer: Cigna Commercial |
$2,560.42
|
| Rate for Payer: First Health Commercial |
$2,930.60
|
| Rate for Payer: Humana Commercial |
$2,622.11
|
| Rate for Payer: Humana KY Medicaid |
$1,060.88
|
| Rate for Payer: Kentucky WC Medicaid |
$1,071.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,529.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,276.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$925.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,082.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,714.66
|
| Rate for Payer: Ohio Health Group HMO |
$2,313.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$616.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$401.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$956.30
|
| Rate for Payer: PHCS Commercial |
$2,961.45
|
| Rate for Payer: United Healthcare All Payer |
$2,714.66
|
|
|
ULTIMA UNIPOLAR ADAP SLEEV 0MM
|
Facility
|
IP
|
$3,084.84
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$401.03 |
| Max. Negotiated Rate |
$2,961.45 |
| Rate for Payer: Aetna Commercial |
$2,375.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,406.18
|
| Rate for Payer: Cash Price |
$1,542.42
|
| Rate for Payer: Cigna Commercial |
$2,560.42
|
| Rate for Payer: First Health Commercial |
$2,930.60
|
| Rate for Payer: Humana Commercial |
$2,622.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,529.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,276.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$925.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,714.66
|
| Rate for Payer: Ohio Health Group HMO |
$2,313.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$616.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$401.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$956.30
|
| Rate for Payer: PHCS Commercial |
$2,961.45
|
| Rate for Payer: United Healthcare All Payer |
$2,714.66
|
|
|
ULTIMA UNIPOLAR ADAP SLEEV 6MM
|
Facility
|
OP
|
$3,084.84
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$401.03 |
| Max. Negotiated Rate |
$2,961.45 |
| Rate for Payer: Aetna Commercial |
$2,375.33
|
| Rate for Payer: Anthem Medicaid |
$1,060.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,406.18
|
| Rate for Payer: Cash Price |
$1,542.42
|
| Rate for Payer: Cigna Commercial |
$2,560.42
|
| Rate for Payer: First Health Commercial |
$2,930.60
|
| Rate for Payer: Humana Commercial |
$2,622.11
|
| Rate for Payer: Humana KY Medicaid |
$1,060.88
|
| Rate for Payer: Kentucky WC Medicaid |
$1,071.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,529.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,276.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$925.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,082.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,714.66
|
| Rate for Payer: Ohio Health Group HMO |
$2,313.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$616.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$401.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$956.30
|
| Rate for Payer: PHCS Commercial |
$2,961.45
|
| Rate for Payer: United Healthcare All Payer |
$2,714.66
|
|
|
ULTIMA UNIPOLAR ADAP SLEEV 6MM
|
Facility
|
IP
|
$3,084.84
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$401.03 |
| Max. Negotiated Rate |
$2,961.45 |
| Rate for Payer: Aetna Commercial |
$2,375.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,406.18
|
| Rate for Payer: Cash Price |
$1,542.42
|
| Rate for Payer: Cigna Commercial |
$2,560.42
|
| Rate for Payer: First Health Commercial |
$2,930.60
|
| Rate for Payer: Humana Commercial |
$2,622.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,529.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,276.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$925.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,714.66
|
| Rate for Payer: Ohio Health Group HMO |
$2,313.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$616.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$401.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$956.30
|
| Rate for Payer: PHCS Commercial |
$2,961.45
|
| Rate for Payer: United Healthcare All Payer |
$2,714.66
|
|
|
ULTIMA UNIPOLAR HEAD 38MM
|
Facility
|
IP
|
$3,617.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$470.28 |
| Max. Negotiated Rate |
$3,472.80 |
| Rate for Payer: Aetna Commercial |
$2,785.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,821.65
|
| Rate for Payer: Cash Price |
$1,808.75
|
| Rate for Payer: Cigna Commercial |
$3,002.52
|
| Rate for Payer: First Health Commercial |
$3,436.62
|
| Rate for Payer: Humana Commercial |
$3,074.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,966.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,669.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,085.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,183.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,713.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$723.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$470.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,121.42
|
| Rate for Payer: PHCS Commercial |
$3,472.80
|
| Rate for Payer: United Healthcare All Payer |
$3,183.40
|
|
|
ULTIMA UNIPOLAR HEAD 38MM
|
Facility
|
OP
|
$3,617.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$470.28 |
| Max. Negotiated Rate |
$3,472.80 |
| Rate for Payer: Aetna Commercial |
$2,785.48
|
| Rate for Payer: Anthem Medicaid |
$1,244.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,821.65
|
| Rate for Payer: Cash Price |
$1,808.75
|
| Rate for Payer: Cigna Commercial |
$3,002.52
|
| Rate for Payer: First Health Commercial |
$3,436.62
|
| Rate for Payer: Humana Commercial |
$3,074.88
|
| Rate for Payer: Humana KY Medicaid |
$1,244.06
|
| Rate for Payer: Kentucky WC Medicaid |
$1,256.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,966.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,669.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,085.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,269.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,183.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,713.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$723.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$470.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,121.42
|
| Rate for Payer: PHCS Commercial |
$3,472.80
|
| Rate for Payer: United Healthcare All Payer |
$3,183.40
|
|
|
ULTIMA UNIPOLAR HEAD 39MM
|
Facility
|
OP
|
$3,617.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$470.28 |
| Max. Negotiated Rate |
$3,472.80 |
| Rate for Payer: Aetna Commercial |
$2,785.48
|
| Rate for Payer: Anthem Medicaid |
$1,244.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,821.65
|
| Rate for Payer: Cash Price |
$1,808.75
|
| Rate for Payer: Cigna Commercial |
$3,002.52
|
| Rate for Payer: First Health Commercial |
$3,436.62
|
| Rate for Payer: Humana Commercial |
$3,074.88
|
| Rate for Payer: Humana KY Medicaid |
$1,244.06
|
| Rate for Payer: Kentucky WC Medicaid |
$1,256.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,966.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,669.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,085.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,269.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,183.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,713.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$723.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$470.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,121.42
|
| Rate for Payer: PHCS Commercial |
$3,472.80
|
| Rate for Payer: United Healthcare All Payer |
$3,183.40
|
|
|
ULTIMA UNIPOLAR HEAD 39MM
|
Facility
|
IP
|
$3,617.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$470.28 |
| Max. Negotiated Rate |
$3,472.80 |
| Rate for Payer: Aetna Commercial |
$2,785.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,821.65
|
| Rate for Payer: Cash Price |
$1,808.75
|
| Rate for Payer: Cigna Commercial |
$3,002.52
|
| Rate for Payer: First Health Commercial |
$3,436.62
|
| Rate for Payer: Humana Commercial |
$3,074.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,966.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,669.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,085.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,183.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,713.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$723.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$470.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,121.42
|
| Rate for Payer: PHCS Commercial |
$3,472.80
|
| Rate for Payer: United Healthcare All Payer |
$3,183.40
|
|
|
ULTIMA UNIPOLAR HEAD 40MM
|
Facility
|
IP
|
$3,617.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$470.28 |
| Max. Negotiated Rate |
$3,472.80 |
| Rate for Payer: Aetna Commercial |
$2,785.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,821.65
|
| Rate for Payer: Cash Price |
$1,808.75
|
| Rate for Payer: Cigna Commercial |
$3,002.52
|
| Rate for Payer: First Health Commercial |
$3,436.62
|
| Rate for Payer: Humana Commercial |
$3,074.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,966.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,669.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,085.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,183.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,713.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$723.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$470.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,121.42
|
| Rate for Payer: PHCS Commercial |
$3,472.80
|
| Rate for Payer: United Healthcare All Payer |
$3,183.40
|
|
|
ULTIMA UNIPOLAR HEAD 40MM
|
Facility
|
OP
|
$3,617.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$470.28 |
| Max. Negotiated Rate |
$3,472.80 |
| Rate for Payer: Aetna Commercial |
$2,785.48
|
| Rate for Payer: Anthem Medicaid |
$1,244.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,821.65
|
| Rate for Payer: Cash Price |
$1,808.75
|
| Rate for Payer: Cigna Commercial |
$3,002.52
|
| Rate for Payer: First Health Commercial |
$3,436.62
|
| Rate for Payer: Humana Commercial |
$3,074.88
|
| Rate for Payer: Humana KY Medicaid |
$1,244.06
|
| Rate for Payer: Kentucky WC Medicaid |
$1,256.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,966.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,669.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,085.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,269.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,183.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,713.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$723.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$470.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,121.42
|
| Rate for Payer: PHCS Commercial |
$3,472.80
|
| Rate for Payer: United Healthcare All Payer |
$3,183.40
|
|
|
ULTIMA UNIPOLAR HEAD 41MM
|
Facility
|
OP
|
$3,617.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$470.28 |
| Max. Negotiated Rate |
$3,472.80 |
| Rate for Payer: Aetna Commercial |
$2,785.48
|
| Rate for Payer: Anthem Medicaid |
$1,244.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,821.65
|
| Rate for Payer: Cash Price |
$1,808.75
|
| Rate for Payer: Cigna Commercial |
$3,002.52
|
| Rate for Payer: First Health Commercial |
$3,436.62
|
| Rate for Payer: Humana Commercial |
$3,074.88
|
| Rate for Payer: Humana KY Medicaid |
$1,244.06
|
| Rate for Payer: Kentucky WC Medicaid |
$1,256.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,966.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,669.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,085.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,269.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,183.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,713.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$723.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$470.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,121.42
|
| Rate for Payer: PHCS Commercial |
$3,472.80
|
| Rate for Payer: United Healthcare All Payer |
$3,183.40
|
|
|
ULTIMA UNIPOLAR HEAD 41MM
|
Facility
|
IP
|
$3,617.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$470.28 |
| Max. Negotiated Rate |
$3,472.80 |
| Rate for Payer: Aetna Commercial |
$2,785.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,821.65
|
| Rate for Payer: Cash Price |
$1,808.75
|
| Rate for Payer: Cigna Commercial |
$3,002.52
|
| Rate for Payer: First Health Commercial |
$3,436.62
|
| Rate for Payer: Humana Commercial |
$3,074.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,966.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,669.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,085.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,183.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,713.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$723.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$470.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,121.42
|
| Rate for Payer: PHCS Commercial |
$3,472.80
|
| Rate for Payer: United Healthcare All Payer |
$3,183.40
|
|
|
ULTIMA UNIPOLAR HEAD 42MM
|
Facility
|
IP
|
$3,617.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$470.28 |
| Max. Negotiated Rate |
$3,472.80 |
| Rate for Payer: Aetna Commercial |
$2,785.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,821.65
|
| Rate for Payer: Cash Price |
$1,808.75
|
| Rate for Payer: Cigna Commercial |
$3,002.52
|
| Rate for Payer: First Health Commercial |
$3,436.62
|
| Rate for Payer: Humana Commercial |
$3,074.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,966.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,669.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,085.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,183.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,713.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$723.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$470.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,121.42
|
| Rate for Payer: PHCS Commercial |
$3,472.80
|
| Rate for Payer: United Healthcare All Payer |
$3,183.40
|
|
|
ULTIMA UNIPOLAR HEAD 42MM
|
Facility
|
OP
|
$3,617.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$470.28 |
| Max. Negotiated Rate |
$3,472.80 |
| Rate for Payer: Aetna Commercial |
$2,785.48
|
| Rate for Payer: Anthem Medicaid |
$1,244.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,821.65
|
| Rate for Payer: Cash Price |
$1,808.75
|
| Rate for Payer: Cigna Commercial |
$3,002.52
|
| Rate for Payer: First Health Commercial |
$3,436.62
|
| Rate for Payer: Humana Commercial |
$3,074.88
|
| Rate for Payer: Humana KY Medicaid |
$1,244.06
|
| Rate for Payer: Kentucky WC Medicaid |
$1,256.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,966.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,669.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,085.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,269.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,183.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,713.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$723.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$470.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,121.42
|
| Rate for Payer: PHCS Commercial |
$3,472.80
|
| Rate for Payer: United Healthcare All Payer |
$3,183.40
|
|
|
ULTIMA UNIPOLAR HEAD 43MM
|
Facility
|
OP
|
$3,617.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$470.28 |
| Max. Negotiated Rate |
$3,472.80 |
| Rate for Payer: Aetna Commercial |
$2,785.48
|
| Rate for Payer: Anthem Medicaid |
$1,244.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,821.65
|
| Rate for Payer: Cash Price |
$1,808.75
|
| Rate for Payer: Cigna Commercial |
$3,002.52
|
| Rate for Payer: First Health Commercial |
$3,436.62
|
| Rate for Payer: Humana Commercial |
$3,074.88
|
| Rate for Payer: Humana KY Medicaid |
$1,244.06
|
| Rate for Payer: Kentucky WC Medicaid |
$1,256.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,966.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,669.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,085.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,269.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,183.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,713.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$723.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$470.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,121.42
|
| Rate for Payer: PHCS Commercial |
$3,472.80
|
| Rate for Payer: United Healthcare All Payer |
$3,183.40
|
|
|
ULTIMA UNIPOLAR HEAD 43MM
|
Facility
|
IP
|
$3,617.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$470.28 |
| Max. Negotiated Rate |
$3,472.80 |
| Rate for Payer: Aetna Commercial |
$2,785.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,821.65
|
| Rate for Payer: Cash Price |
$1,808.75
|
| Rate for Payer: Cigna Commercial |
$3,002.52
|
| Rate for Payer: First Health Commercial |
$3,436.62
|
| Rate for Payer: Humana Commercial |
$3,074.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,966.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,669.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,085.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,183.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,713.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$723.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$470.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,121.42
|
| Rate for Payer: PHCS Commercial |
$3,472.80
|
| Rate for Payer: United Healthcare All Payer |
$3,183.40
|
|
|
ULTIMA UNIPOLAR HEAD 44MM
|
Facility
|
IP
|
$3,617.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$470.28 |
| Max. Negotiated Rate |
$3,472.80 |
| Rate for Payer: Aetna Commercial |
$2,785.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,821.65
|
| Rate for Payer: Cash Price |
$1,808.75
|
| Rate for Payer: Cigna Commercial |
$3,002.52
|
| Rate for Payer: First Health Commercial |
$3,436.62
|
| Rate for Payer: Humana Commercial |
$3,074.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,966.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,669.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,085.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,183.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,713.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$723.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$470.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,121.42
|
| Rate for Payer: PHCS Commercial |
$3,472.80
|
| Rate for Payer: United Healthcare All Payer |
$3,183.40
|
|
