|
ULTIMA UNIPOLAR HEAD 57MM
|
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 57MM
|
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 58MM
|
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 58MM
|
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 60MM
|
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 60MM
|
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 63MM
|
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 63MM
|
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 SLEEVE 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 SLEEVE 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 SLEEVE 10MM
|
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 SLEEVE 10MM
|
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 SLEEVE -3MM
|
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 SLEEVE -3MM
|
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 SLEEVE 5MM
|
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 SLEEVE 5MM
|
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 UNIPOLR ADAP SLEEV 12MM
|
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 UNIPOLR ADAP SLEEV 12MM
|
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
|
|
|
ULTIVA 1000MCG
|
Facility
|
IP
|
$148.55
|
|
|
Service Code
|
NDC 143939101
|
| Hospital Charge Code |
25003870
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.31 |
| Max. Negotiated Rate |
$142.61 |
| Rate for Payer: Aetna Commercial |
$114.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$115.87
|
| Rate for Payer: Cash Price |
$74.28
|
| Rate for Payer: Cigna Commercial |
$123.30
|
| Rate for Payer: First Health Commercial |
$141.12
|
| Rate for Payer: Humana Commercial |
$126.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$121.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$109.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$130.72
|
| Rate for Payer: Ohio Health Group HMO |
$111.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.05
|
| Rate for Payer: PHCS Commercial |
$142.61
|
| Rate for Payer: United Healthcare All Payer |
$130.72
|
|
|
ULTIVA 1000MCG
|
Facility
|
OP
|
$148.55
|
|
|
Service Code
|
NDC 143939101
|
| Hospital Charge Code |
25003870
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.31 |
| Max. Negotiated Rate |
$142.61 |
| Rate for Payer: Aetna Commercial |
$114.38
|
| Rate for Payer: Anthem Medicaid |
$51.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$115.87
|
| Rate for Payer: Cash Price |
$74.28
|
| Rate for Payer: Cigna Commercial |
$123.30
|
| Rate for Payer: First Health Commercial |
$141.12
|
| Rate for Payer: Humana Commercial |
$126.27
|
| Rate for Payer: Humana KY Medicaid |
$51.09
|
| Rate for Payer: Kentucky WC Medicaid |
$51.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$121.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$109.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$52.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$130.72
|
| Rate for Payer: Ohio Health Group HMO |
$111.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.05
|
| Rate for Payer: PHCS Commercial |
$142.61
|
| Rate for Payer: United Healthcare All Payer |
$130.72
|
|
|
ULTIVA 1,000MCG/100ML ANE
|
Facility
|
IP
|
$136.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.71 |
| Max. Negotiated Rate |
$130.80 |
| Rate for Payer: Aetna Commercial |
$104.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$106.28
|
| Rate for Payer: Cash Price |
$68.12
|
| Rate for Payer: Cigna Commercial |
$113.09
|
| Rate for Payer: First Health Commercial |
$129.44
|
| Rate for Payer: Humana Commercial |
$115.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$111.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$100.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$119.90
|
| Rate for Payer: Ohio Health Group HMO |
$102.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.24
|
| Rate for Payer: PHCS Commercial |
$130.80
|
| Rate for Payer: United Healthcare All Payer |
$119.90
|
|
|
ULTIVA 1,000MCG/100ML ANE
|
Facility
|
OP
|
$136.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.71 |
| Max. Negotiated Rate |
$130.80 |
| Rate for Payer: Aetna Commercial |
$104.91
|
| Rate for Payer: Anthem Medicaid |
$46.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$106.28
|
| Rate for Payer: Cash Price |
$68.12
|
| Rate for Payer: Cigna Commercial |
$113.09
|
| Rate for Payer: First Health Commercial |
$129.44
|
| Rate for Payer: Humana Commercial |
$115.81
|
| Rate for Payer: Humana KY Medicaid |
$46.86
|
| Rate for Payer: Kentucky WC Medicaid |
$47.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$111.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$100.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$47.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$119.90
|
| Rate for Payer: Ohio Health Group HMO |
$102.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.24
|
| Rate for Payer: PHCS Commercial |
$130.80
|
| Rate for Payer: United Healthcare All Payer |
$119.90
|
|
|
ULTIVA 1,000MCG/50ML ANE
|
Facility
|
IP
|
$136.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004216
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.71 |
| Max. Negotiated Rate |
$130.80 |
| Rate for Payer: Aetna Commercial |
$104.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$106.28
|
| Rate for Payer: Cash Price |
$68.12
|
| Rate for Payer: Cigna Commercial |
$113.09
|
| Rate for Payer: First Health Commercial |
$129.44
|
| Rate for Payer: Humana Commercial |
$115.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$111.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$100.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$119.90
|
| Rate for Payer: Ohio Health Group HMO |
$102.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.24
|
| Rate for Payer: PHCS Commercial |
$130.80
|
| Rate for Payer: United Healthcare All Payer |
$119.90
|
|
|
ULTIVA 1,000MCG/50ML ANE
|
Facility
|
OP
|
$136.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004216
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.71 |
| Max. Negotiated Rate |
$130.80 |
| Rate for Payer: Aetna Commercial |
$104.91
|
| Rate for Payer: Anthem Medicaid |
$46.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$106.28
|
| Rate for Payer: Cash Price |
$68.12
|
| Rate for Payer: Cigna Commercial |
$113.09
|
| Rate for Payer: First Health Commercial |
$129.44
|
| Rate for Payer: Humana Commercial |
$115.81
|
| Rate for Payer: Humana KY Medicaid |
$46.86
|
| Rate for Payer: Kentucky WC Medicaid |
$47.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$111.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$100.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$47.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$119.90
|
| Rate for Payer: Ohio Health Group HMO |
$102.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.24
|
| Rate for Payer: PHCS Commercial |
$130.80
|
| Rate for Payer: United Healthcare All Payer |
$119.90
|
|
|
ULTIVA 9REMIFENTANIL 1MG/3ML
|
Facility
|
IP
|
$330.25
|
|
|
Service Code
|
NDC 143939101
|
| Hospital Charge Code |
25003550
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.93 |
| Max. Negotiated Rate |
$317.04 |
| Rate for Payer: Aetna Commercial |
$254.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$257.60
|
| Rate for Payer: Cash Price |
$165.12
|
| Rate for Payer: Cigna Commercial |
$274.11
|
| Rate for Payer: First Health Commercial |
$313.74
|
| Rate for Payer: Humana Commercial |
$280.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$270.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$243.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$99.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$290.62
|
| Rate for Payer: Ohio Health Group HMO |
$247.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$66.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$102.38
|
| Rate for Payer: PHCS Commercial |
$317.04
|
| Rate for Payer: United Healthcare All Payer |
$290.62
|
|
