|
ULTANE (SEVOFLURANE) PER 10ML
|
Facility
|
IP
|
$280.00
|
|
|
Service Code
|
NDC 10019065164
|
| Hospital Charge Code |
25003549
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$84.00 |
| 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 |
$224.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$193.20
|
| Rate for Payer: PHCS Commercial |
$268.80
|
| Rate for Payer: United Healthcare All Payer |
$246.40
|
|
|
ULTANE (SEVOFLURANE) PER 10ML
|
Facility
|
OP
|
$280.00
|
|
|
Service Code
|
NDC 10019065164
|
| Hospital Charge Code |
25003549
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$84.00 |
| 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 |
$224.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$193.20
|
| Rate for Payer: PHCS Commercial |
$268.80
|
| Rate for Payer: United Healthcare All Payer |
$246.40
|
|
|
ULTIMA ACETABULAR ROOF RING 40
|
Facility
|
OP
|
$8,590.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.21 |
| Max. Negotiated Rate |
$8,247.07 |
| Rate for Payer: Aetna Commercial |
$6,614.84
|
| Rate for Payer: Anthem Medicaid |
$2,954.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,700.75
|
| Rate for Payer: Cash Price |
$4,295.35
|
| Rate for Payer: Cigna Commercial |
$7,130.28
|
| Rate for Payer: First Health Commercial |
$8,161.16
|
| Rate for Payer: Humana Commercial |
$7,302.10
|
| Rate for Payer: Humana KY Medicaid |
$2,954.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,984.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,044.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,339.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,577.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,013.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,559.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,443.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,872.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,473.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,927.58
|
| Rate for Payer: PHCS Commercial |
$8,247.07
|
| Rate for Payer: United Healthcare All Payer |
$7,559.82
|
|
|
ULTIMA ACETABULAR ROOF RING 40
|
Facility
|
IP
|
$8,590.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.21 |
| Max. Negotiated Rate |
$8,247.07 |
| Rate for Payer: Aetna Commercial |
$6,614.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,700.75
|
| Rate for Payer: Cash Price |
$4,295.35
|
| Rate for Payer: Cigna Commercial |
$7,130.28
|
| Rate for Payer: First Health Commercial |
$8,161.16
|
| Rate for Payer: Humana Commercial |
$7,302.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,044.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,339.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,577.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,559.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,443.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,872.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,473.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,927.58
|
| Rate for Payer: PHCS Commercial |
$8,247.07
|
| Rate for Payer: United Healthcare All Payer |
$7,559.82
|
|
|
ULTIMA ACETABULAR ROOF RING 42
|
Facility
|
IP
|
$8,590.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.21 |
| Max. Negotiated Rate |
$8,247.07 |
| Rate for Payer: Aetna Commercial |
$6,614.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,700.75
|
| Rate for Payer: Cash Price |
$4,295.35
|
| Rate for Payer: Cigna Commercial |
$7,130.28
|
| Rate for Payer: First Health Commercial |
$8,161.16
|
| Rate for Payer: Humana Commercial |
$7,302.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,044.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,339.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,577.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,559.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,443.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,872.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,473.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,927.58
|
| Rate for Payer: PHCS Commercial |
$8,247.07
|
| Rate for Payer: United Healthcare All Payer |
$7,559.82
|
|
|
ULTIMA ACETABULAR ROOF RING 42
|
Facility
|
OP
|
$8,590.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.21 |
| Max. Negotiated Rate |
$8,247.07 |
| Rate for Payer: Aetna Commercial |
$6,614.84
|
| Rate for Payer: Anthem Medicaid |
$2,954.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,700.75
|
| Rate for Payer: Cash Price |
$4,295.35
|
| Rate for Payer: Cigna Commercial |
$7,130.28
|
| Rate for Payer: First Health Commercial |
$8,161.16
|
| Rate for Payer: Humana Commercial |
$7,302.10
|
| Rate for Payer: Humana KY Medicaid |
$2,954.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,984.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,044.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,339.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,577.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,013.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,559.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,443.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,872.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,473.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,927.58
|
| Rate for Payer: PHCS Commercial |
$8,247.07
|
| Rate for Payer: United Healthcare All Payer |
$7,559.82
|
|
|
ULTIMA ACETABULAR ROOF RING 44
|
Facility
|
OP
|
$8,590.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.21 |
| Max. Negotiated Rate |
$8,247.07 |
| Rate for Payer: Aetna Commercial |
$6,614.84
|
| Rate for Payer: Anthem Medicaid |
$2,954.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,700.75
|
| Rate for Payer: Cash Price |
$4,295.35
|
| Rate for Payer: Cigna Commercial |
$7,130.28
|
| Rate for Payer: First Health Commercial |
$8,161.16
|
| Rate for Payer: Humana Commercial |
$7,302.10
|
| Rate for Payer: Humana KY Medicaid |
$2,954.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,984.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,044.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,339.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,577.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,013.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,559.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,443.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,872.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,473.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,927.58
|
| Rate for Payer: PHCS Commercial |
$8,247.07
|
| Rate for Payer: United Healthcare All Payer |
$7,559.82
|
|
|
ULTIMA ACETABULAR ROOF RING 44
|
Facility
|
IP
|
$8,590.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.21 |
| Max. Negotiated Rate |
$8,247.07 |
| Rate for Payer: Aetna Commercial |
$6,614.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,700.75
|
| Rate for Payer: Cash Price |
$4,295.35
|
| Rate for Payer: Cigna Commercial |
$7,130.28
|
| Rate for Payer: First Health Commercial |
$8,161.16
|
| Rate for Payer: Humana Commercial |
$7,302.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,044.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,339.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,577.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,559.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,443.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,872.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,473.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,927.58
|
| Rate for Payer: PHCS Commercial |
$8,247.07
|
| Rate for Payer: United Healthcare All Payer |
$7,559.82
|
|
|
ULTIMA ACETABULAR ROOF RING 46
|
Facility
|
IP
|
$8,590.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.21 |
| Max. Negotiated Rate |
$8,247.07 |
| Rate for Payer: Aetna Commercial |
$6,614.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,700.75
|
| Rate for Payer: Cash Price |
$4,295.35
|
| Rate for Payer: Cigna Commercial |
$7,130.28
|
| Rate for Payer: First Health Commercial |
$8,161.16
|
| Rate for Payer: Humana Commercial |
$7,302.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,044.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,339.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,577.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,559.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,443.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,872.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,473.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,927.58
|
| Rate for Payer: PHCS Commercial |
$8,247.07
|
| Rate for Payer: United Healthcare All Payer |
$7,559.82
|
|
|
ULTIMA ACETABULAR ROOF RING 46
|
Facility
|
OP
|
$8,590.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.21 |
| Max. Negotiated Rate |
$8,247.07 |
| Rate for Payer: Aetna Commercial |
$6,614.84
|
| Rate for Payer: Anthem Medicaid |
$2,954.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,700.75
|
| Rate for Payer: Cash Price |
$4,295.35
|
| Rate for Payer: Cigna Commercial |
$7,130.28
|
| Rate for Payer: First Health Commercial |
$8,161.16
|
| Rate for Payer: Humana Commercial |
$7,302.10
|
| Rate for Payer: Humana KY Medicaid |
$2,954.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,984.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,044.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,339.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,577.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,013.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,559.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,443.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,872.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,473.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,927.58
|
| Rate for Payer: PHCS Commercial |
$8,247.07
|
| Rate for Payer: United Healthcare All Payer |
$7,559.82
|
|
|
ULTIMA ACETABULAR ROOF RING 48
|
Facility
|
OP
|
$8,590.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.21 |
| Max. Negotiated Rate |
$8,247.07 |
| Rate for Payer: Aetna Commercial |
$6,614.84
|
| Rate for Payer: Anthem Medicaid |
$2,954.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,700.75
|
| Rate for Payer: Cash Price |
$4,295.35
|
| Rate for Payer: Cigna Commercial |
$7,130.28
|
| Rate for Payer: First Health Commercial |
$8,161.16
|
| Rate for Payer: Humana Commercial |
$7,302.10
|
| Rate for Payer: Humana KY Medicaid |
$2,954.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,984.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,044.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,339.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,577.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,013.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,559.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,443.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,872.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,473.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,927.58
|
| Rate for Payer: PHCS Commercial |
$8,247.07
|
| Rate for Payer: United Healthcare All Payer |
$7,559.82
|
|
|
ULTIMA ACETABULAR ROOF RING 48
|
Facility
|
IP
|
$8,590.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.21 |
| Max. Negotiated Rate |
$8,247.07 |
| Rate for Payer: Aetna Commercial |
$6,614.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,700.75
|
| Rate for Payer: Cash Price |
$4,295.35
|
| Rate for Payer: Cigna Commercial |
$7,130.28
|
| Rate for Payer: First Health Commercial |
$8,161.16
|
| Rate for Payer: Humana Commercial |
$7,302.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,044.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,339.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,577.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,559.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,443.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,872.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,473.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,927.58
|
| Rate for Payer: PHCS Commercial |
$8,247.07
|
| Rate for Payer: United Healthcare All Payer |
$7,559.82
|
|
|
ULTIMA ACETABULAR ROOF RING 50
|
Facility
|
IP
|
$8,590.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.21 |
| Max. Negotiated Rate |
$8,247.07 |
| Rate for Payer: Aetna Commercial |
$6,614.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,700.75
|
| Rate for Payer: Cash Price |
$4,295.35
|
| Rate for Payer: Cigna Commercial |
$7,130.28
|
| Rate for Payer: First Health Commercial |
$8,161.16
|
| Rate for Payer: Humana Commercial |
$7,302.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,044.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,339.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,577.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,559.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,443.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,872.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,473.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,927.58
|
| Rate for Payer: PHCS Commercial |
$8,247.07
|
| Rate for Payer: United Healthcare All Payer |
$7,559.82
|
|
|
ULTIMA ACETABULAR ROOF RING 50
|
Facility
|
OP
|
$8,590.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.21 |
| Max. Negotiated Rate |
$8,247.07 |
| Rate for Payer: Aetna Commercial |
$6,614.84
|
| Rate for Payer: Anthem Medicaid |
$2,954.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,700.75
|
| Rate for Payer: Cash Price |
$4,295.35
|
| Rate for Payer: Cigna Commercial |
$7,130.28
|
| Rate for Payer: First Health Commercial |
$8,161.16
|
| Rate for Payer: Humana Commercial |
$7,302.10
|
| Rate for Payer: Humana KY Medicaid |
$2,954.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,984.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,044.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,339.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,577.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,013.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,559.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,443.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,872.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,473.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,927.58
|
| Rate for Payer: PHCS Commercial |
$8,247.07
|
| Rate for Payer: United Healthcare All Payer |
$7,559.82
|
|
|
ULTIMA ACETABULAR ROOF RING 52
|
Facility
|
OP
|
$8,590.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.21 |
| Max. Negotiated Rate |
$8,247.07 |
| Rate for Payer: Aetna Commercial |
$6,614.84
|
| Rate for Payer: Anthem Medicaid |
$2,954.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,700.75
|
| Rate for Payer: Cash Price |
$4,295.35
|
| Rate for Payer: Cigna Commercial |
$7,130.28
|
| Rate for Payer: First Health Commercial |
$8,161.16
|
| Rate for Payer: Humana Commercial |
$7,302.10
|
| Rate for Payer: Humana KY Medicaid |
$2,954.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,984.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,044.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,339.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,577.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,013.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,559.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,443.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,872.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,473.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,927.58
|
| Rate for Payer: PHCS Commercial |
$8,247.07
|
| Rate for Payer: United Healthcare All Payer |
$7,559.82
|
|
|
ULTIMA ACETABULAR ROOF RING 52
|
Facility
|
IP
|
$8,590.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.21 |
| Max. Negotiated Rate |
$8,247.07 |
| Rate for Payer: Aetna Commercial |
$6,614.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,700.75
|
| Rate for Payer: Cash Price |
$4,295.35
|
| Rate for Payer: Cigna Commercial |
$7,130.28
|
| Rate for Payer: First Health Commercial |
$8,161.16
|
| Rate for Payer: Humana Commercial |
$7,302.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,044.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,339.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,577.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,559.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,443.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,872.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,473.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,927.58
|
| Rate for Payer: PHCS Commercial |
$8,247.07
|
| Rate for Payer: United Healthcare All Payer |
$7,559.82
|
|
|
ULTIMA ACETABULAR ROOF RING 54
|
Facility
|
IP
|
$8,590.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.21 |
| Max. Negotiated Rate |
$8,247.07 |
| Rate for Payer: Aetna Commercial |
$6,614.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,700.75
|
| Rate for Payer: Cash Price |
$4,295.35
|
| Rate for Payer: Cigna Commercial |
$7,130.28
|
| Rate for Payer: First Health Commercial |
$8,161.16
|
| Rate for Payer: Humana Commercial |
$7,302.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,044.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,339.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,577.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,559.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,443.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,872.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,473.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,927.58
|
| Rate for Payer: PHCS Commercial |
$8,247.07
|
| Rate for Payer: United Healthcare All Payer |
$7,559.82
|
|
|
ULTIMA ACETABULAR ROOF RING 54
|
Facility
|
OP
|
$8,590.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.21 |
| Max. Negotiated Rate |
$8,247.07 |
| Rate for Payer: Aetna Commercial |
$6,614.84
|
| Rate for Payer: Anthem Medicaid |
$2,954.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,700.75
|
| Rate for Payer: Cash Price |
$4,295.35
|
| Rate for Payer: Cigna Commercial |
$7,130.28
|
| Rate for Payer: First Health Commercial |
$8,161.16
|
| Rate for Payer: Humana Commercial |
$7,302.10
|
| Rate for Payer: Humana KY Medicaid |
$2,954.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,984.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,044.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,339.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,577.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,013.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,559.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,443.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,872.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,473.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,927.58
|
| Rate for Payer: PHCS Commercial |
$8,247.07
|
| Rate for Payer: United Healthcare All Payer |
$7,559.82
|
|
|
ULTIMA ACETABULAR ROOF RING 56
|
Facility
|
IP
|
$8,590.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.21 |
| Max. Negotiated Rate |
$8,247.07 |
| Rate for Payer: Aetna Commercial |
$6,614.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,700.75
|
| Rate for Payer: Cash Price |
$4,295.35
|
| Rate for Payer: Cigna Commercial |
$7,130.28
|
| Rate for Payer: First Health Commercial |
$8,161.16
|
| Rate for Payer: Humana Commercial |
$7,302.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,044.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,339.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,577.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,559.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,443.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,872.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,473.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,927.58
|
| Rate for Payer: PHCS Commercial |
$8,247.07
|
| Rate for Payer: United Healthcare All Payer |
$7,559.82
|
|
|
ULTIMA ACETABULAR ROOF RING 56
|
Facility
|
OP
|
$8,590.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.21 |
| Max. Negotiated Rate |
$8,247.07 |
| Rate for Payer: Aetna Commercial |
$6,614.84
|
| Rate for Payer: Anthem Medicaid |
$2,954.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,700.75
|
| Rate for Payer: Cash Price |
$4,295.35
|
| Rate for Payer: Cigna Commercial |
$7,130.28
|
| Rate for Payer: First Health Commercial |
$8,161.16
|
| Rate for Payer: Humana Commercial |
$7,302.10
|
| Rate for Payer: Humana KY Medicaid |
$2,954.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,984.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,044.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,339.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,577.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,013.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,559.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,443.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,872.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,473.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,927.58
|
| Rate for Payer: PHCS Commercial |
$8,247.07
|
| Rate for Payer: United Healthcare All Payer |
$7,559.82
|
|
|
ULTIMA ACETABULAR ROOF RING 58
|
Facility
|
IP
|
$8,590.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.21 |
| Max. Negotiated Rate |
$8,247.07 |
| Rate for Payer: Aetna Commercial |
$6,614.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,700.75
|
| Rate for Payer: Cash Price |
$4,295.35
|
| Rate for Payer: Cigna Commercial |
$7,130.28
|
| Rate for Payer: First Health Commercial |
$8,161.16
|
| Rate for Payer: Humana Commercial |
$7,302.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,044.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,339.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,577.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,559.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,443.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,872.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,473.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,927.58
|
| Rate for Payer: PHCS Commercial |
$8,247.07
|
| Rate for Payer: United Healthcare All Payer |
$7,559.82
|
|
|
ULTIMA ACETABULAR ROOF RING 58
|
Facility
|
OP
|
$8,590.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.21 |
| Max. Negotiated Rate |
$8,247.07 |
| Rate for Payer: Aetna Commercial |
$6,614.84
|
| Rate for Payer: Anthem Medicaid |
$2,954.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,700.75
|
| Rate for Payer: Cash Price |
$4,295.35
|
| Rate for Payer: Cigna Commercial |
$7,130.28
|
| Rate for Payer: First Health Commercial |
$8,161.16
|
| Rate for Payer: Humana Commercial |
$7,302.10
|
| Rate for Payer: Humana KY Medicaid |
$2,954.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,984.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,044.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,339.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,577.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,013.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,559.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,443.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,872.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,473.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,927.58
|
| Rate for Payer: PHCS Commercial |
$8,247.07
|
| Rate for Payer: United Healthcare All Payer |
$7,559.82
|
|
|
ULTIMA ACETABULAR ROOF RING 60
|
Facility
|
IP
|
$8,590.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.21 |
| Max. Negotiated Rate |
$8,247.07 |
| Rate for Payer: Aetna Commercial |
$6,614.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,700.75
|
| Rate for Payer: Cash Price |
$4,295.35
|
| Rate for Payer: Cigna Commercial |
$7,130.28
|
| Rate for Payer: First Health Commercial |
$8,161.16
|
| Rate for Payer: Humana Commercial |
$7,302.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,044.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,339.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,577.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,559.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,443.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,872.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,473.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,927.58
|
| Rate for Payer: PHCS Commercial |
$8,247.07
|
| Rate for Payer: United Healthcare All Payer |
$7,559.82
|
|
|
ULTIMA ACETABULAR ROOF RING 60
|
Facility
|
OP
|
$8,590.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.21 |
| Max. Negotiated Rate |
$8,247.07 |
| Rate for Payer: Aetna Commercial |
$6,614.84
|
| Rate for Payer: Anthem Medicaid |
$2,954.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,700.75
|
| Rate for Payer: Cash Price |
$4,295.35
|
| Rate for Payer: Cigna Commercial |
$7,130.28
|
| Rate for Payer: First Health Commercial |
$8,161.16
|
| Rate for Payer: Humana Commercial |
$7,302.10
|
| Rate for Payer: Humana KY Medicaid |
$2,954.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,984.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,044.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,339.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,577.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,013.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,559.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,443.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,872.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,473.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,927.58
|
| Rate for Payer: PHCS Commercial |
$8,247.07
|
| Rate for Payer: United Healthcare All Payer |
$7,559.82
|
|
|
ULTIMA ACETABULAR ROOF RING 62
|
Facility
|
OP
|
$8,590.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,577.21 |
| Max. Negotiated Rate |
$8,247.07 |
| Rate for Payer: Aetna Commercial |
$6,614.84
|
| Rate for Payer: Anthem Medicaid |
$2,954.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,700.75
|
| Rate for Payer: Cash Price |
$4,295.35
|
| Rate for Payer: Cigna Commercial |
$7,130.28
|
| Rate for Payer: First Health Commercial |
$8,161.16
|
| Rate for Payer: Humana Commercial |
$7,302.10
|
| Rate for Payer: Humana KY Medicaid |
$2,954.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,984.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,044.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,339.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,577.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,013.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,559.82
|
| Rate for Payer: Ohio Health Group HMO |
$6,443.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,872.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,473.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,927.58
|
| Rate for Payer: PHCS Commercial |
$8,247.07
|
| Rate for Payer: United Healthcare All Payer |
$7,559.82
|
|
