|
ULTIMA UNIPOLAR HEAD 48MM
|
Facility
|
IP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 48MM
|
Facility
|
OP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem Medicaid |
$1,210.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Humana KY Medicaid |
$1,210.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,222.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,234.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 49MM
|
Facility
|
IP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 49MM
|
Facility
|
OP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem Medicaid |
$1,210.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Humana KY Medicaid |
$1,210.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,222.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,234.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 50MM
|
Facility
|
IP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 50MM
|
Facility
|
OP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem Medicaid |
$1,210.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Humana KY Medicaid |
$1,210.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,222.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,234.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 51MM
|
Facility
|
IP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 51MM
|
Facility
|
OP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem Medicaid |
$1,210.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Humana KY Medicaid |
$1,210.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,222.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,234.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 52MM
|
Facility
|
IP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 52MM
|
Facility
|
OP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem Medicaid |
$1,210.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Humana KY Medicaid |
$1,210.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,222.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,234.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 53MM
|
Facility
|
OP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem Medicaid |
$1,210.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Humana KY Medicaid |
$1,210.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,222.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,234.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 53MM
|
Facility
|
IP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 54MM
|
Facility
|
OP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem Medicaid |
$1,210.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Humana KY Medicaid |
$1,210.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,222.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,234.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 54MM
|
Facility
|
IP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 55MM
|
Facility
|
IP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 55MM
|
Facility
|
OP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem Medicaid |
$1,210.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Humana KY Medicaid |
$1,210.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,222.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,234.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 56MM
|
Facility
|
OP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem Medicaid |
$1,210.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Humana KY Medicaid |
$1,210.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,222.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,234.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 56MM
|
Facility
|
IP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 57MM
|
Facility
|
OP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem Medicaid |
$1,210.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Humana KY Medicaid |
$1,210.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,222.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,234.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 57MM
|
Facility
|
IP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 58MM
|
Facility
|
IP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 58MM
|
Facility
|
OP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem Medicaid |
$1,210.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Humana KY Medicaid |
$1,210.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,222.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,234.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 60MM
|
Facility
|
IP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 60MM
|
Facility
|
OP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem Medicaid |
$1,210.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Humana KY Medicaid |
$1,210.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,222.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,234.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR HEAD 63MM
|
Facility
|
OP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem Medicaid |
$1,210.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Humana KY Medicaid |
$1,210.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,222.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,234.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
