|
EQUINOXE REP PLATE 4.5MM
|
Facility
|
OP
|
$5,675.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$737.82 |
| Max. Negotiated Rate |
$5,448.48 |
| Rate for Payer: Aetna Commercial |
$4,370.14
|
| Rate for Payer: Anthem Medicaid |
$1,951.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,426.89
|
| Rate for Payer: Cash Price |
$2,837.75
|
| Rate for Payer: Cigna Commercial |
$4,710.66
|
| Rate for Payer: First Health Commercial |
$5,391.72
|
| Rate for Payer: Humana Commercial |
$4,824.18
|
| Rate for Payer: Humana KY Medicaid |
$1,951.80
|
| Rate for Payer: Kentucky WC Medicaid |
$1,971.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,653.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,188.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,702.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,990.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,994.44
|
| Rate for Payer: Ohio Health Group HMO |
$4,256.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,135.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$737.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,759.40
|
| Rate for Payer: PHCS Commercial |
$5,448.48
|
| Rate for Payer: United Healthcare All Payer |
$4,994.44
|
|
|
EQUINOXE REP PLATE 4.5MM
|
Facility
|
IP
|
$5,675.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$737.82 |
| Max. Negotiated Rate |
$5,448.48 |
| Rate for Payer: Aetna Commercial |
$4,370.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,426.89
|
| Rate for Payer: Cash Price |
$2,837.75
|
| Rate for Payer: Cigna Commercial |
$4,710.66
|
| Rate for Payer: First Health Commercial |
$5,391.72
|
| Rate for Payer: Humana Commercial |
$4,824.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,653.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,188.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,702.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,994.44
|
| Rate for Payer: Ohio Health Group HMO |
$4,256.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,135.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$737.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,759.40
|
| Rate for Payer: PHCS Commercial |
$5,448.48
|
| Rate for Payer: United Healthcare All Payer |
$4,994.44
|
|
|
EQUINOXE REV ADAPT PLATE +0
|
Facility
|
OP
|
$11,366.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,477.64 |
| Max. Negotiated Rate |
$10,911.84 |
| Rate for Payer: Aetna Commercial |
$8,752.20
|
| Rate for Payer: Anthem Medicaid |
$3,908.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,865.87
|
| Rate for Payer: Cash Price |
$5,683.25
|
| Rate for Payer: Cigna Commercial |
$9,434.20
|
| Rate for Payer: First Health Commercial |
$10,798.18
|
| Rate for Payer: Humana Commercial |
$9,661.52
|
| Rate for Payer: Humana KY Medicaid |
$3,908.94
|
| Rate for Payer: Kentucky WC Medicaid |
$3,948.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,320.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,388.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,409.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,987.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,002.52
|
| Rate for Payer: Ohio Health Group HMO |
$8,524.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,273.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,477.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,523.62
|
| Rate for Payer: PHCS Commercial |
$10,911.84
|
| Rate for Payer: United Healthcare All Payer |
$10,002.52
|
|
|
EQUINOXE REV ADAPT PLATE +0
|
Facility
|
IP
|
$11,366.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,477.64 |
| Max. Negotiated Rate |
$10,911.84 |
| Rate for Payer: Aetna Commercial |
$8,752.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,865.87
|
| Rate for Payer: Cash Price |
$5,683.25
|
| Rate for Payer: Cigna Commercial |
$9,434.20
|
| Rate for Payer: First Health Commercial |
$10,798.18
|
| Rate for Payer: Humana Commercial |
$9,661.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,320.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,388.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,409.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,002.52
|
| Rate for Payer: Ohio Health Group HMO |
$8,524.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,273.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,477.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,523.62
|
| Rate for Payer: PHCS Commercial |
$10,911.84
|
| Rate for Payer: United Healthcare All Payer |
$10,002.52
|
|
|
EQUINOXE REV ADAPT PLATE +10
|
Facility
|
OP
|
$13,647.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,774.21 |
| Max. Negotiated Rate |
$13,101.84 |
| Rate for Payer: Aetna Commercial |
$10,508.77
|
| Rate for Payer: Anthem Medicaid |
$4,693.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,645.24
|
| Rate for Payer: Cash Price |
$6,823.88
|
| Rate for Payer: Cigna Commercial |
$11,327.63
|
| Rate for Payer: First Health Commercial |
$12,965.36
|
| Rate for Payer: Humana Commercial |
$11,600.59
|
| Rate for Payer: Humana KY Medicaid |
$4,693.46
|
| Rate for Payer: Kentucky WC Medicaid |
$4,741.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,191.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,072.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,094.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,787.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,010.02
|
| Rate for Payer: Ohio Health Group HMO |
$10,235.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,729.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,774.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,230.80
|
| Rate for Payer: PHCS Commercial |
$13,101.84
|
| Rate for Payer: United Healthcare All Payer |
$12,010.02
|
|
|
EQUINOXE REV ADAPT PLATE +10
|
Facility
|
IP
|
$13,647.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,774.21 |
| Max. Negotiated Rate |
$13,101.84 |
| Rate for Payer: Aetna Commercial |
$10,508.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,645.24
|
| Rate for Payer: Cash Price |
$6,823.88
|
| Rate for Payer: Cigna Commercial |
$11,327.63
|
| Rate for Payer: First Health Commercial |
$12,965.36
|
| Rate for Payer: Humana Commercial |
$11,600.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,191.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,072.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,094.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,010.02
|
| Rate for Payer: Ohio Health Group HMO |
$10,235.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,729.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,774.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,230.80
|
| Rate for Payer: PHCS Commercial |
$13,101.84
|
| Rate for Payer: United Healthcare All Payer |
$12,010.02
|
|
|
EQUINOXE REV ADAPT PLATE +5
|
Facility
|
OP
|
$11,366.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,477.64 |
| Max. Negotiated Rate |
$10,911.84 |
| Rate for Payer: Aetna Commercial |
$8,752.20
|
| Rate for Payer: Anthem Medicaid |
$3,908.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,865.87
|
| Rate for Payer: Cash Price |
$5,683.25
|
| Rate for Payer: Cigna Commercial |
$9,434.20
|
| Rate for Payer: First Health Commercial |
$10,798.18
|
| Rate for Payer: Humana Commercial |
$9,661.52
|
| Rate for Payer: Humana KY Medicaid |
$3,908.94
|
| Rate for Payer: Kentucky WC Medicaid |
$3,948.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,320.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,388.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,409.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,987.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,002.52
|
| Rate for Payer: Ohio Health Group HMO |
$8,524.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,273.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,477.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,523.62
|
| Rate for Payer: PHCS Commercial |
$10,911.84
|
| Rate for Payer: United Healthcare All Payer |
$10,002.52
|
|
|
EQUINOXE REV ADAPT PLATE +5
|
Facility
|
IP
|
$11,366.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,477.64 |
| Max. Negotiated Rate |
$10,911.84 |
| Rate for Payer: Aetna Commercial |
$8,752.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,865.87
|
| Rate for Payer: Cash Price |
$5,683.25
|
| Rate for Payer: Cigna Commercial |
$9,434.20
|
| Rate for Payer: First Health Commercial |
$10,798.18
|
| Rate for Payer: Humana Commercial |
$9,661.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,320.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,388.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,409.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,002.52
|
| Rate for Payer: Ohio Health Group HMO |
$8,524.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,273.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,477.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,523.62
|
| Rate for Payer: PHCS Commercial |
$10,911.84
|
| Rate for Payer: United Healthcare All Payer |
$10,002.52
|
|
|
EQUINOXE REV GLENOID PLATE
|
Facility
|
OP
|
$9,494.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,234.23 |
| Max. Negotiated Rate |
$9,114.34 |
| Rate for Payer: Aetna Commercial |
$7,310.46
|
| Rate for Payer: Anthem Medicaid |
$3,265.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,405.40
|
| Rate for Payer: Cash Price |
$4,747.05
|
| Rate for Payer: Cigna Commercial |
$7,880.10
|
| Rate for Payer: First Health Commercial |
$9,019.40
|
| Rate for Payer: Humana Commercial |
$8,069.98
|
| Rate for Payer: Humana KY Medicaid |
$3,265.02
|
| Rate for Payer: Kentucky WC Medicaid |
$3,298.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,785.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,006.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,848.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,330.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,354.81
|
| Rate for Payer: Ohio Health Group HMO |
$7,120.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,898.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,234.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,943.17
|
| Rate for Payer: PHCS Commercial |
$9,114.34
|
| Rate for Payer: United Healthcare All Payer |
$8,354.81
|
|
|
EQUINOXE REV GLENOID PLATE
|
Facility
|
IP
|
$9,494.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,234.23 |
| Max. Negotiated Rate |
$9,114.34 |
| Rate for Payer: Aetna Commercial |
$7,310.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,405.40
|
| Rate for Payer: Cash Price |
$4,747.05
|
| Rate for Payer: Cigna Commercial |
$7,880.10
|
| Rate for Payer: First Health Commercial |
$9,019.40
|
| Rate for Payer: Humana Commercial |
$8,069.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,785.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,006.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,848.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,354.81
|
| Rate for Payer: Ohio Health Group HMO |
$7,120.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,898.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,234.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,943.17
|
| Rate for Payer: PHCS Commercial |
$9,114.34
|
| Rate for Payer: United Healthcare All Payer |
$8,354.81
|
|
|
EQUINOXE REV GLENOSHPERE 38MM
|
Facility
|
IP
|
$9,019.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,172.55 |
| Max. Negotiated Rate |
$8,658.82 |
| Rate for Payer: Aetna Commercial |
$6,945.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,035.29
|
| Rate for Payer: Cash Price |
$4,509.80
|
| Rate for Payer: Cigna Commercial |
$7,486.27
|
| Rate for Payer: First Health Commercial |
$8,568.62
|
| Rate for Payer: Humana Commercial |
$7,666.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,396.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,656.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,705.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,937.25
|
| Rate for Payer: Ohio Health Group HMO |
$6,764.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,803.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,172.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,796.08
|
| Rate for Payer: PHCS Commercial |
$8,658.82
|
| Rate for Payer: United Healthcare All Payer |
$7,937.25
|
|
|
EQUINOXE REV GLENOSHPERE 38MM
|
Facility
|
OP
|
$9,019.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,172.55 |
| Max. Negotiated Rate |
$8,658.82 |
| Rate for Payer: Aetna Commercial |
$6,945.09
|
| Rate for Payer: Anthem Medicaid |
$3,101.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,035.29
|
| Rate for Payer: Cash Price |
$4,509.80
|
| Rate for Payer: Cigna Commercial |
$7,486.27
|
| Rate for Payer: First Health Commercial |
$8,568.62
|
| Rate for Payer: Humana Commercial |
$7,666.66
|
| Rate for Payer: Humana KY Medicaid |
$3,101.84
|
| Rate for Payer: Kentucky WC Medicaid |
$3,133.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,396.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,656.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,705.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,164.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,937.25
|
| Rate for Payer: Ohio Health Group HMO |
$6,764.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,803.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,172.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,796.08
|
| Rate for Payer: PHCS Commercial |
$8,658.82
|
| Rate for Payer: United Healthcare All Payer |
$7,937.25
|
|
|
EQUINOXE REV GLENOSHPERE 42MM
|
Facility
|
IP
|
$9,019.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,172.55 |
| Max. Negotiated Rate |
$8,658.82 |
| Rate for Payer: Aetna Commercial |
$6,945.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,035.29
|
| Rate for Payer: Cash Price |
$4,509.80
|
| Rate for Payer: Cigna Commercial |
$7,486.27
|
| Rate for Payer: First Health Commercial |
$8,568.62
|
| Rate for Payer: Humana Commercial |
$7,666.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,396.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,656.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,705.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,937.25
|
| Rate for Payer: Ohio Health Group HMO |
$6,764.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,803.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,172.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,796.08
|
| Rate for Payer: PHCS Commercial |
$8,658.82
|
| Rate for Payer: United Healthcare All Payer |
$7,937.25
|
|
|
EQUINOXE REV GLENOSHPERE 42MM
|
Facility
|
OP
|
$9,019.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,172.55 |
| Max. Negotiated Rate |
$8,658.82 |
| Rate for Payer: Aetna Commercial |
$6,945.09
|
| Rate for Payer: Anthem Medicaid |
$3,101.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,035.29
|
| Rate for Payer: Cash Price |
$4,509.80
|
| Rate for Payer: Cigna Commercial |
$7,486.27
|
| Rate for Payer: First Health Commercial |
$8,568.62
|
| Rate for Payer: Humana Commercial |
$7,666.66
|
| Rate for Payer: Humana KY Medicaid |
$3,101.84
|
| Rate for Payer: Kentucky WC Medicaid |
$3,133.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,396.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,656.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,705.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,164.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,937.25
|
| Rate for Payer: Ohio Health Group HMO |
$6,764.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,803.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,172.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,796.08
|
| Rate for Payer: PHCS Commercial |
$8,658.82
|
| Rate for Payer: United Healthcare All Payer |
$7,937.25
|
|
|
EQUINOXE REV GLENOSHPERE 46MM
|
Facility
|
IP
|
$9,019.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,172.55 |
| Max. Negotiated Rate |
$8,658.82 |
| Rate for Payer: Aetna Commercial |
$6,945.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,035.29
|
| Rate for Payer: Cash Price |
$4,509.80
|
| Rate for Payer: Cigna Commercial |
$7,486.27
|
| Rate for Payer: First Health Commercial |
$8,568.62
|
| Rate for Payer: Humana Commercial |
$7,666.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,396.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,656.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,705.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,937.25
|
| Rate for Payer: Ohio Health Group HMO |
$6,764.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,803.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,172.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,796.08
|
| Rate for Payer: PHCS Commercial |
$8,658.82
|
| Rate for Payer: United Healthcare All Payer |
$7,937.25
|
|
|
EQUINOXE REV GLENOSHPERE 46MM
|
Facility
|
OP
|
$9,019.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,172.55 |
| Max. Negotiated Rate |
$8,658.82 |
| Rate for Payer: Aetna Commercial |
$6,945.09
|
| Rate for Payer: Anthem Medicaid |
$3,101.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,035.29
|
| Rate for Payer: Cash Price |
$4,509.80
|
| Rate for Payer: Cigna Commercial |
$7,486.27
|
| Rate for Payer: First Health Commercial |
$8,568.62
|
| Rate for Payer: Humana Commercial |
$7,666.66
|
| Rate for Payer: Humana KY Medicaid |
$3,101.84
|
| Rate for Payer: Kentucky WC Medicaid |
$3,133.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,396.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,656.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,705.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,164.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,937.25
|
| Rate for Payer: Ohio Health Group HMO |
$6,764.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,803.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,172.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,796.08
|
| Rate for Payer: PHCS Commercial |
$8,658.82
|
| Rate for Payer: United Healthcare All Payer |
$7,937.25
|
|
|
EQUINOXE REV HUM LINER 38MM +0
|
Facility
|
OP
|
$5,598.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$727.80 |
| Max. Negotiated Rate |
$5,374.56 |
| Rate for Payer: Aetna Commercial |
$4,310.84
|
| Rate for Payer: Anthem Medicaid |
$1,925.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,366.83
|
| Rate for Payer: Cash Price |
$2,799.25
|
| Rate for Payer: Cigna Commercial |
$4,646.76
|
| Rate for Payer: First Health Commercial |
$5,318.58
|
| Rate for Payer: Humana Commercial |
$4,758.72
|
| Rate for Payer: Humana KY Medicaid |
$1,925.32
|
| Rate for Payer: Kentucky WC Medicaid |
$1,944.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,590.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,131.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,679.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,963.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,926.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,198.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,119.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$727.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,735.54
|
| Rate for Payer: PHCS Commercial |
$5,374.56
|
| Rate for Payer: United Healthcare All Payer |
$4,926.68
|
|
|
EQUINOXE REV HUM LINER 38MM +0
|
Facility
|
IP
|
$5,598.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$727.80 |
| Max. Negotiated Rate |
$5,374.56 |
| Rate for Payer: Aetna Commercial |
$4,310.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,366.83
|
| Rate for Payer: Cash Price |
$2,799.25
|
| Rate for Payer: Cigna Commercial |
$4,646.76
|
| Rate for Payer: First Health Commercial |
$5,318.58
|
| Rate for Payer: Humana Commercial |
$4,758.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,590.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,131.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,679.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,926.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,198.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,119.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$727.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,735.54
|
| Rate for Payer: PHCS Commercial |
$5,374.56
|
| Rate for Payer: United Healthcare All Payer |
$4,926.68
|
|
|
EQUINOXE REV HUM LINER 42MM +0
|
Facility
|
IP
|
$5,598.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$727.80 |
| Max. Negotiated Rate |
$5,374.56 |
| Rate for Payer: Aetna Commercial |
$4,310.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,366.83
|
| Rate for Payer: Cash Price |
$2,799.25
|
| Rate for Payer: Cigna Commercial |
$4,646.76
|
| Rate for Payer: First Health Commercial |
$5,318.58
|
| Rate for Payer: Humana Commercial |
$4,758.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,590.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,131.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,679.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,926.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,198.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,119.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$727.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,735.54
|
| Rate for Payer: PHCS Commercial |
$5,374.56
|
| Rate for Payer: United Healthcare All Payer |
$4,926.68
|
|
|
EQUINOXE REV HUM LINER 42MM +0
|
Facility
|
OP
|
$5,598.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$727.80 |
| Max. Negotiated Rate |
$5,374.56 |
| Rate for Payer: Aetna Commercial |
$4,310.84
|
| Rate for Payer: Anthem Medicaid |
$1,925.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,366.83
|
| Rate for Payer: Cash Price |
$2,799.25
|
| Rate for Payer: Cigna Commercial |
$4,646.76
|
| Rate for Payer: First Health Commercial |
$5,318.58
|
| Rate for Payer: Humana Commercial |
$4,758.72
|
| Rate for Payer: Humana KY Medicaid |
$1,925.32
|
| Rate for Payer: Kentucky WC Medicaid |
$1,944.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,590.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,131.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,679.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,963.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,926.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,198.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,119.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$727.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,735.54
|
| Rate for Payer: PHCS Commercial |
$5,374.56
|
| Rate for Payer: United Healthcare All Payer |
$4,926.68
|
|
|
EQUINOXE REV HUM LINER 46MM +0
|
Facility
|
IP
|
$5,598.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$727.80 |
| Max. Negotiated Rate |
$5,374.56 |
| Rate for Payer: Aetna Commercial |
$4,310.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,366.83
|
| Rate for Payer: Cash Price |
$2,799.25
|
| Rate for Payer: Cigna Commercial |
$4,646.76
|
| Rate for Payer: First Health Commercial |
$5,318.58
|
| Rate for Payer: Humana Commercial |
$4,758.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,590.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,131.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,679.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,926.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,198.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,119.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$727.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,735.54
|
| Rate for Payer: PHCS Commercial |
$5,374.56
|
| Rate for Payer: United Healthcare All Payer |
$4,926.68
|
|
|
EQUINOXE REV HUM LINER 46MM +0
|
Facility
|
OP
|
$5,598.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$727.80 |
| Max. Negotiated Rate |
$5,374.56 |
| Rate for Payer: Aetna Commercial |
$4,310.84
|
| Rate for Payer: Anthem Medicaid |
$1,925.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,366.83
|
| Rate for Payer: Cash Price |
$2,799.25
|
| Rate for Payer: Cigna Commercial |
$4,646.76
|
| Rate for Payer: First Health Commercial |
$5,318.58
|
| Rate for Payer: Humana Commercial |
$4,758.72
|
| Rate for Payer: Humana KY Medicaid |
$1,925.32
|
| Rate for Payer: Kentucky WC Medicaid |
$1,944.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,590.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,131.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,679.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,963.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,926.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,198.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,119.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$727.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,735.54
|
| Rate for Payer: PHCS Commercial |
$5,374.56
|
| Rate for Payer: United Healthcare All Payer |
$4,926.68
|
|
|
EQUINOXE REV HUM LINR 38MM+2.5
|
Facility
|
OP
|
$5,598.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$727.80 |
| Max. Negotiated Rate |
$5,374.56 |
| Rate for Payer: Aetna Commercial |
$4,310.84
|
| Rate for Payer: Anthem Medicaid |
$1,925.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,366.83
|
| Rate for Payer: Cash Price |
$2,799.25
|
| Rate for Payer: Cigna Commercial |
$4,646.76
|
| Rate for Payer: First Health Commercial |
$5,318.58
|
| Rate for Payer: Humana Commercial |
$4,758.72
|
| Rate for Payer: Humana KY Medicaid |
$1,925.32
|
| Rate for Payer: Kentucky WC Medicaid |
$1,944.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,590.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,131.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,679.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,963.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,926.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,198.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,119.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$727.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,735.54
|
| Rate for Payer: PHCS Commercial |
$5,374.56
|
| Rate for Payer: United Healthcare All Payer |
$4,926.68
|
|
|
EQUINOXE REV HUM LINR 38MM+2.5
|
Facility
|
IP
|
$5,598.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$727.80 |
| Max. Negotiated Rate |
$5,374.56 |
| Rate for Payer: Aetna Commercial |
$4,310.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,366.83
|
| Rate for Payer: Cash Price |
$2,799.25
|
| Rate for Payer: Cigna Commercial |
$4,646.76
|
| Rate for Payer: First Health Commercial |
$5,318.58
|
| Rate for Payer: Humana Commercial |
$4,758.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,590.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,131.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,679.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,926.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,198.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,119.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$727.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,735.54
|
| Rate for Payer: PHCS Commercial |
$5,374.56
|
| Rate for Payer: United Healthcare All Payer |
$4,926.68
|
|
|
EQUINOXE REV HUM LINR 42MM+2.5
|
Facility
|
IP
|
$5,598.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$727.80 |
| Max. Negotiated Rate |
$5,374.56 |
| Rate for Payer: Aetna Commercial |
$4,310.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,366.83
|
| Rate for Payer: Cash Price |
$2,799.25
|
| Rate for Payer: Cigna Commercial |
$4,646.76
|
| Rate for Payer: First Health Commercial |
$5,318.58
|
| Rate for Payer: Humana Commercial |
$4,758.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,590.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,131.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,679.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,926.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,198.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,119.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$727.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,735.54
|
| Rate for Payer: PHCS Commercial |
$5,374.56
|
| Rate for Payer: United Healthcare All Payer |
$4,926.68
|
|
