|
EQUINOXE HUM STEM SZ 11
|
Facility
|
OP
|
$10,928.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,278.42 |
| Max. Negotiated Rate |
$10,490.96 |
| Rate for Payer: Aetna Commercial |
$8,414.62
|
| Rate for Payer: Anthem Medicaid |
$3,758.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,523.90
|
| Rate for Payer: Cash Price |
$5,464.04
|
| Rate for Payer: Cigna Commercial |
$9,070.31
|
| Rate for Payer: First Health Commercial |
$10,381.68
|
| Rate for Payer: Humana Commercial |
$9,288.87
|
| Rate for Payer: Humana KY Medicaid |
$3,758.17
|
| Rate for Payer: Kentucky WC Medicaid |
$3,796.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,961.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,064.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,278.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,833.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,616.71
|
| Rate for Payer: Ohio Health Group HMO |
$8,196.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,742.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,507.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,540.38
|
| Rate for Payer: PHCS Commercial |
$10,490.96
|
| Rate for Payer: United Healthcare All Payer |
$9,616.71
|
|
|
EQUINOXE HUM STEM SZ 11
|
Facility
|
IP
|
$10,928.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,278.42 |
| Max. Negotiated Rate |
$10,490.96 |
| Rate for Payer: Aetna Commercial |
$8,414.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,523.90
|
| Rate for Payer: Cash Price |
$5,464.04
|
| Rate for Payer: Cigna Commercial |
$9,070.31
|
| Rate for Payer: First Health Commercial |
$10,381.68
|
| Rate for Payer: Humana Commercial |
$9,288.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,961.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,064.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,278.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,616.71
|
| Rate for Payer: Ohio Health Group HMO |
$8,196.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,742.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,507.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,540.38
|
| Rate for Payer: PHCS Commercial |
$10,490.96
|
| Rate for Payer: United Healthcare All Payer |
$9,616.71
|
|
|
EQUINOXE HUM STEM SZ 13
|
Facility
|
IP
|
$10,928.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,278.42 |
| Max. Negotiated Rate |
$10,490.96 |
| Rate for Payer: Aetna Commercial |
$8,414.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,523.90
|
| Rate for Payer: Cash Price |
$5,464.04
|
| Rate for Payer: Cigna Commercial |
$9,070.31
|
| Rate for Payer: First Health Commercial |
$10,381.68
|
| Rate for Payer: Humana Commercial |
$9,288.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,961.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,064.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,278.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,616.71
|
| Rate for Payer: Ohio Health Group HMO |
$8,196.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,742.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,507.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,540.38
|
| Rate for Payer: PHCS Commercial |
$10,490.96
|
| Rate for Payer: United Healthcare All Payer |
$9,616.71
|
|
|
EQUINOXE HUM STEM SZ 13
|
Facility
|
OP
|
$10,928.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,278.42 |
| Max. Negotiated Rate |
$10,490.96 |
| Rate for Payer: Aetna Commercial |
$8,414.62
|
| Rate for Payer: Anthem Medicaid |
$3,758.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,523.90
|
| Rate for Payer: Cash Price |
$5,464.04
|
| Rate for Payer: Cigna Commercial |
$9,070.31
|
| Rate for Payer: First Health Commercial |
$10,381.68
|
| Rate for Payer: Humana Commercial |
$9,288.87
|
| Rate for Payer: Humana KY Medicaid |
$3,758.17
|
| Rate for Payer: Kentucky WC Medicaid |
$3,796.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,961.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,064.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,278.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,833.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,616.71
|
| Rate for Payer: Ohio Health Group HMO |
$8,196.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,742.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,507.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,540.38
|
| Rate for Payer: PHCS Commercial |
$10,490.96
|
| Rate for Payer: United Healthcare All Payer |
$9,616.71
|
|
|
EQUINOXE HUM STEM SZ 15
|
Facility
|
IP
|
$10,928.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,278.42 |
| Max. Negotiated Rate |
$10,490.96 |
| Rate for Payer: Aetna Commercial |
$8,414.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,523.90
|
| Rate for Payer: Cash Price |
$5,464.04
|
| Rate for Payer: Cigna Commercial |
$9,070.31
|
| Rate for Payer: First Health Commercial |
$10,381.68
|
| Rate for Payer: Humana Commercial |
$9,288.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,961.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,064.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,278.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,616.71
|
| Rate for Payer: Ohio Health Group HMO |
$8,196.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,742.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,507.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,540.38
|
| Rate for Payer: PHCS Commercial |
$10,490.96
|
| Rate for Payer: United Healthcare All Payer |
$9,616.71
|
|
|
EQUINOXE HUM STEM SZ 15
|
Facility
|
OP
|
$10,928.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,278.42 |
| Max. Negotiated Rate |
$10,490.96 |
| Rate for Payer: Aetna Commercial |
$8,414.62
|
| Rate for Payer: Anthem Medicaid |
$3,758.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,523.90
|
| Rate for Payer: Cash Price |
$5,464.04
|
| Rate for Payer: Cigna Commercial |
$9,070.31
|
| Rate for Payer: First Health Commercial |
$10,381.68
|
| Rate for Payer: Humana Commercial |
$9,288.87
|
| Rate for Payer: Humana KY Medicaid |
$3,758.17
|
| Rate for Payer: Kentucky WC Medicaid |
$3,796.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,961.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,064.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,278.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,833.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,616.71
|
| Rate for Payer: Ohio Health Group HMO |
$8,196.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,742.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,507.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,540.38
|
| Rate for Payer: PHCS Commercial |
$10,490.96
|
| Rate for Payer: United Healthcare All Payer |
$9,616.71
|
|
|
EQUINOXE HUM STEM SZ 17
|
Facility
|
IP
|
$10,928.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,278.42 |
| Max. Negotiated Rate |
$10,490.96 |
| Rate for Payer: Aetna Commercial |
$8,414.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,523.90
|
| Rate for Payer: Cash Price |
$5,464.04
|
| Rate for Payer: Cigna Commercial |
$9,070.31
|
| Rate for Payer: First Health Commercial |
$10,381.68
|
| Rate for Payer: Humana Commercial |
$9,288.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,961.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,064.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,278.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,616.71
|
| Rate for Payer: Ohio Health Group HMO |
$8,196.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,742.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,507.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,540.38
|
| Rate for Payer: PHCS Commercial |
$10,490.96
|
| Rate for Payer: United Healthcare All Payer |
$9,616.71
|
|
|
EQUINOXE HUM STEM SZ 17
|
Facility
|
OP
|
$10,928.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,278.42 |
| Max. Negotiated Rate |
$10,490.96 |
| Rate for Payer: Aetna Commercial |
$8,414.62
|
| Rate for Payer: Anthem Medicaid |
$3,758.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,523.90
|
| Rate for Payer: Cash Price |
$5,464.04
|
| Rate for Payer: Cigna Commercial |
$9,070.31
|
| Rate for Payer: First Health Commercial |
$10,381.68
|
| Rate for Payer: Humana Commercial |
$9,288.87
|
| Rate for Payer: Humana KY Medicaid |
$3,758.17
|
| Rate for Payer: Kentucky WC Medicaid |
$3,796.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,961.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,064.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,278.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,833.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,616.71
|
| Rate for Payer: Ohio Health Group HMO |
$8,196.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,742.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,507.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,540.38
|
| Rate for Payer: PHCS Commercial |
$10,490.96
|
| Rate for Payer: United Healthcare All Payer |
$9,616.71
|
|
|
EQUINOXE HUM STEM SZ 19
|
Facility
|
OP
|
$10,928.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,278.42 |
| Max. Negotiated Rate |
$10,490.96 |
| Rate for Payer: Aetna Commercial |
$8,414.62
|
| Rate for Payer: Anthem Medicaid |
$3,758.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,523.90
|
| Rate for Payer: Cash Price |
$5,464.04
|
| Rate for Payer: Cigna Commercial |
$9,070.31
|
| Rate for Payer: First Health Commercial |
$10,381.68
|
| Rate for Payer: Humana Commercial |
$9,288.87
|
| Rate for Payer: Humana KY Medicaid |
$3,758.17
|
| Rate for Payer: Kentucky WC Medicaid |
$3,796.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,961.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,064.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,278.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,833.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,616.71
|
| Rate for Payer: Ohio Health Group HMO |
$8,196.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,742.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,507.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,540.38
|
| Rate for Payer: PHCS Commercial |
$10,490.96
|
| Rate for Payer: United Healthcare All Payer |
$9,616.71
|
|
|
EQUINOXE HUM STEM SZ 19
|
Facility
|
IP
|
$10,928.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,278.42 |
| Max. Negotiated Rate |
$10,490.96 |
| Rate for Payer: Aetna Commercial |
$8,414.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,523.90
|
| Rate for Payer: Cash Price |
$5,464.04
|
| Rate for Payer: Cigna Commercial |
$9,070.31
|
| Rate for Payer: First Health Commercial |
$10,381.68
|
| Rate for Payer: Humana Commercial |
$9,288.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,961.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,064.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,278.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,616.71
|
| Rate for Payer: Ohio Health Group HMO |
$8,196.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,742.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,507.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,540.38
|
| Rate for Payer: PHCS Commercial |
$10,490.96
|
| Rate for Payer: United Healthcare All Payer |
$9,616.71
|
|
|
EQUINOXE REP PLATE 1.5MM
|
Facility
|
IP
|
$5,723.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,717.12 |
| Max. Negotiated Rate |
$5,494.80 |
| Rate for Payer: Aetna Commercial |
$4,407.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,464.52
|
| Rate for Payer: Cash Price |
$2,861.88
|
| Rate for Payer: Cigna Commercial |
$4,750.71
|
| Rate for Payer: First Health Commercial |
$5,437.56
|
| Rate for Payer: Humana Commercial |
$4,865.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,693.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,224.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,717.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,036.90
|
| Rate for Payer: Ohio Health Group HMO |
$4,292.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,579.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,979.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,949.39
|
| Rate for Payer: PHCS Commercial |
$5,494.80
|
| Rate for Payer: United Healthcare All Payer |
$5,036.90
|
|
|
EQUINOXE REP PLATE 1.5MM
|
Facility
|
OP
|
$5,723.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,717.12 |
| Max. Negotiated Rate |
$5,494.80 |
| Rate for Payer: Aetna Commercial |
$4,407.29
|
| Rate for Payer: Anthem Medicaid |
$1,968.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,464.52
|
| Rate for Payer: Cash Price |
$2,861.88
|
| Rate for Payer: Cigna Commercial |
$4,750.71
|
| Rate for Payer: First Health Commercial |
$5,437.56
|
| Rate for Payer: Humana Commercial |
$4,865.19
|
| Rate for Payer: Humana KY Medicaid |
$1,968.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,988.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,693.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,224.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,717.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,007.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,036.90
|
| Rate for Payer: Ohio Health Group HMO |
$4,292.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,579.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,979.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,949.39
|
| Rate for Payer: PHCS Commercial |
$5,494.80
|
| Rate for Payer: United Healthcare All Payer |
$5,036.90
|
|
|
EQUINOXE REP PLATE 4.5MM
|
Facility
|
IP
|
$5,723.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,717.12 |
| Max. Negotiated Rate |
$5,494.80 |
| Rate for Payer: Aetna Commercial |
$4,407.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,464.52
|
| Rate for Payer: Cash Price |
$2,861.88
|
| Rate for Payer: Cigna Commercial |
$4,750.71
|
| Rate for Payer: First Health Commercial |
$5,437.56
|
| Rate for Payer: Humana Commercial |
$4,865.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,693.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,224.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,717.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,036.90
|
| Rate for Payer: Ohio Health Group HMO |
$4,292.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,579.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,979.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,949.39
|
| Rate for Payer: PHCS Commercial |
$5,494.80
|
| Rate for Payer: United Healthcare All Payer |
$5,036.90
|
|
|
EQUINOXE REP PLATE 4.5MM
|
Facility
|
OP
|
$5,723.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,717.12 |
| Max. Negotiated Rate |
$5,494.80 |
| Rate for Payer: Aetna Commercial |
$4,407.29
|
| Rate for Payer: Anthem Medicaid |
$1,968.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,464.52
|
| Rate for Payer: Cash Price |
$2,861.88
|
| Rate for Payer: Cigna Commercial |
$4,750.71
|
| Rate for Payer: First Health Commercial |
$5,437.56
|
| Rate for Payer: Humana Commercial |
$4,865.19
|
| Rate for Payer: Humana KY Medicaid |
$1,968.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,988.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,693.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,224.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,717.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,007.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,036.90
|
| Rate for Payer: Ohio Health Group HMO |
$4,292.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,579.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,979.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,949.39
|
| Rate for Payer: PHCS Commercial |
$5,494.80
|
| Rate for Payer: United Healthcare All Payer |
$5,036.90
|
|
|
EQUINOXE REV ADAPT PLATE +0
|
Facility
|
IP
|
$11,610.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,483.21 |
| Max. Negotiated Rate |
$11,146.27 |
| Rate for Payer: Aetna Commercial |
$8,940.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,056.35
|
| Rate for Payer: Cash Price |
$5,805.35
|
| Rate for Payer: Cigna Commercial |
$9,636.88
|
| Rate for Payer: First Health Commercial |
$11,030.17
|
| Rate for Payer: Humana Commercial |
$9,869.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,520.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,568.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,483.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,217.42
|
| Rate for Payer: Ohio Health Group HMO |
$8,708.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,288.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,101.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,011.38
|
| Rate for Payer: PHCS Commercial |
$11,146.27
|
| Rate for Payer: United Healthcare All Payer |
$10,217.42
|
|
|
EQUINOXE REV ADAPT PLATE +0
|
Facility
|
OP
|
$11,610.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,483.21 |
| Max. Negotiated Rate |
$11,146.27 |
| Rate for Payer: Aetna Commercial |
$8,940.24
|
| Rate for Payer: Anthem Medicaid |
$3,992.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,056.35
|
| Rate for Payer: Cash Price |
$5,805.35
|
| Rate for Payer: Cigna Commercial |
$9,636.88
|
| Rate for Payer: First Health Commercial |
$11,030.17
|
| Rate for Payer: Humana Commercial |
$9,869.09
|
| Rate for Payer: Humana KY Medicaid |
$3,992.92
|
| Rate for Payer: Kentucky WC Medicaid |
$4,033.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,520.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,568.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,483.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,073.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,217.42
|
| Rate for Payer: Ohio Health Group HMO |
$8,708.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,288.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,101.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,011.38
|
| Rate for Payer: PHCS Commercial |
$11,146.27
|
| Rate for Payer: United Healthcare All Payer |
$10,217.42
|
|
|
EQUINOXE REV ADAPT PLATE +10
|
Facility
|
IP
|
$13,904.45
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,171.34 |
| Max. Negotiated Rate |
$13,348.27 |
| Rate for Payer: Aetna Commercial |
$10,706.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,845.47
|
| Rate for Payer: Cash Price |
$6,952.23
|
| Rate for Payer: Cigna Commercial |
$11,540.69
|
| Rate for Payer: First Health Commercial |
$13,209.23
|
| Rate for Payer: Humana Commercial |
$11,818.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,401.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,261.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,171.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,235.92
|
| Rate for Payer: Ohio Health Group HMO |
$10,428.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,123.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,096.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,594.07
|
| Rate for Payer: PHCS Commercial |
$13,348.27
|
| Rate for Payer: United Healthcare All Payer |
$12,235.92
|
|
|
EQUINOXE REV ADAPT PLATE +10
|
Facility
|
OP
|
$13,904.45
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,171.34 |
| Max. Negotiated Rate |
$13,348.27 |
| Rate for Payer: Aetna Commercial |
$10,706.43
|
| Rate for Payer: Anthem Medicaid |
$4,781.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,845.47
|
| Rate for Payer: Cash Price |
$6,952.23
|
| Rate for Payer: Cigna Commercial |
$11,540.69
|
| Rate for Payer: First Health Commercial |
$13,209.23
|
| Rate for Payer: Humana Commercial |
$11,818.78
|
| Rate for Payer: Humana KY Medicaid |
$4,781.74
|
| Rate for Payer: Kentucky WC Medicaid |
$4,830.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,401.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,261.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,171.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,877.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,235.92
|
| Rate for Payer: Ohio Health Group HMO |
$10,428.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,123.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,096.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,594.07
|
| Rate for Payer: PHCS Commercial |
$13,348.27
|
| Rate for Payer: United Healthcare All Payer |
$12,235.92
|
|
|
EQUINOXE REV ADAPT PLATE +5
|
Facility
|
OP
|
$11,610.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,483.21 |
| Max. Negotiated Rate |
$11,146.27 |
| Rate for Payer: Aetna Commercial |
$8,940.24
|
| Rate for Payer: Anthem Medicaid |
$3,992.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,056.35
|
| Rate for Payer: Cash Price |
$5,805.35
|
| Rate for Payer: Cigna Commercial |
$9,636.88
|
| Rate for Payer: First Health Commercial |
$11,030.17
|
| Rate for Payer: Humana Commercial |
$9,869.09
|
| Rate for Payer: Humana KY Medicaid |
$3,992.92
|
| Rate for Payer: Kentucky WC Medicaid |
$4,033.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,520.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,568.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,483.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,073.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,217.42
|
| Rate for Payer: Ohio Health Group HMO |
$8,708.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,288.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,101.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,011.38
|
| Rate for Payer: PHCS Commercial |
$11,146.27
|
| Rate for Payer: United Healthcare All Payer |
$10,217.42
|
|
|
EQUINOXE REV ADAPT PLATE +5
|
Facility
|
IP
|
$11,610.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,483.21 |
| Max. Negotiated Rate |
$11,146.27 |
| Rate for Payer: Aetna Commercial |
$8,940.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,056.35
|
| Rate for Payer: Cash Price |
$5,805.35
|
| Rate for Payer: Cigna Commercial |
$9,636.88
|
| Rate for Payer: First Health Commercial |
$11,030.17
|
| Rate for Payer: Humana Commercial |
$9,869.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,520.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,568.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,483.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,217.42
|
| Rate for Payer: Ohio Health Group HMO |
$8,708.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,288.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,101.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,011.38
|
| Rate for Payer: PHCS Commercial |
$11,146.27
|
| Rate for Payer: United Healthcare All Payer |
$10,217.42
|
|
|
EQUINOXE REV GLENOID PLATE
|
Facility
|
OP
|
$9,694.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,908.23 |
| Max. Negotiated Rate |
$9,306.34 |
| Rate for Payer: Aetna Commercial |
$7,464.46
|
| Rate for Payer: Anthem Medicaid |
$3,333.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,561.40
|
| Rate for Payer: Cash Price |
$4,847.05
|
| Rate for Payer: Cigna Commercial |
$8,046.10
|
| Rate for Payer: First Health Commercial |
$9,209.40
|
| Rate for Payer: Humana Commercial |
$8,239.99
|
| Rate for Payer: Humana KY Medicaid |
$3,333.80
|
| Rate for Payer: Kentucky WC Medicaid |
$3,367.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,949.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,154.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,908.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,400.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,530.81
|
| Rate for Payer: Ohio Health Group HMO |
$7,270.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,755.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,433.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,688.93
|
| Rate for Payer: PHCS Commercial |
$9,306.34
|
| Rate for Payer: United Healthcare All Payer |
$8,530.81
|
|
|
EQUINOXE REV GLENOID PLATE
|
Facility
|
IP
|
$9,694.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,908.23 |
| Max. Negotiated Rate |
$9,306.34 |
| Rate for Payer: Aetna Commercial |
$7,464.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,561.40
|
| Rate for Payer: Cash Price |
$4,847.05
|
| Rate for Payer: Cigna Commercial |
$8,046.10
|
| Rate for Payer: First Health Commercial |
$9,209.40
|
| Rate for Payer: Humana Commercial |
$8,239.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,949.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,154.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,908.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,530.81
|
| Rate for Payer: Ohio Health Group HMO |
$7,270.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,755.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,433.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,688.93
|
| Rate for Payer: PHCS Commercial |
$9,306.34
|
| Rate for Payer: United Healthcare All Payer |
$8,530.81
|
|
|
EQUINOXE REV GLENOSHPERE 38MM
|
Facility
|
IP
|
$9,219.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,765.88 |
| Max. Negotiated Rate |
$8,850.82 |
| Rate for Payer: Aetna Commercial |
$7,099.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,191.29
|
| Rate for Payer: Cash Price |
$4,609.80
|
| Rate for Payer: Cigna Commercial |
$7,652.27
|
| Rate for Payer: First Health Commercial |
$8,758.62
|
| Rate for Payer: Humana Commercial |
$7,836.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,560.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,804.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,765.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,113.25
|
| Rate for Payer: Ohio Health Group HMO |
$6,914.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,375.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,021.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,361.52
|
| Rate for Payer: PHCS Commercial |
$8,850.82
|
| Rate for Payer: United Healthcare All Payer |
$8,113.25
|
|
|
EQUINOXE REV GLENOSHPERE 38MM
|
Facility
|
OP
|
$9,219.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,765.88 |
| Max. Negotiated Rate |
$8,850.82 |
| Rate for Payer: Aetna Commercial |
$7,099.09
|
| Rate for Payer: Anthem Medicaid |
$3,170.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,191.29
|
| Rate for Payer: Cash Price |
$4,609.80
|
| Rate for Payer: Cigna Commercial |
$7,652.27
|
| Rate for Payer: First Health Commercial |
$8,758.62
|
| Rate for Payer: Humana Commercial |
$7,836.66
|
| Rate for Payer: Humana KY Medicaid |
$3,170.62
|
| Rate for Payer: Kentucky WC Medicaid |
$3,202.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,560.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,804.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,765.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,234.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,113.25
|
| Rate for Payer: Ohio Health Group HMO |
$6,914.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,375.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,021.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,361.52
|
| Rate for Payer: PHCS Commercial |
$8,850.82
|
| Rate for Payer: United Healthcare All Payer |
$8,113.25
|
|
|
EQUINOXE REV GLENOSHPERE 42MM
|
Facility
|
OP
|
$9,219.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,765.88 |
| Max. Negotiated Rate |
$8,850.82 |
| Rate for Payer: Aetna Commercial |
$7,099.09
|
| Rate for Payer: Anthem Medicaid |
$3,170.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,191.29
|
| Rate for Payer: Cash Price |
$4,609.80
|
| Rate for Payer: Cigna Commercial |
$7,652.27
|
| Rate for Payer: First Health Commercial |
$8,758.62
|
| Rate for Payer: Humana Commercial |
$7,836.66
|
| Rate for Payer: Humana KY Medicaid |
$3,170.62
|
| Rate for Payer: Kentucky WC Medicaid |
$3,202.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,560.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,804.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,765.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,234.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,113.25
|
| Rate for Payer: Ohio Health Group HMO |
$6,914.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,375.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,021.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,361.52
|
| Rate for Payer: PHCS Commercial |
$8,850.82
|
| Rate for Payer: United Healthcare All Payer |
$8,113.25
|
|
