|
RESTORATION MOD PROX 31MM +0
|
Facility
|
IP
|
$18,332.16
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,383.18 |
| Max. Negotiated Rate |
$17,598.87 |
| Rate for Payer: Aetna Commercial |
$14,115.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,299.08
|
| Rate for Payer: Cash Price |
$9,166.08
|
| Rate for Payer: Cigna Commercial |
$15,215.69
|
| Rate for Payer: First Health Commercial |
$17,415.55
|
| Rate for Payer: Humana Commercial |
$15,582.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,032.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,529.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,499.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,132.30
|
| Rate for Payer: Ohio Health Group HMO |
$13,749.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,666.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,383.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,682.97
|
| Rate for Payer: PHCS Commercial |
$17,598.87
|
| Rate for Payer: United Healthcare All Payer |
$16,132.30
|
|
|
RESTORATION MOD STD 29MM +0
|
Facility
|
OP
|
$18,332.16
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,383.18 |
| Max. Negotiated Rate |
$17,598.87 |
| Rate for Payer: Aetna Commercial |
$14,115.76
|
| Rate for Payer: Anthem Medicaid |
$6,304.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,299.08
|
| Rate for Payer: Cash Price |
$9,166.08
|
| Rate for Payer: Cigna Commercial |
$15,215.69
|
| Rate for Payer: First Health Commercial |
$17,415.55
|
| Rate for Payer: Humana Commercial |
$15,582.34
|
| Rate for Payer: Humana KY Medicaid |
$6,304.43
|
| Rate for Payer: Kentucky WC Medicaid |
$6,368.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,032.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,529.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,499.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,430.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,132.30
|
| Rate for Payer: Ohio Health Group HMO |
$13,749.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,666.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,383.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,682.97
|
| Rate for Payer: PHCS Commercial |
$17,598.87
|
| Rate for Payer: United Healthcare All Payer |
$16,132.30
|
|
|
RESTORATION MOD STD 29MM +0
|
Facility
|
IP
|
$18,332.16
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,383.18 |
| Max. Negotiated Rate |
$17,598.87 |
| Rate for Payer: Aetna Commercial |
$14,115.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,299.08
|
| Rate for Payer: Cash Price |
$9,166.08
|
| Rate for Payer: Cigna Commercial |
$15,215.69
|
| Rate for Payer: First Health Commercial |
$17,415.55
|
| Rate for Payer: Humana Commercial |
$15,582.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,032.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,529.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,499.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,132.30
|
| Rate for Payer: Ohio Health Group HMO |
$13,749.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,666.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,383.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,682.97
|
| Rate for Payer: PHCS Commercial |
$17,598.87
|
| Rate for Payer: United Healthcare All Payer |
$16,132.30
|
|
|
RESTORATION PS7/17 BOW 241MM R
|
Facility
|
IP
|
$22,874.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,973.72 |
| Max. Negotiated Rate |
$21,959.81 |
| Rate for Payer: Aetna Commercial |
$17,613.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,842.34
|
| Rate for Payer: Cash Price |
$11,437.40
|
| Rate for Payer: Cigna Commercial |
$18,986.08
|
| Rate for Payer: First Health Commercial |
$21,731.06
|
| Rate for Payer: Humana Commercial |
$19,443.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,757.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,881.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,862.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,129.82
|
| Rate for Payer: Ohio Health Group HMO |
$17,156.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,574.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,973.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,091.19
|
| Rate for Payer: PHCS Commercial |
$21,959.81
|
| Rate for Payer: United Healthcare All Payer |
$20,129.82
|
|
|
RESTORATION PS7/17 BOW 241MM R
|
Facility
|
OP
|
$22,874.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,973.72 |
| Max. Negotiated Rate |
$21,959.81 |
| Rate for Payer: Aetna Commercial |
$17,613.60
|
| Rate for Payer: Anthem Medicaid |
$7,866.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,842.34
|
| Rate for Payer: Cash Price |
$11,437.40
|
| Rate for Payer: Cigna Commercial |
$18,986.08
|
| Rate for Payer: First Health Commercial |
$21,731.06
|
| Rate for Payer: Humana Commercial |
$19,443.58
|
| Rate for Payer: Humana KY Medicaid |
$7,866.64
|
| Rate for Payer: Kentucky WC Medicaid |
$7,946.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,757.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,881.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,862.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,024.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,129.82
|
| Rate for Payer: Ohio Health Group HMO |
$17,156.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,574.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,973.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,091.19
|
| Rate for Payer: PHCS Commercial |
$21,959.81
|
| Rate for Payer: United Healthcare All Payer |
$20,129.82
|
|
|
RESTORATN DIST STEM 21 * 195MM
|
Facility
|
OP
|
$15,023.04
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,953.00 |
| Max. Negotiated Rate |
$14,422.12 |
| Rate for Payer: Aetna Commercial |
$11,567.74
|
| Rate for Payer: Anthem Medicaid |
$5,166.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,717.97
|
| Rate for Payer: Cash Price |
$7,511.52
|
| Rate for Payer: Cigna Commercial |
$12,469.12
|
| Rate for Payer: First Health Commercial |
$14,271.89
|
| Rate for Payer: Humana Commercial |
$12,769.58
|
| Rate for Payer: Humana KY Medicaid |
$5,166.42
|
| Rate for Payer: Kentucky WC Medicaid |
$5,219.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,318.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,087.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,506.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,270.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,220.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,267.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,004.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,953.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,657.14
|
| Rate for Payer: PHCS Commercial |
$14,422.12
|
| Rate for Payer: United Healthcare All Payer |
$13,220.28
|
|
|
RESTORATN DIST STEM 21 * 195MM
|
Facility
|
IP
|
$15,023.04
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,953.00 |
| Max. Negotiated Rate |
$14,422.12 |
| Rate for Payer: Aetna Commercial |
$11,567.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,717.97
|
| Rate for Payer: Cash Price |
$7,511.52
|
| Rate for Payer: Cigna Commercial |
$12,469.12
|
| Rate for Payer: First Health Commercial |
$14,271.89
|
| Rate for Payer: Humana Commercial |
$12,769.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,318.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,087.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,506.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,220.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,267.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,004.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,953.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,657.14
|
| Rate for Payer: PHCS Commercial |
$14,422.12
|
| Rate for Payer: United Healthcare All Payer |
$13,220.28
|
|
|
RESTORATN DIST STEM 22 * 195MM
|
Facility
|
OP
|
$15,624.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,031.24 |
| Max. Negotiated Rate |
$14,999.96 |
| Rate for Payer: Aetna Commercial |
$12,031.22
|
| Rate for Payer: Anthem Medicaid |
$5,373.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,187.47
|
| Rate for Payer: Cash Price |
$7,812.48
|
| Rate for Payer: Cigna Commercial |
$12,968.72
|
| Rate for Payer: First Health Commercial |
$14,843.71
|
| Rate for Payer: Humana Commercial |
$13,281.22
|
| Rate for Payer: Humana KY Medicaid |
$5,373.42
|
| Rate for Payer: Kentucky WC Medicaid |
$5,428.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,812.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,531.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,687.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,481.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,749.96
|
| Rate for Payer: Ohio Health Group HMO |
$11,718.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,124.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,031.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,843.74
|
| Rate for Payer: PHCS Commercial |
$14,999.96
|
| Rate for Payer: United Healthcare All Payer |
$13,749.96
|
|
|
RESTORATN DIST STEM 22 * 195MM
|
Facility
|
IP
|
$15,624.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,031.24 |
| Max. Negotiated Rate |
$14,999.96 |
| Rate for Payer: Aetna Commercial |
$12,031.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,187.47
|
| Rate for Payer: Cash Price |
$7,812.48
|
| Rate for Payer: Cigna Commercial |
$12,968.72
|
| Rate for Payer: First Health Commercial |
$14,843.71
|
| Rate for Payer: Humana Commercial |
$13,281.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,812.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,531.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,687.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,749.96
|
| Rate for Payer: Ohio Health Group HMO |
$11,718.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,124.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,031.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,843.74
|
| Rate for Payer: PHCS Commercial |
$14,999.96
|
| Rate for Payer: United Healthcare All Payer |
$13,749.96
|
|
|
RESTORATN GAP II SHELL 48MM L
|
Facility
|
OP
|
$13,654.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,775.06 |
| Max. Negotiated Rate |
$13,108.15 |
| Rate for Payer: Aetna Commercial |
$10,513.83
|
| Rate for Payer: Anthem Medicaid |
$4,695.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,650.37
|
| Rate for Payer: Cash Price |
$6,827.16
|
| Rate for Payer: Cigna Commercial |
$11,333.09
|
| Rate for Payer: First Health Commercial |
$12,971.60
|
| Rate for Payer: Humana Commercial |
$11,606.17
|
| Rate for Payer: Humana KY Medicaid |
$4,695.72
|
| Rate for Payer: Kentucky WC Medicaid |
$4,743.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,196.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,076.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,096.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,789.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,015.80
|
| Rate for Payer: Ohio Health Group HMO |
$10,240.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,730.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,775.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,232.84
|
| Rate for Payer: PHCS Commercial |
$13,108.15
|
| Rate for Payer: United Healthcare All Payer |
$12,015.80
|
|
|
RESTORATN GAP II SHELL 48MM L
|
Facility
|
IP
|
$13,654.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,775.06 |
| Max. Negotiated Rate |
$13,108.15 |
| Rate for Payer: Aetna Commercial |
$10,513.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,650.37
|
| Rate for Payer: Cash Price |
$6,827.16
|
| Rate for Payer: Cigna Commercial |
$11,333.09
|
| Rate for Payer: First Health Commercial |
$12,971.60
|
| Rate for Payer: Humana Commercial |
$11,606.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,196.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,076.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,096.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,015.80
|
| Rate for Payer: Ohio Health Group HMO |
$10,240.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,730.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,775.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,232.84
|
| Rate for Payer: PHCS Commercial |
$13,108.15
|
| Rate for Payer: United Healthcare All Payer |
$12,015.80
|
|
|
RESTORATN GAP II SHELL 48MM R
|
Facility
|
OP
|
$13,654.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,775.06 |
| Max. Negotiated Rate |
$13,108.15 |
| Rate for Payer: Aetna Commercial |
$10,513.83
|
| Rate for Payer: Anthem Medicaid |
$4,695.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,650.37
|
| Rate for Payer: Cash Price |
$6,827.16
|
| Rate for Payer: Cigna Commercial |
$11,333.09
|
| Rate for Payer: First Health Commercial |
$12,971.60
|
| Rate for Payer: Humana Commercial |
$11,606.17
|
| Rate for Payer: Humana KY Medicaid |
$4,695.72
|
| Rate for Payer: Kentucky WC Medicaid |
$4,743.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,196.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,076.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,096.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,789.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,015.80
|
| Rate for Payer: Ohio Health Group HMO |
$10,240.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,730.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,775.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,232.84
|
| Rate for Payer: PHCS Commercial |
$13,108.15
|
| Rate for Payer: United Healthcare All Payer |
$12,015.80
|
|
|
RESTORATN GAP II SHELL 48MM R
|
Facility
|
IP
|
$13,654.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,775.06 |
| Max. Negotiated Rate |
$13,108.15 |
| Rate for Payer: Aetna Commercial |
$10,513.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,650.37
|
| Rate for Payer: Cash Price |
$6,827.16
|
| Rate for Payer: Cigna Commercial |
$11,333.09
|
| Rate for Payer: First Health Commercial |
$12,971.60
|
| Rate for Payer: Humana Commercial |
$11,606.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,196.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,076.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,096.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,015.80
|
| Rate for Payer: Ohio Health Group HMO |
$10,240.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,730.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,775.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,232.84
|
| Rate for Payer: PHCS Commercial |
$13,108.15
|
| Rate for Payer: United Healthcare All Payer |
$12,015.80
|
|
|
RESTORATN GAP II SHELL 52MM L
|
Facility
|
IP
|
$13,654.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,775.06 |
| Max. Negotiated Rate |
$13,108.15 |
| Rate for Payer: Aetna Commercial |
$10,513.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,650.37
|
| Rate for Payer: Cash Price |
$6,827.16
|
| Rate for Payer: Cigna Commercial |
$11,333.09
|
| Rate for Payer: First Health Commercial |
$12,971.60
|
| Rate for Payer: Humana Commercial |
$11,606.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,196.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,076.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,096.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,015.80
|
| Rate for Payer: Ohio Health Group HMO |
$10,240.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,730.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,775.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,232.84
|
| Rate for Payer: PHCS Commercial |
$13,108.15
|
| Rate for Payer: United Healthcare All Payer |
$12,015.80
|
|
|
RESTORATN GAP II SHELL 52MM L
|
Facility
|
OP
|
$13,654.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,775.06 |
| Max. Negotiated Rate |
$13,108.15 |
| Rate for Payer: Aetna Commercial |
$10,513.83
|
| Rate for Payer: Anthem Medicaid |
$4,695.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,650.37
|
| Rate for Payer: Cash Price |
$6,827.16
|
| Rate for Payer: Cigna Commercial |
$11,333.09
|
| Rate for Payer: First Health Commercial |
$12,971.60
|
| Rate for Payer: Humana Commercial |
$11,606.17
|
| Rate for Payer: Humana KY Medicaid |
$4,695.72
|
| Rate for Payer: Kentucky WC Medicaid |
$4,743.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,196.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,076.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,096.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,789.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,015.80
|
| Rate for Payer: Ohio Health Group HMO |
$10,240.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,730.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,775.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,232.84
|
| Rate for Payer: PHCS Commercial |
$13,108.15
|
| Rate for Payer: United Healthcare All Payer |
$12,015.80
|
|
|
RESTORATN GAP II SHELL 52MM R
|
Facility
|
OP
|
$13,654.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,775.06 |
| Max. Negotiated Rate |
$13,108.15 |
| Rate for Payer: Aetna Commercial |
$10,513.83
|
| Rate for Payer: Anthem Medicaid |
$4,695.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,650.37
|
| Rate for Payer: Cash Price |
$6,827.16
|
| Rate for Payer: Cigna Commercial |
$11,333.09
|
| Rate for Payer: First Health Commercial |
$12,971.60
|
| Rate for Payer: Humana Commercial |
$11,606.17
|
| Rate for Payer: Humana KY Medicaid |
$4,695.72
|
| Rate for Payer: Kentucky WC Medicaid |
$4,743.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,196.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,076.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,096.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,789.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,015.80
|
| Rate for Payer: Ohio Health Group HMO |
$10,240.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,730.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,775.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,232.84
|
| Rate for Payer: PHCS Commercial |
$13,108.15
|
| Rate for Payer: United Healthcare All Payer |
$12,015.80
|
|
|
RESTORATN GAP II SHELL 52MM R
|
Facility
|
IP
|
$13,654.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,775.06 |
| Max. Negotiated Rate |
$13,108.15 |
| Rate for Payer: Aetna Commercial |
$10,513.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,650.37
|
| Rate for Payer: Cash Price |
$6,827.16
|
| Rate for Payer: Cigna Commercial |
$11,333.09
|
| Rate for Payer: First Health Commercial |
$12,971.60
|
| Rate for Payer: Humana Commercial |
$11,606.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,196.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,076.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,096.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,015.80
|
| Rate for Payer: Ohio Health Group HMO |
$10,240.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,730.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,775.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,232.84
|
| Rate for Payer: PHCS Commercial |
$13,108.15
|
| Rate for Payer: United Healthcare All Payer |
$12,015.80
|
|
|
RESTORATN GAP II SHELL 56MM L
|
Facility
|
OP
|
$13,654.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,775.06 |
| Max. Negotiated Rate |
$13,108.15 |
| Rate for Payer: Aetna Commercial |
$10,513.83
|
| Rate for Payer: Anthem Medicaid |
$4,695.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,650.37
|
| Rate for Payer: Cash Price |
$6,827.16
|
| Rate for Payer: Cigna Commercial |
$11,333.09
|
| Rate for Payer: First Health Commercial |
$12,971.60
|
| Rate for Payer: Humana Commercial |
$11,606.17
|
| Rate for Payer: Humana KY Medicaid |
$4,695.72
|
| Rate for Payer: Kentucky WC Medicaid |
$4,743.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,196.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,076.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,096.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,789.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,015.80
|
| Rate for Payer: Ohio Health Group HMO |
$10,240.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,730.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,775.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,232.84
|
| Rate for Payer: PHCS Commercial |
$13,108.15
|
| Rate for Payer: United Healthcare All Payer |
$12,015.80
|
|
|
RESTORATN GAP II SHELL 56MM L
|
Facility
|
IP
|
$13,654.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,775.06 |
| Max. Negotiated Rate |
$13,108.15 |
| Rate for Payer: Aetna Commercial |
$10,513.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,650.37
|
| Rate for Payer: Cash Price |
$6,827.16
|
| Rate for Payer: Cigna Commercial |
$11,333.09
|
| Rate for Payer: First Health Commercial |
$12,971.60
|
| Rate for Payer: Humana Commercial |
$11,606.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,196.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,076.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,096.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,015.80
|
| Rate for Payer: Ohio Health Group HMO |
$10,240.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,730.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,775.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,232.84
|
| Rate for Payer: PHCS Commercial |
$13,108.15
|
| Rate for Payer: United Healthcare All Payer |
$12,015.80
|
|
|
RESTORATN GAP II SHELL 56MM R
|
Facility
|
IP
|
$13,654.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,775.06 |
| Max. Negotiated Rate |
$13,108.15 |
| Rate for Payer: Aetna Commercial |
$10,513.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,650.37
|
| Rate for Payer: Cash Price |
$6,827.16
|
| Rate for Payer: Cigna Commercial |
$11,333.09
|
| Rate for Payer: First Health Commercial |
$12,971.60
|
| Rate for Payer: Humana Commercial |
$11,606.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,196.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,076.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,096.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,015.80
|
| Rate for Payer: Ohio Health Group HMO |
$10,240.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,730.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,775.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,232.84
|
| Rate for Payer: PHCS Commercial |
$13,108.15
|
| Rate for Payer: United Healthcare All Payer |
$12,015.80
|
|
|
RESTORATN GAP II SHELL 56MM R
|
Facility
|
OP
|
$13,654.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,775.06 |
| Max. Negotiated Rate |
$13,108.15 |
| Rate for Payer: Aetna Commercial |
$10,513.83
|
| Rate for Payer: Anthem Medicaid |
$4,695.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,650.37
|
| Rate for Payer: Cash Price |
$6,827.16
|
| Rate for Payer: Cigna Commercial |
$11,333.09
|
| Rate for Payer: First Health Commercial |
$12,971.60
|
| Rate for Payer: Humana Commercial |
$11,606.17
|
| Rate for Payer: Humana KY Medicaid |
$4,695.72
|
| Rate for Payer: Kentucky WC Medicaid |
$4,743.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,196.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,076.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,096.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,789.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,015.80
|
| Rate for Payer: Ohio Health Group HMO |
$10,240.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,730.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,775.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,232.84
|
| Rate for Payer: PHCS Commercial |
$13,108.15
|
| Rate for Payer: United Healthcare All Payer |
$12,015.80
|
|
|
RESTORATN GAP II SHELL 60MM L
|
Facility
|
OP
|
$13,654.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,775.06 |
| Max. Negotiated Rate |
$13,108.15 |
| Rate for Payer: Aetna Commercial |
$10,513.83
|
| Rate for Payer: Anthem Medicaid |
$4,695.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,650.37
|
| Rate for Payer: Cash Price |
$6,827.16
|
| Rate for Payer: Cigna Commercial |
$11,333.09
|
| Rate for Payer: First Health Commercial |
$12,971.60
|
| Rate for Payer: Humana Commercial |
$11,606.17
|
| Rate for Payer: Humana KY Medicaid |
$4,695.72
|
| Rate for Payer: Kentucky WC Medicaid |
$4,743.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,196.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,076.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,096.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,789.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,015.80
|
| Rate for Payer: Ohio Health Group HMO |
$10,240.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,730.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,775.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,232.84
|
| Rate for Payer: PHCS Commercial |
$13,108.15
|
| Rate for Payer: United Healthcare All Payer |
$12,015.80
|
|
|
RESTORATN GAP II SHELL 60MM L
|
Facility
|
IP
|
$13,654.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,775.06 |
| Max. Negotiated Rate |
$13,108.15 |
| Rate for Payer: Aetna Commercial |
$10,513.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,650.37
|
| Rate for Payer: Cash Price |
$6,827.16
|
| Rate for Payer: Cigna Commercial |
$11,333.09
|
| Rate for Payer: First Health Commercial |
$12,971.60
|
| Rate for Payer: Humana Commercial |
$11,606.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,196.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,076.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,096.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,015.80
|
| Rate for Payer: Ohio Health Group HMO |
$10,240.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,730.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,775.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,232.84
|
| Rate for Payer: PHCS Commercial |
$13,108.15
|
| Rate for Payer: United Healthcare All Payer |
$12,015.80
|
|
|
RESTORATN GAP II SHELL 60MM R
|
Facility
|
OP
|
$13,654.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,775.06 |
| Max. Negotiated Rate |
$13,108.15 |
| Rate for Payer: Aetna Commercial |
$10,513.83
|
| Rate for Payer: Anthem Medicaid |
$4,695.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,650.37
|
| Rate for Payer: Cash Price |
$6,827.16
|
| Rate for Payer: Cigna Commercial |
$11,333.09
|
| Rate for Payer: First Health Commercial |
$12,971.60
|
| Rate for Payer: Humana Commercial |
$11,606.17
|
| Rate for Payer: Humana KY Medicaid |
$4,695.72
|
| Rate for Payer: Kentucky WC Medicaid |
$4,743.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,196.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,076.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,096.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,789.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,015.80
|
| Rate for Payer: Ohio Health Group HMO |
$10,240.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,730.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,775.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,232.84
|
| Rate for Payer: PHCS Commercial |
$13,108.15
|
| Rate for Payer: United Healthcare All Payer |
$12,015.80
|
|
|
RESTORATN GAP II SHELL 60MM R
|
Facility
|
IP
|
$13,654.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,775.06 |
| Max. Negotiated Rate |
$13,108.15 |
| Rate for Payer: Aetna Commercial |
$10,513.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,650.37
|
| Rate for Payer: Cash Price |
$6,827.16
|
| Rate for Payer: Cigna Commercial |
$11,333.09
|
| Rate for Payer: First Health Commercial |
$12,971.60
|
| Rate for Payer: Humana Commercial |
$11,606.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,196.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,076.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,096.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,015.80
|
| Rate for Payer: Ohio Health Group HMO |
$10,240.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,730.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,775.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,232.84
|
| Rate for Payer: PHCS Commercial |
$13,108.15
|
| Rate for Payer: United Healthcare All Payer |
$12,015.80
|
|
