|
RESTORATN GAP II SHELL 64MM 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 64MM 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 64MM 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 64MM 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 68MM 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 68MM 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 68MM 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 68MM 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 72MM 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 72MM 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 72MM 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 72MM 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 HIP STEM 40*205 SZ10
|
Facility
|
OP
|
$29,366.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,817.62 |
| Max. Negotiated Rate |
$28,191.67 |
| Rate for Payer: Aetna Commercial |
$22,612.07
|
| Rate for Payer: Anthem Medicaid |
$10,099.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,905.73
|
| Rate for Payer: Cash Price |
$14,683.16
|
| Rate for Payer: Cigna Commercial |
$24,374.05
|
| Rate for Payer: First Health Commercial |
$27,898.00
|
| Rate for Payer: Humana Commercial |
$24,961.37
|
| Rate for Payer: Humana KY Medicaid |
$10,099.08
|
| Rate for Payer: Kentucky WC Medicaid |
$10,201.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24,080.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,672.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,809.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,301.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,842.36
|
| Rate for Payer: Ohio Health Group HMO |
$22,024.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,873.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,817.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,103.56
|
| Rate for Payer: PHCS Commercial |
$28,191.67
|
| Rate for Payer: United Healthcare All Payer |
$25,842.36
|
|
|
RESTORATN HIP STEM 40*205 SZ10
|
Facility
|
IP
|
$29,366.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,817.62 |
| Max. Negotiated Rate |
$28,191.67 |
| Rate for Payer: Aetna Commercial |
$22,612.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,905.73
|
| Rate for Payer: Cash Price |
$14,683.16
|
| Rate for Payer: Cigna Commercial |
$24,374.05
|
| Rate for Payer: First Health Commercial |
$27,898.00
|
| Rate for Payer: Humana Commercial |
$24,961.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24,080.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,672.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,809.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,842.36
|
| Rate for Payer: Ohio Health Group HMO |
$22,024.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,873.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,817.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,103.56
|
| Rate for Payer: PHCS Commercial |
$28,191.67
|
| Rate for Payer: United Healthcare All Payer |
$25,842.36
|
|
|
RESTORATN MOD HIP STEM 16*235M
|
Facility
|
IP
|
$17,644.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,293.75 |
| Max. Negotiated Rate |
$16,938.43 |
| Rate for Payer: Aetna Commercial |
$13,586.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,762.48
|
| Rate for Payer: Cash Price |
$8,822.10
|
| Rate for Payer: Cigna Commercial |
$14,644.69
|
| Rate for Payer: First Health Commercial |
$16,761.99
|
| Rate for Payer: Humana Commercial |
$14,997.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,468.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,021.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,293.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,526.90
|
| Rate for Payer: Ohio Health Group HMO |
$13,233.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,528.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,293.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.70
|
| Rate for Payer: PHCS Commercial |
$16,938.43
|
| Rate for Payer: United Healthcare All Payer |
$15,526.90
|
|
|
RESTORATN MOD HIP STEM 16*235M
|
Facility
|
OP
|
$17,644.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,293.75 |
| Max. Negotiated Rate |
$16,938.43 |
| Rate for Payer: Aetna Commercial |
$13,586.03
|
| Rate for Payer: Anthem Medicaid |
$6,067.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,762.48
|
| Rate for Payer: Cash Price |
$8,822.10
|
| Rate for Payer: Cigna Commercial |
$14,644.69
|
| Rate for Payer: First Health Commercial |
$16,761.99
|
| Rate for Payer: Humana Commercial |
$14,997.57
|
| Rate for Payer: Humana KY Medicaid |
$6,067.84
|
| Rate for Payer: Kentucky WC Medicaid |
$6,129.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,468.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,021.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,293.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,189.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,526.90
|
| Rate for Payer: Ohio Health Group HMO |
$13,233.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,528.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,293.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.70
|
| Rate for Payer: PHCS Commercial |
$16,938.43
|
| Rate for Payer: United Healthcare All Payer |
$15,526.90
|
|
|
RESTORATN MOD HIP STEM 19*155M
|
Facility
|
IP
|
$16,464.84
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,140.43 |
| Max. Negotiated Rate |
$15,806.25 |
| Rate for Payer: Aetna Commercial |
$12,677.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,842.58
|
| Rate for Payer: Cash Price |
$8,232.42
|
| Rate for Payer: Cigna Commercial |
$13,665.82
|
| Rate for Payer: First Health Commercial |
$15,641.60
|
| Rate for Payer: Humana Commercial |
$13,995.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,501.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,151.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,939.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,489.06
|
| Rate for Payer: Ohio Health Group HMO |
$12,348.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,292.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,140.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,104.10
|
| Rate for Payer: PHCS Commercial |
$15,806.25
|
| Rate for Payer: United Healthcare All Payer |
$14,489.06
|
|
|
RESTORATN MOD HIP STEM 19*155M
|
Facility
|
OP
|
$16,464.84
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,140.43 |
| Max. Negotiated Rate |
$15,806.25 |
| Rate for Payer: Aetna Commercial |
$12,677.93
|
| Rate for Payer: Anthem Medicaid |
$5,662.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,842.58
|
| Rate for Payer: Cash Price |
$8,232.42
|
| Rate for Payer: Cigna Commercial |
$13,665.82
|
| Rate for Payer: First Health Commercial |
$15,641.60
|
| Rate for Payer: Humana Commercial |
$13,995.11
|
| Rate for Payer: Humana KY Medicaid |
$5,662.26
|
| Rate for Payer: Kentucky WC Medicaid |
$5,719.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,501.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,151.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,939.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,775.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,489.06
|
| Rate for Payer: Ohio Health Group HMO |
$12,348.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,292.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,140.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,104.10
|
| Rate for Payer: PHCS Commercial |
$15,806.25
|
| Rate for Payer: United Healthcare All Payer |
$14,489.06
|
|
|
RESTORATN MOD HIP STEM 19*235M
|
Facility
|
OP
|
$17,644.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,293.75 |
| Max. Negotiated Rate |
$16,938.43 |
| Rate for Payer: Aetna Commercial |
$13,586.03
|
| Rate for Payer: Anthem Medicaid |
$6,067.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,762.48
|
| Rate for Payer: Cash Price |
$8,822.10
|
| Rate for Payer: Cigna Commercial |
$14,644.69
|
| Rate for Payer: First Health Commercial |
$16,761.99
|
| Rate for Payer: Humana Commercial |
$14,997.57
|
| Rate for Payer: Humana KY Medicaid |
$6,067.84
|
| Rate for Payer: Kentucky WC Medicaid |
$6,129.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,468.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,021.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,293.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,189.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,526.90
|
| Rate for Payer: Ohio Health Group HMO |
$13,233.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,528.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,293.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.70
|
| Rate for Payer: PHCS Commercial |
$16,938.43
|
| Rate for Payer: United Healthcare All Payer |
$15,526.90
|
|
|
RESTORATN MOD HIP STEM 19*235M
|
Facility
|
IP
|
$17,644.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,293.75 |
| Max. Negotiated Rate |
$16,938.43 |
| Rate for Payer: Aetna Commercial |
$13,586.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,762.48
|
| Rate for Payer: Cash Price |
$8,822.10
|
| Rate for Payer: Cigna Commercial |
$14,644.69
|
| Rate for Payer: First Health Commercial |
$16,761.99
|
| Rate for Payer: Humana Commercial |
$14,997.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,468.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,021.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,293.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,526.90
|
| Rate for Payer: Ohio Health Group HMO |
$13,233.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,528.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,293.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.70
|
| Rate for Payer: PHCS Commercial |
$16,938.43
|
| Rate for Payer: United Healthcare All Payer |
$15,526.90
|
|
|
RESTORATN MOD HIP SYS 25M +10
|
Facility
|
OP
|
$23,327.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,032.56 |
| Max. Negotiated Rate |
$22,394.30 |
| Rate for Payer: Aetna Commercial |
$17,962.10
|
| Rate for Payer: Anthem Medicaid |
$8,022.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,195.37
|
| Rate for Payer: Cash Price |
$11,663.70
|
| Rate for Payer: Cigna Commercial |
$19,361.74
|
| Rate for Payer: First Health Commercial |
$22,161.03
|
| Rate for Payer: Humana Commercial |
$19,828.29
|
| Rate for Payer: Humana KY Medicaid |
$8,022.29
|
| Rate for Payer: Kentucky WC Medicaid |
$8,103.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,128.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,215.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,998.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,183.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,528.11
|
| Rate for Payer: Ohio Health Group HMO |
$17,495.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,665.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,032.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,231.49
|
| Rate for Payer: PHCS Commercial |
$22,394.30
|
| Rate for Payer: United Healthcare All Payer |
$20,528.11
|
|
|
RESTORATN MOD HIP SYS 25M +10
|
Facility
|
IP
|
$23,327.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,032.56 |
| Max. Negotiated Rate |
$22,394.30 |
| Rate for Payer: Aetna Commercial |
$17,962.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,195.37
|
| Rate for Payer: Cash Price |
$11,663.70
|
| Rate for Payer: Cigna Commercial |
$19,361.74
|
| Rate for Payer: First Health Commercial |
$22,161.03
|
| Rate for Payer: Humana Commercial |
$19,828.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,128.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,215.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,998.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,528.11
|
| Rate for Payer: Ohio Health Group HMO |
$17,495.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,665.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,032.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,231.49
|
| Rate for Payer: PHCS Commercial |
$22,394.30
|
| Rate for Payer: United Healthcare All Payer |
$20,528.11
|
|
|
RESTORATN MOD HIP V40 23MM +20
|
Facility
|
IP
|
$20,970.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,726.18 |
| Max. Negotiated Rate |
$20,131.78 |
| Rate for Payer: Aetna Commercial |
$16,147.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,357.07
|
| Rate for Payer: Cash Price |
$10,485.30
|
| Rate for Payer: Cigna Commercial |
$17,405.60
|
| Rate for Payer: First Health Commercial |
$19,922.07
|
| Rate for Payer: Humana Commercial |
$17,825.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,195.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,476.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,291.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,454.13
|
| Rate for Payer: Ohio Health Group HMO |
$15,727.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,194.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,726.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,500.89
|
| Rate for Payer: PHCS Commercial |
$20,131.78
|
| Rate for Payer: United Healthcare All Payer |
$18,454.13
|
|
|
RESTORATN MOD HIP V40 23MM +20
|
Facility
|
OP
|
$20,970.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,726.18 |
| Max. Negotiated Rate |
$20,131.78 |
| Rate for Payer: Aetna Commercial |
$16,147.36
|
| Rate for Payer: Anthem Medicaid |
$7,211.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,357.07
|
| Rate for Payer: Cash Price |
$10,485.30
|
| Rate for Payer: Cigna Commercial |
$17,405.60
|
| Rate for Payer: First Health Commercial |
$19,922.07
|
| Rate for Payer: Humana Commercial |
$17,825.01
|
| Rate for Payer: Humana KY Medicaid |
$7,211.79
|
| Rate for Payer: Kentucky WC Medicaid |
$7,285.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,195.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,476.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,291.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,356.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,454.13
|
| Rate for Payer: Ohio Health Group HMO |
$15,727.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,194.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,726.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,500.89
|
| Rate for Payer: PHCS Commercial |
$20,131.78
|
| Rate for Payer: United Healthcare All Payer |
$18,454.13
|
|
|
RESTORATN MOD HIP V40 25MM +20
|
Facility
|
IP
|
$22,156.12
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,880.30 |
| Max. Negotiated Rate |
$21,269.88 |
| Rate for Payer: Aetna Commercial |
$17,060.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,281.77
|
| Rate for Payer: Cash Price |
$11,078.06
|
| Rate for Payer: Cigna Commercial |
$18,389.58
|
| Rate for Payer: First Health Commercial |
$21,048.31
|
| Rate for Payer: Humana Commercial |
$18,832.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,168.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,351.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,646.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,497.39
|
| Rate for Payer: Ohio Health Group HMO |
$16,617.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,431.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,880.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,868.40
|
| Rate for Payer: PHCS Commercial |
$21,269.88
|
| Rate for Payer: United Healthcare All Payer |
$19,497.39
|
|
