|
RESTORATION MOD STD 29MM +0
|
Facility
|
OP
|
$18,924.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,677.42 |
| Max. Negotiated Rate |
$18,167.73 |
| Rate for Payer: Aetna Commercial |
$14,572.03
|
| Rate for Payer: Anthem Medicaid |
$6,508.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,761.28
|
| Rate for Payer: Cash Price |
$9,462.36
|
| Rate for Payer: Cigna Commercial |
$15,707.52
|
| Rate for Payer: First Health Commercial |
$17,978.48
|
| Rate for Payer: Humana Commercial |
$16,086.01
|
| Rate for Payer: Humana KY Medicaid |
$6,508.21
|
| Rate for Payer: Kentucky WC Medicaid |
$6,574.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,518.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,966.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,677.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,638.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,653.75
|
| Rate for Payer: Ohio Health Group HMO |
$14,193.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,139.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,464.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,058.06
|
| Rate for Payer: PHCS Commercial |
$18,167.73
|
| Rate for Payer: United Healthcare All Payer |
$16,653.75
|
|
|
RESTORATION PS7/17 BOW 241MM R
|
Facility
|
OP
|
$23,570.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,071.00 |
| Max. Negotiated Rate |
$22,627.20 |
| Rate for Payer: Aetna Commercial |
$18,148.90
|
| Rate for Payer: Anthem Medicaid |
$8,105.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,384.60
|
| Rate for Payer: Cash Price |
$11,785.00
|
| Rate for Payer: Cigna Commercial |
$19,563.10
|
| Rate for Payer: First Health Commercial |
$22,391.50
|
| Rate for Payer: Humana Commercial |
$20,034.50
|
| Rate for Payer: Humana KY Medicaid |
$8,105.72
|
| Rate for Payer: Kentucky WC Medicaid |
$8,188.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,327.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,394.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,071.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,268.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,741.60
|
| Rate for Payer: Ohio Health Group HMO |
$17,677.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,856.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,505.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,263.30
|
| Rate for Payer: PHCS Commercial |
$22,627.20
|
| Rate for Payer: United Healthcare All Payer |
$20,741.60
|
|
|
RESTORATION PS7/17 BOW 241MM R
|
Facility
|
IP
|
$23,570.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,071.00 |
| Max. Negotiated Rate |
$22,627.20 |
| Rate for Payer: Aetna Commercial |
$18,148.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,384.60
|
| Rate for Payer: Cash Price |
$11,785.00
|
| Rate for Payer: Cigna Commercial |
$19,563.10
|
| Rate for Payer: First Health Commercial |
$22,391.50
|
| Rate for Payer: Humana Commercial |
$20,034.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,327.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,394.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,071.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,741.60
|
| Rate for Payer: Ohio Health Group HMO |
$17,677.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,856.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,505.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,263.30
|
| Rate for Payer: PHCS Commercial |
$22,627.20
|
| Rate for Payer: United Healthcare All Payer |
$20,741.60
|
|
|
RESTORATN DIST STEM 21 * 195MM
|
Facility
|
OP
|
$15,523.68
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,657.10 |
| Max. Negotiated Rate |
$14,902.73 |
| Rate for Payer: Aetna Commercial |
$11,953.23
|
| Rate for Payer: Anthem Medicaid |
$5,338.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,108.47
|
| Rate for Payer: Cash Price |
$7,761.84
|
| Rate for Payer: Cigna Commercial |
$12,884.65
|
| Rate for Payer: First Health Commercial |
$14,747.50
|
| Rate for Payer: Humana Commercial |
$13,195.13
|
| Rate for Payer: Humana KY Medicaid |
$5,338.59
|
| Rate for Payer: Kentucky WC Medicaid |
$5,392.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,729.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,456.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,657.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,445.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,660.84
|
| Rate for Payer: Ohio Health Group HMO |
$11,642.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,418.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,505.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,711.34
|
| Rate for Payer: PHCS Commercial |
$14,902.73
|
| Rate for Payer: United Healthcare All Payer |
$13,660.84
|
|
|
RESTORATN DIST STEM 21 * 195MM
|
Facility
|
IP
|
$15,523.68
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,657.10 |
| Max. Negotiated Rate |
$14,902.73 |
| Rate for Payer: Aetna Commercial |
$11,953.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,108.47
|
| Rate for Payer: Cash Price |
$7,761.84
|
| Rate for Payer: Cigna Commercial |
$12,884.65
|
| Rate for Payer: First Health Commercial |
$14,747.50
|
| Rate for Payer: Humana Commercial |
$13,195.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,729.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,456.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,657.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,660.84
|
| Rate for Payer: Ohio Health Group HMO |
$11,642.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,418.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,505.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,711.34
|
| Rate for Payer: PHCS Commercial |
$14,902.73
|
| Rate for Payer: United Healthcare All Payer |
$13,660.84
|
|
|
RESTORATN DIST STEM 22 * 195MM
|
Facility
|
IP
|
$16,142.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,842.70 |
| Max. Negotiated Rate |
$15,496.63 |
| Rate for Payer: Aetna Commercial |
$12,429.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,591.01
|
| Rate for Payer: Cash Price |
$8,071.16
|
| Rate for Payer: Cigna Commercial |
$13,398.13
|
| Rate for Payer: First Health Commercial |
$15,335.20
|
| Rate for Payer: Humana Commercial |
$13,720.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,236.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,913.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,842.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,205.24
|
| Rate for Payer: Ohio Health Group HMO |
$12,106.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,913.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,043.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,138.20
|
| Rate for Payer: PHCS Commercial |
$15,496.63
|
| Rate for Payer: United Healthcare All Payer |
$14,205.24
|
|
|
RESTORATN DIST STEM 22 * 195MM
|
Facility
|
OP
|
$16,142.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,842.70 |
| Max. Negotiated Rate |
$15,496.63 |
| Rate for Payer: Aetna Commercial |
$12,429.59
|
| Rate for Payer: Anthem Medicaid |
$5,551.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,591.01
|
| Rate for Payer: Cash Price |
$8,071.16
|
| Rate for Payer: Cigna Commercial |
$13,398.13
|
| Rate for Payer: First Health Commercial |
$15,335.20
|
| Rate for Payer: Humana Commercial |
$13,720.97
|
| Rate for Payer: Humana KY Medicaid |
$5,551.34
|
| Rate for Payer: Kentucky WC Medicaid |
$5,607.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,236.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,913.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,842.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,662.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,205.24
|
| Rate for Payer: Ohio Health Group HMO |
$12,106.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,913.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,043.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,138.20
|
| Rate for Payer: PHCS Commercial |
$15,496.63
|
| Rate for Payer: United Healthcare All Payer |
$14,205.24
|
|
|
RESTORATN GAP II SHELL 48MM L
|
Facility
|
OP
|
$13,911.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,173.32 |
| Max. Negotiated Rate |
$13,354.62 |
| Rate for Payer: Aetna Commercial |
$10,711.52
|
| Rate for Payer: Anthem Medicaid |
$4,784.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,850.63
|
| Rate for Payer: Cash Price |
$6,955.53
|
| Rate for Payer: Cigna Commercial |
$11,546.18
|
| Rate for Payer: First Health Commercial |
$13,215.51
|
| Rate for Payer: Humana Commercial |
$11,824.40
|
| Rate for Payer: Humana KY Medicaid |
$4,784.01
|
| Rate for Payer: Kentucky WC Medicaid |
$4,832.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,407.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,266.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,173.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,880.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,241.73
|
| Rate for Payer: Ohio Health Group HMO |
$10,433.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,128.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,102.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,598.63
|
| Rate for Payer: PHCS Commercial |
$13,354.62
|
| Rate for Payer: United Healthcare All Payer |
$12,241.73
|
|
|
RESTORATN GAP II SHELL 48MM L
|
Facility
|
IP
|
$13,911.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,173.32 |
| Max. Negotiated Rate |
$13,354.62 |
| Rate for Payer: Aetna Commercial |
$10,711.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,850.63
|
| Rate for Payer: Cash Price |
$6,955.53
|
| Rate for Payer: Cigna Commercial |
$11,546.18
|
| Rate for Payer: First Health Commercial |
$13,215.51
|
| Rate for Payer: Humana Commercial |
$11,824.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,407.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,266.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,173.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,241.73
|
| Rate for Payer: Ohio Health Group HMO |
$10,433.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,128.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,102.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,598.63
|
| Rate for Payer: PHCS Commercial |
$13,354.62
|
| Rate for Payer: United Healthcare All Payer |
$12,241.73
|
|
|
RESTORATN GAP II SHELL 48MM R
|
Facility
|
OP
|
$13,911.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,173.32 |
| Max. Negotiated Rate |
$13,354.62 |
| Rate for Payer: Aetna Commercial |
$10,711.52
|
| Rate for Payer: Anthem Medicaid |
$4,784.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,850.63
|
| Rate for Payer: Cash Price |
$6,955.53
|
| Rate for Payer: Cigna Commercial |
$11,546.18
|
| Rate for Payer: First Health Commercial |
$13,215.51
|
| Rate for Payer: Humana Commercial |
$11,824.40
|
| Rate for Payer: Humana KY Medicaid |
$4,784.01
|
| Rate for Payer: Kentucky WC Medicaid |
$4,832.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,407.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,266.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,173.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,880.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,241.73
|
| Rate for Payer: Ohio Health Group HMO |
$10,433.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,128.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,102.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,598.63
|
| Rate for Payer: PHCS Commercial |
$13,354.62
|
| Rate for Payer: United Healthcare All Payer |
$12,241.73
|
|
|
RESTORATN GAP II SHELL 48MM R
|
Facility
|
IP
|
$13,911.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,173.32 |
| Max. Negotiated Rate |
$13,354.62 |
| Rate for Payer: Aetna Commercial |
$10,711.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,850.63
|
| Rate for Payer: Cash Price |
$6,955.53
|
| Rate for Payer: Cigna Commercial |
$11,546.18
|
| Rate for Payer: First Health Commercial |
$13,215.51
|
| Rate for Payer: Humana Commercial |
$11,824.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,407.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,266.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,173.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,241.73
|
| Rate for Payer: Ohio Health Group HMO |
$10,433.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,128.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,102.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,598.63
|
| Rate for Payer: PHCS Commercial |
$13,354.62
|
| Rate for Payer: United Healthcare All Payer |
$12,241.73
|
|
|
RESTORATN GAP II SHELL 52MM L
|
Facility
|
IP
|
$13,911.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,173.32 |
| Max. Negotiated Rate |
$13,354.62 |
| Rate for Payer: Aetna Commercial |
$10,711.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,850.63
|
| Rate for Payer: Cash Price |
$6,955.53
|
| Rate for Payer: Cigna Commercial |
$11,546.18
|
| Rate for Payer: First Health Commercial |
$13,215.51
|
| Rate for Payer: Humana Commercial |
$11,824.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,407.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,266.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,173.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,241.73
|
| Rate for Payer: Ohio Health Group HMO |
$10,433.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,128.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,102.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,598.63
|
| Rate for Payer: PHCS Commercial |
$13,354.62
|
| Rate for Payer: United Healthcare All Payer |
$12,241.73
|
|
|
RESTORATN GAP II SHELL 52MM L
|
Facility
|
OP
|
$13,911.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,173.32 |
| Max. Negotiated Rate |
$13,354.62 |
| Rate for Payer: Aetna Commercial |
$10,711.52
|
| Rate for Payer: Anthem Medicaid |
$4,784.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,850.63
|
| Rate for Payer: Cash Price |
$6,955.53
|
| Rate for Payer: Cigna Commercial |
$11,546.18
|
| Rate for Payer: First Health Commercial |
$13,215.51
|
| Rate for Payer: Humana Commercial |
$11,824.40
|
| Rate for Payer: Humana KY Medicaid |
$4,784.01
|
| Rate for Payer: Kentucky WC Medicaid |
$4,832.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,407.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,266.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,173.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,880.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,241.73
|
| Rate for Payer: Ohio Health Group HMO |
$10,433.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,128.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,102.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,598.63
|
| Rate for Payer: PHCS Commercial |
$13,354.62
|
| Rate for Payer: United Healthcare All Payer |
$12,241.73
|
|
|
RESTORATN GAP II SHELL 52MM R
|
Facility
|
OP
|
$13,911.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,173.32 |
| Max. Negotiated Rate |
$13,354.62 |
| Rate for Payer: Aetna Commercial |
$10,711.52
|
| Rate for Payer: Anthem Medicaid |
$4,784.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,850.63
|
| Rate for Payer: Cash Price |
$6,955.53
|
| Rate for Payer: Cigna Commercial |
$11,546.18
|
| Rate for Payer: First Health Commercial |
$13,215.51
|
| Rate for Payer: Humana Commercial |
$11,824.40
|
| Rate for Payer: Humana KY Medicaid |
$4,784.01
|
| Rate for Payer: Kentucky WC Medicaid |
$4,832.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,407.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,266.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,173.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,880.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,241.73
|
| Rate for Payer: Ohio Health Group HMO |
$10,433.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,128.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,102.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,598.63
|
| Rate for Payer: PHCS Commercial |
$13,354.62
|
| Rate for Payer: United Healthcare All Payer |
$12,241.73
|
|
|
RESTORATN GAP II SHELL 52MM R
|
Facility
|
IP
|
$13,911.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,173.32 |
| Max. Negotiated Rate |
$13,354.62 |
| Rate for Payer: Aetna Commercial |
$10,711.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,850.63
|
| Rate for Payer: Cash Price |
$6,955.53
|
| Rate for Payer: Cigna Commercial |
$11,546.18
|
| Rate for Payer: First Health Commercial |
$13,215.51
|
| Rate for Payer: Humana Commercial |
$11,824.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,407.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,266.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,173.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,241.73
|
| Rate for Payer: Ohio Health Group HMO |
$10,433.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,128.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,102.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,598.63
|
| Rate for Payer: PHCS Commercial |
$13,354.62
|
| Rate for Payer: United Healthcare All Payer |
$12,241.73
|
|
|
RESTORATN GAP II SHELL 56MM L
|
Facility
|
IP
|
$13,911.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,173.32 |
| Max. Negotiated Rate |
$13,354.62 |
| Rate for Payer: Aetna Commercial |
$10,711.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,850.63
|
| Rate for Payer: Cash Price |
$6,955.53
|
| Rate for Payer: Cigna Commercial |
$11,546.18
|
| Rate for Payer: First Health Commercial |
$13,215.51
|
| Rate for Payer: Humana Commercial |
$11,824.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,407.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,266.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,173.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,241.73
|
| Rate for Payer: Ohio Health Group HMO |
$10,433.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,128.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,102.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,598.63
|
| Rate for Payer: PHCS Commercial |
$13,354.62
|
| Rate for Payer: United Healthcare All Payer |
$12,241.73
|
|
|
RESTORATN GAP II SHELL 56MM L
|
Facility
|
OP
|
$13,911.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,173.32 |
| Max. Negotiated Rate |
$13,354.62 |
| Rate for Payer: Aetna Commercial |
$10,711.52
|
| Rate for Payer: Anthem Medicaid |
$4,784.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,850.63
|
| Rate for Payer: Cash Price |
$6,955.53
|
| Rate for Payer: Cigna Commercial |
$11,546.18
|
| Rate for Payer: First Health Commercial |
$13,215.51
|
| Rate for Payer: Humana Commercial |
$11,824.40
|
| Rate for Payer: Humana KY Medicaid |
$4,784.01
|
| Rate for Payer: Kentucky WC Medicaid |
$4,832.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,407.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,266.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,173.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,880.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,241.73
|
| Rate for Payer: Ohio Health Group HMO |
$10,433.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,128.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,102.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,598.63
|
| Rate for Payer: PHCS Commercial |
$13,354.62
|
| Rate for Payer: United Healthcare All Payer |
$12,241.73
|
|
|
RESTORATN GAP II SHELL 56MM R
|
Facility
|
IP
|
$13,911.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,173.32 |
| Max. Negotiated Rate |
$13,354.62 |
| Rate for Payer: Aetna Commercial |
$10,711.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,850.63
|
| Rate for Payer: Cash Price |
$6,955.53
|
| Rate for Payer: Cigna Commercial |
$11,546.18
|
| Rate for Payer: First Health Commercial |
$13,215.51
|
| Rate for Payer: Humana Commercial |
$11,824.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,407.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,266.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,173.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,241.73
|
| Rate for Payer: Ohio Health Group HMO |
$10,433.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,128.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,102.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,598.63
|
| Rate for Payer: PHCS Commercial |
$13,354.62
|
| Rate for Payer: United Healthcare All Payer |
$12,241.73
|
|
|
RESTORATN GAP II SHELL 56MM R
|
Facility
|
OP
|
$13,911.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,173.32 |
| Max. Negotiated Rate |
$13,354.62 |
| Rate for Payer: Aetna Commercial |
$10,711.52
|
| Rate for Payer: Anthem Medicaid |
$4,784.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,850.63
|
| Rate for Payer: Cash Price |
$6,955.53
|
| Rate for Payer: Cigna Commercial |
$11,546.18
|
| Rate for Payer: First Health Commercial |
$13,215.51
|
| Rate for Payer: Humana Commercial |
$11,824.40
|
| Rate for Payer: Humana KY Medicaid |
$4,784.01
|
| Rate for Payer: Kentucky WC Medicaid |
$4,832.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,407.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,266.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,173.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,880.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,241.73
|
| Rate for Payer: Ohio Health Group HMO |
$10,433.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,128.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,102.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,598.63
|
| Rate for Payer: PHCS Commercial |
$13,354.62
|
| Rate for Payer: United Healthcare All Payer |
$12,241.73
|
|
|
RESTORATN GAP II SHELL 60MM L
|
Facility
|
IP
|
$13,911.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,173.32 |
| Max. Negotiated Rate |
$13,354.62 |
| Rate for Payer: Aetna Commercial |
$10,711.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,850.63
|
| Rate for Payer: Cash Price |
$6,955.53
|
| Rate for Payer: Cigna Commercial |
$11,546.18
|
| Rate for Payer: First Health Commercial |
$13,215.51
|
| Rate for Payer: Humana Commercial |
$11,824.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,407.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,266.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,173.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,241.73
|
| Rate for Payer: Ohio Health Group HMO |
$10,433.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,128.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,102.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,598.63
|
| Rate for Payer: PHCS Commercial |
$13,354.62
|
| Rate for Payer: United Healthcare All Payer |
$12,241.73
|
|
|
RESTORATN GAP II SHELL 60MM L
|
Facility
|
OP
|
$13,911.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,173.32 |
| Max. Negotiated Rate |
$13,354.62 |
| Rate for Payer: Aetna Commercial |
$10,711.52
|
| Rate for Payer: Anthem Medicaid |
$4,784.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,850.63
|
| Rate for Payer: Cash Price |
$6,955.53
|
| Rate for Payer: Cigna Commercial |
$11,546.18
|
| Rate for Payer: First Health Commercial |
$13,215.51
|
| Rate for Payer: Humana Commercial |
$11,824.40
|
| Rate for Payer: Humana KY Medicaid |
$4,784.01
|
| Rate for Payer: Kentucky WC Medicaid |
$4,832.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,407.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,266.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,173.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,880.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,241.73
|
| Rate for Payer: Ohio Health Group HMO |
$10,433.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,128.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,102.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,598.63
|
| Rate for Payer: PHCS Commercial |
$13,354.62
|
| Rate for Payer: United Healthcare All Payer |
$12,241.73
|
|
|
RESTORATN GAP II SHELL 60MM R
|
Facility
|
OP
|
$13,911.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,173.32 |
| Max. Negotiated Rate |
$13,354.62 |
| Rate for Payer: Aetna Commercial |
$10,711.52
|
| Rate for Payer: Anthem Medicaid |
$4,784.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,850.63
|
| Rate for Payer: Cash Price |
$6,955.53
|
| Rate for Payer: Cigna Commercial |
$11,546.18
|
| Rate for Payer: First Health Commercial |
$13,215.51
|
| Rate for Payer: Humana Commercial |
$11,824.40
|
| Rate for Payer: Humana KY Medicaid |
$4,784.01
|
| Rate for Payer: Kentucky WC Medicaid |
$4,832.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,407.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,266.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,173.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,880.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,241.73
|
| Rate for Payer: Ohio Health Group HMO |
$10,433.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,128.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,102.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,598.63
|
| Rate for Payer: PHCS Commercial |
$13,354.62
|
| Rate for Payer: United Healthcare All Payer |
$12,241.73
|
|
|
RESTORATN GAP II SHELL 60MM R
|
Facility
|
IP
|
$13,911.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,173.32 |
| Max. Negotiated Rate |
$13,354.62 |
| Rate for Payer: Aetna Commercial |
$10,711.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,850.63
|
| Rate for Payer: Cash Price |
$6,955.53
|
| Rate for Payer: Cigna Commercial |
$11,546.18
|
| Rate for Payer: First Health Commercial |
$13,215.51
|
| Rate for Payer: Humana Commercial |
$11,824.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,407.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,266.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,173.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,241.73
|
| Rate for Payer: Ohio Health Group HMO |
$10,433.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,128.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,102.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,598.63
|
| Rate for Payer: PHCS Commercial |
$13,354.62
|
| Rate for Payer: United Healthcare All Payer |
$12,241.73
|
|
|
RESTORATN GAP II SHELL 64MM L
|
Facility
|
OP
|
$13,911.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,173.32 |
| Max. Negotiated Rate |
$13,354.62 |
| Rate for Payer: Aetna Commercial |
$10,711.52
|
| Rate for Payer: Anthem Medicaid |
$4,784.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,850.63
|
| Rate for Payer: Cash Price |
$6,955.53
|
| Rate for Payer: Cigna Commercial |
$11,546.18
|
| Rate for Payer: First Health Commercial |
$13,215.51
|
| Rate for Payer: Humana Commercial |
$11,824.40
|
| Rate for Payer: Humana KY Medicaid |
$4,784.01
|
| Rate for Payer: Kentucky WC Medicaid |
$4,832.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,407.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,266.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,173.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,880.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,241.73
|
| Rate for Payer: Ohio Health Group HMO |
$10,433.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,128.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,102.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,598.63
|
| Rate for Payer: PHCS Commercial |
$13,354.62
|
| Rate for Payer: United Healthcare All Payer |
$12,241.73
|
|
|
RESTORATN GAP II SHELL 64MM L
|
Facility
|
IP
|
$13,911.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,173.32 |
| Max. Negotiated Rate |
$13,354.62 |
| Rate for Payer: Aetna Commercial |
$10,711.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,850.63
|
| Rate for Payer: Cash Price |
$6,955.53
|
| Rate for Payer: Cigna Commercial |
$11,546.18
|
| Rate for Payer: First Health Commercial |
$13,215.51
|
| Rate for Payer: Humana Commercial |
$11,824.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,407.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,266.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,173.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,241.73
|
| Rate for Payer: Ohio Health Group HMO |
$10,433.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,128.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,102.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,598.63
|
| Rate for Payer: PHCS Commercial |
$13,354.62
|
| Rate for Payer: United Healthcare All Payer |
$12,241.73
|
|
