|
RESTORATN GAP II SHELL 64MM 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 64MM 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 68MM 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 68MM 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 68MM 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 68MM 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 72MM 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 72MM 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 72MM 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 72MM 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 HIP STEM 40*205 SZ10
|
Facility
|
OP
|
$30,239.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,071.81 |
| Max. Negotiated Rate |
$29,029.80 |
| Rate for Payer: Aetna Commercial |
$23,284.32
|
| Rate for Payer: Anthem Medicaid |
$10,399.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23,586.72
|
| Rate for Payer: Cash Price |
$15,119.69
|
| Rate for Payer: Cigna Commercial |
$25,098.69
|
| Rate for Payer: First Health Commercial |
$28,727.41
|
| Rate for Payer: Humana Commercial |
$25,703.47
|
| Rate for Payer: Humana KY Medicaid |
$10,399.32
|
| Rate for Payer: Kentucky WC Medicaid |
$10,505.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24,796.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22,316.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,071.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,607.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$26,610.65
|
| Rate for Payer: Ohio Health Group HMO |
$22,679.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24,191.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26,308.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20,865.17
|
| Rate for Payer: PHCS Commercial |
$29,029.80
|
| Rate for Payer: United Healthcare All Payer |
$26,610.65
|
|
|
RESTORATN HIP STEM 40*205 SZ10
|
Facility
|
IP
|
$30,239.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,071.81 |
| Max. Negotiated Rate |
$29,029.80 |
| Rate for Payer: Aetna Commercial |
$23,284.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23,586.72
|
| Rate for Payer: Cash Price |
$15,119.69
|
| Rate for Payer: Cigna Commercial |
$25,098.69
|
| Rate for Payer: First Health Commercial |
$28,727.41
|
| Rate for Payer: Humana Commercial |
$25,703.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24,796.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22,316.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,071.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$26,610.65
|
| Rate for Payer: Ohio Health Group HMO |
$22,679.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24,191.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26,308.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20,865.17
|
| Rate for Payer: PHCS Commercial |
$29,029.80
|
| Rate for Payer: United Healthcare All Payer |
$26,610.65
|
|
|
RESTORATN MOD HIP STEM 16*235M
|
Facility
|
OP
|
$18,217.65
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,465.30 |
| Max. Negotiated Rate |
$17,488.94 |
| Rate for Payer: Aetna Commercial |
$14,027.59
|
| Rate for Payer: Anthem Medicaid |
$6,265.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,209.77
|
| Rate for Payer: Cash Price |
$9,108.83
|
| Rate for Payer: Cigna Commercial |
$15,120.65
|
| Rate for Payer: First Health Commercial |
$17,306.77
|
| Rate for Payer: Humana Commercial |
$15,485.00
|
| Rate for Payer: Humana KY Medicaid |
$6,265.05
|
| Rate for Payer: Kentucky WC Medicaid |
$6,328.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,938.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,444.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,465.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,390.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,031.53
|
| Rate for Payer: Ohio Health Group HMO |
$13,663.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,574.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,849.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,570.18
|
| Rate for Payer: PHCS Commercial |
$17,488.94
|
| Rate for Payer: United Healthcare All Payer |
$16,031.53
|
|
|
RESTORATN MOD HIP STEM 16*235M
|
Facility
|
IP
|
$18,217.65
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,465.30 |
| Max. Negotiated Rate |
$17,488.94 |
| Rate for Payer: Aetna Commercial |
$14,027.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,209.77
|
| Rate for Payer: Cash Price |
$9,108.83
|
| Rate for Payer: Cigna Commercial |
$15,120.65
|
| Rate for Payer: First Health Commercial |
$17,306.77
|
| Rate for Payer: Humana Commercial |
$15,485.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,938.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,444.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,465.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,031.53
|
| Rate for Payer: Ohio Health Group HMO |
$13,663.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,574.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,849.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,570.18
|
| Rate for Payer: PHCS Commercial |
$17,488.94
|
| Rate for Payer: United Healthcare All Payer |
$16,031.53
|
|
|
RESTORATN MOD HIP STEM 19*155M
|
Facility
|
OP
|
$17,005.53
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,101.66 |
| Max. Negotiated Rate |
$16,325.31 |
| Rate for Payer: Aetna Commercial |
$13,094.26
|
| Rate for Payer: Anthem Medicaid |
$5,848.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,264.31
|
| Rate for Payer: Cash Price |
$8,502.76
|
| Rate for Payer: Cigna Commercial |
$14,114.59
|
| Rate for Payer: First Health Commercial |
$16,155.25
|
| Rate for Payer: Humana Commercial |
$14,454.70
|
| Rate for Payer: Humana KY Medicaid |
$5,848.20
|
| Rate for Payer: Kentucky WC Medicaid |
$5,907.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,944.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,550.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,101.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,965.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,964.87
|
| Rate for Payer: Ohio Health Group HMO |
$12,754.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,604.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,794.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,733.82
|
| Rate for Payer: PHCS Commercial |
$16,325.31
|
| Rate for Payer: United Healthcare All Payer |
$14,964.87
|
|
|
RESTORATN MOD HIP STEM 19*155M
|
Facility
|
IP
|
$17,005.53
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,101.66 |
| Max. Negotiated Rate |
$16,325.31 |
| Rate for Payer: Aetna Commercial |
$13,094.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,264.31
|
| Rate for Payer: Cash Price |
$8,502.76
|
| Rate for Payer: Cigna Commercial |
$14,114.59
|
| Rate for Payer: First Health Commercial |
$16,155.25
|
| Rate for Payer: Humana Commercial |
$14,454.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,944.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,550.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,101.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,964.87
|
| Rate for Payer: Ohio Health Group HMO |
$12,754.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,604.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,794.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,733.82
|
| Rate for Payer: PHCS Commercial |
$16,325.31
|
| Rate for Payer: United Healthcare All Payer |
$14,964.87
|
|
|
RESTORATN MOD HIP STEM 19*235M
|
Facility
|
IP
|
$18,217.65
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,465.30 |
| Max. Negotiated Rate |
$17,488.94 |
| Rate for Payer: Aetna Commercial |
$14,027.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,209.77
|
| Rate for Payer: Cash Price |
$9,108.83
|
| Rate for Payer: Cigna Commercial |
$15,120.65
|
| Rate for Payer: First Health Commercial |
$17,306.77
|
| Rate for Payer: Humana Commercial |
$15,485.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,938.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,444.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,465.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,031.53
|
| Rate for Payer: Ohio Health Group HMO |
$13,663.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,574.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,849.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,570.18
|
| Rate for Payer: PHCS Commercial |
$17,488.94
|
| Rate for Payer: United Healthcare All Payer |
$16,031.53
|
|
|
RESTORATN MOD HIP STEM 19*235M
|
Facility
|
OP
|
$18,217.65
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,465.30 |
| Max. Negotiated Rate |
$17,488.94 |
| Rate for Payer: Aetna Commercial |
$14,027.59
|
| Rate for Payer: Anthem Medicaid |
$6,265.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,209.77
|
| Rate for Payer: Cash Price |
$9,108.83
|
| Rate for Payer: Cigna Commercial |
$15,120.65
|
| Rate for Payer: First Health Commercial |
$17,306.77
|
| Rate for Payer: Humana Commercial |
$15,485.00
|
| Rate for Payer: Humana KY Medicaid |
$6,265.05
|
| Rate for Payer: Kentucky WC Medicaid |
$6,328.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,938.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,444.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,465.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,390.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,031.53
|
| Rate for Payer: Ohio Health Group HMO |
$13,663.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,574.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,849.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,570.18
|
| Rate for Payer: PHCS Commercial |
$17,488.94
|
| Rate for Payer: United Healthcare All Payer |
$16,031.53
|
|
|
RESTORATN MOD HIP SYS 25M +10
|
Facility
|
IP
|
$24,035.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,210.50 |
| Max. Negotiated Rate |
$23,073.60 |
| Rate for Payer: Aetna Commercial |
$18,506.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,747.30
|
| Rate for Payer: Cash Price |
$12,017.50
|
| Rate for Payer: Cigna Commercial |
$19,949.05
|
| Rate for Payer: First Health Commercial |
$22,833.25
|
| Rate for Payer: Humana Commercial |
$20,429.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,708.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,737.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,210.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,150.80
|
| Rate for Payer: Ohio Health Group HMO |
$18,026.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,228.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,910.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,584.15
|
| Rate for Payer: PHCS Commercial |
$23,073.60
|
| Rate for Payer: United Healthcare All Payer |
$21,150.80
|
|
|
RESTORATN MOD HIP SYS 25M +10
|
Facility
|
OP
|
$24,035.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,210.50 |
| Max. Negotiated Rate |
$23,073.60 |
| Rate for Payer: Aetna Commercial |
$18,506.95
|
| Rate for Payer: Anthem Medicaid |
$8,265.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,747.30
|
| Rate for Payer: Cash Price |
$12,017.50
|
| Rate for Payer: Cigna Commercial |
$19,949.05
|
| Rate for Payer: First Health Commercial |
$22,833.25
|
| Rate for Payer: Humana Commercial |
$20,429.75
|
| Rate for Payer: Humana KY Medicaid |
$8,265.64
|
| Rate for Payer: Kentucky WC Medicaid |
$8,349.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,708.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,737.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,210.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,431.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,150.80
|
| Rate for Payer: Ohio Health Group HMO |
$18,026.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,228.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,910.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,584.15
|
| Rate for Payer: PHCS Commercial |
$23,073.60
|
| Rate for Payer: United Healthcare All Payer |
$21,150.80
|
|
|
RESTORATN MOD HIP V40 23MM +20
|
Facility
|
OP
|
$21,613.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,484.09 |
| Max. Negotiated Rate |
$20,749.08 |
| Rate for Payer: Aetna Commercial |
$16,642.49
|
| Rate for Payer: Anthem Medicaid |
$7,432.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,858.62
|
| Rate for Payer: Cash Price |
$10,806.81
|
| Rate for Payer: Cigna Commercial |
$17,939.30
|
| Rate for Payer: First Health Commercial |
$20,532.94
|
| Rate for Payer: Humana Commercial |
$18,371.58
|
| Rate for Payer: Humana KY Medicaid |
$7,432.92
|
| Rate for Payer: Kentucky WC Medicaid |
$7,508.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,723.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,950.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,484.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,582.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,019.99
|
| Rate for Payer: Ohio Health Group HMO |
$16,210.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,290.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,803.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,913.40
|
| Rate for Payer: PHCS Commercial |
$20,749.08
|
| Rate for Payer: United Healthcare All Payer |
$19,019.99
|
|
|
RESTORATN MOD HIP V40 23MM +20
|
Facility
|
IP
|
$21,613.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,484.09 |
| Max. Negotiated Rate |
$20,749.08 |
| Rate for Payer: Aetna Commercial |
$16,642.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,858.62
|
| Rate for Payer: Cash Price |
$10,806.81
|
| Rate for Payer: Cigna Commercial |
$17,939.30
|
| Rate for Payer: First Health Commercial |
$20,532.94
|
| Rate for Payer: Humana Commercial |
$18,371.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,723.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,950.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,484.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,019.99
|
| Rate for Payer: Ohio Health Group HMO |
$16,210.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,290.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,803.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,913.40
|
| Rate for Payer: PHCS Commercial |
$20,749.08
|
| Rate for Payer: United Healthcare All Payer |
$19,019.99
|
|
|
RESTORATN MOD HIP V40 25MM +20
|
Facility
|
OP
|
$22,831.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,849.49 |
| Max. Negotiated Rate |
$21,918.36 |
| Rate for Payer: Aetna Commercial |
$17,580.35
|
| Rate for Payer: Anthem Medicaid |
$7,851.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,808.66
|
| Rate for Payer: Cash Price |
$11,415.81
|
| Rate for Payer: Cigna Commercial |
$18,950.24
|
| Rate for Payer: First Health Commercial |
$21,690.04
|
| Rate for Payer: Humana Commercial |
$19,406.88
|
| Rate for Payer: Humana KY Medicaid |
$7,851.79
|
| Rate for Payer: Kentucky WC Medicaid |
$7,931.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,721.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,849.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,849.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,009.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,091.83
|
| Rate for Payer: Ohio Health Group HMO |
$17,123.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,265.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,863.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,753.82
|
| Rate for Payer: PHCS Commercial |
$21,918.36
|
| Rate for Payer: United Healthcare All Payer |
$20,091.83
|
|
|
RESTORATN MOD HIP V40 25MM +20
|
Facility
|
IP
|
$22,831.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,849.49 |
| Max. Negotiated Rate |
$21,918.36 |
| Rate for Payer: Aetna Commercial |
$17,580.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,808.66
|
| Rate for Payer: Cash Price |
$11,415.81
|
| Rate for Payer: Cigna Commercial |
$18,950.24
|
| Rate for Payer: First Health Commercial |
$21,690.04
|
| Rate for Payer: Humana Commercial |
$19,406.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,721.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,849.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,849.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,091.83
|
| Rate for Payer: Ohio Health Group HMO |
$17,123.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,265.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,863.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,753.82
|
| Rate for Payer: PHCS Commercial |
$21,918.36
|
| Rate for Payer: United Healthcare All Payer |
$20,091.83
|
|
|
RESTORATN PS 1/11 203MM BOW L
|
Facility
|
IP
|
$23,453.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,035.90 |
| Max. Negotiated Rate |
$22,514.88 |
| Rate for Payer: Aetna Commercial |
$18,058.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,293.34
|
| Rate for Payer: Cash Price |
$11,726.50
|
| Rate for Payer: Cigna Commercial |
$19,465.99
|
| Rate for Payer: First Health Commercial |
$22,280.35
|
| Rate for Payer: Humana Commercial |
$19,935.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,231.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,308.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,035.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,638.64
|
| Rate for Payer: Ohio Health Group HMO |
$17,589.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,762.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,404.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,182.57
|
| Rate for Payer: PHCS Commercial |
$22,514.88
|
| Rate for Payer: United Healthcare All Payer |
$20,638.64
|
|
