|
RESTORATN PS 5/15 BOW 233MM 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 PS 5/17 203MM BOW L
|
Facility
|
OP
|
$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 Medicaid |
$8,065.49
|
| 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: Humana KY Medicaid |
$8,065.49
|
| Rate for Payer: Kentucky WC Medicaid |
$8,147.57
|
| 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: Molina Healthcare Medicaid |
$8,227.31
|
| 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
|
|
|
RESTORATN PS 5/17 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
|
|
|
RESTORATN PS 5/17 203MM BOW R
|
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
|
|
|
RESTORATN PS 5/17 203MM BOW R
|
Facility
|
OP
|
$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 Medicaid |
$8,065.49
|
| 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: Humana KY Medicaid |
$8,065.49
|
| Rate for Payer: Kentucky WC Medicaid |
$8,147.57
|
| 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: Molina Healthcare Medicaid |
$8,227.31
|
| 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
|
|
|
RESTORATN PS 6/16 203MM BOW L
|
Facility
|
OP
|
$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 Medicaid |
$8,065.49
|
| 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: Humana KY Medicaid |
$8,065.49
|
| Rate for Payer: Kentucky WC Medicaid |
$8,147.57
|
| 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: Molina Healthcare Medicaid |
$8,227.31
|
| 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
|
|
|
RESTORATN PS 6/16 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
|
|
|
RESTORATN PS 6/16 203MM BOW R
|
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
|
|
|
RESTORATN PS 6/16 203MM BOW R
|
Facility
|
OP
|
$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 Medicaid |
$8,065.49
|
| 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: Humana KY Medicaid |
$8,065.49
|
| Rate for Payer: Kentucky WC Medicaid |
$8,147.57
|
| 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: Molina Healthcare Medicaid |
$8,227.31
|
| 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
|
|
|
RESTORATN PS 6/16 BOW 242MM L
|
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 PS 6/16 BOW 242MM L
|
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
|
|
|
RESTORATN PS 6/16 BOW 242MM 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 PS 6/16 BOW 242MM 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
|
|
|
RESTORATN PS 6/18 203MM BOW L
|
Facility
|
OP
|
$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 Medicaid |
$8,065.49
|
| 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: Humana KY Medicaid |
$8,065.49
|
| Rate for Payer: Kentucky WC Medicaid |
$8,147.57
|
| 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: Molina Healthcare Medicaid |
$8,227.31
|
| 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
|
|
|
RESTORATN PS 6/18 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
|
|
|
RESTORATN PS 6/18 203MM BOW R
|
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
|
|
|
RESTORATN PS 6/18 203MM BOW R
|
Facility
|
OP
|
$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 Medicaid |
$8,065.49
|
| 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: Humana KY Medicaid |
$8,065.49
|
| Rate for Payer: Kentucky WC Medicaid |
$8,147.57
|
| 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: Molina Healthcare Medicaid |
$8,227.31
|
| 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
|
|
|
RESTORATN PS 7/17 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
|
|
|
RESTORATN PS 7/17 203MM BOW L
|
Facility
|
OP
|
$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 Medicaid |
$8,065.49
|
| 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: Humana KY Medicaid |
$8,065.49
|
| Rate for Payer: Kentucky WC Medicaid |
$8,147.57
|
| 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: Molina Healthcare Medicaid |
$8,227.31
|
| 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
|
|
|
RESTORATN PS 7/17 203MM BOW R
|
Facility
|
OP
|
$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 Medicaid |
$8,065.49
|
| 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: Humana KY Medicaid |
$8,065.49
|
| Rate for Payer: Kentucky WC Medicaid |
$8,147.57
|
| 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: Molina Healthcare Medicaid |
$8,227.31
|
| 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
|
|
|
RESTORATN PS 7/17 203MM BOW R
|
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
|
|
|
RESTORATN PS 7/17 BOW 241MM L
|
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
|
|
|
RESTORATN PS 7/17 BOW 241MM L
|
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 PS 7/19 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
|
|
|
RESTORATN PS 7/19 203MM BOW L
|
Facility
|
OP
|
$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 Medicaid |
$8,065.49
|
| 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: Humana KY Medicaid |
$8,065.49
|
| Rate for Payer: Kentucky WC Medicaid |
$8,147.57
|
| 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: Molina Healthcare Medicaid |
$8,227.31
|
| 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
|
|
