|
RESTOR PS 4/16 203M RVHIP STEM
|
Facility
|
OP
|
$22,481.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,744.30 |
| Max. Negotiated Rate |
$21,581.76 |
| Rate for Payer: Aetna Commercial |
$17,310.37
|
| Rate for Payer: Anthem Medicaid |
$7,731.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,535.18
|
| Rate for Payer: Cash Price |
$11,240.50
|
| Rate for Payer: Cigna Commercial |
$18,659.23
|
| Rate for Payer: First Health Commercial |
$21,356.95
|
| Rate for Payer: Humana Commercial |
$19,108.85
|
| Rate for Payer: Humana KY Medicaid |
$7,731.22
|
| Rate for Payer: Kentucky WC Medicaid |
$7,809.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,434.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,590.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,744.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,886.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,783.28
|
| Rate for Payer: Ohio Health Group HMO |
$16,860.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,984.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,558.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,511.89
|
| Rate for Payer: PHCS Commercial |
$21,581.76
|
| Rate for Payer: United Healthcare All Payer |
$19,783.28
|
|
|
RESTOR PS 5/15 165M RVHIP STEM
|
Facility
|
IP
|
$21,185.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,355.50 |
| Max. Negotiated Rate |
$20,337.60 |
| Rate for Payer: Aetna Commercial |
$16,312.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,524.30
|
| Rate for Payer: Cash Price |
$10,592.50
|
| Rate for Payer: Cigna Commercial |
$17,583.55
|
| Rate for Payer: First Health Commercial |
$20,125.75
|
| Rate for Payer: Humana Commercial |
$18,007.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,371.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,634.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,355.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,642.80
|
| Rate for Payer: Ohio Health Group HMO |
$15,888.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,430.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,617.65
|
| Rate for Payer: PHCS Commercial |
$20,337.60
|
| Rate for Payer: United Healthcare All Payer |
$18,642.80
|
|
|
RESTOR PS 5/15 165M RVHIP STEM
|
Facility
|
OP
|
$21,185.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,355.50 |
| Max. Negotiated Rate |
$20,337.60 |
| Rate for Payer: Aetna Commercial |
$16,312.45
|
| Rate for Payer: Anthem Medicaid |
$7,285.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,524.30
|
| Rate for Payer: Cash Price |
$10,592.50
|
| Rate for Payer: Cigna Commercial |
$17,583.55
|
| Rate for Payer: First Health Commercial |
$20,125.75
|
| Rate for Payer: Humana Commercial |
$18,007.25
|
| Rate for Payer: Humana KY Medicaid |
$7,285.52
|
| Rate for Payer: Kentucky WC Medicaid |
$7,359.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,371.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,634.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,355.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,431.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,642.80
|
| Rate for Payer: Ohio Health Group HMO |
$15,888.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,430.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,617.65
|
| Rate for Payer: PHCS Commercial |
$20,337.60
|
| Rate for Payer: United Healthcare All Payer |
$18,642.80
|
|
|
RESTOR PS 5/15 203M RVHIP STEM
|
Facility
|
IP
|
$22,481.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,744.30 |
| Max. Negotiated Rate |
$21,581.76 |
| Rate for Payer: Aetna Commercial |
$17,310.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,535.18
|
| Rate for Payer: Cash Price |
$11,240.50
|
| Rate for Payer: Cigna Commercial |
$18,659.23
|
| Rate for Payer: First Health Commercial |
$21,356.95
|
| Rate for Payer: Humana Commercial |
$19,108.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,434.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,590.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,744.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,783.28
|
| Rate for Payer: Ohio Health Group HMO |
$16,860.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,984.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,558.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,511.89
|
| Rate for Payer: PHCS Commercial |
$21,581.76
|
| Rate for Payer: United Healthcare All Payer |
$19,783.28
|
|
|
RESTOR PS 5/15 203M RVHIP STEM
|
Facility
|
OP
|
$22,481.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,744.30 |
| Max. Negotiated Rate |
$21,581.76 |
| Rate for Payer: Aetna Commercial |
$17,310.37
|
| Rate for Payer: Anthem Medicaid |
$7,731.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,535.18
|
| Rate for Payer: Cash Price |
$11,240.50
|
| Rate for Payer: Cigna Commercial |
$18,659.23
|
| Rate for Payer: First Health Commercial |
$21,356.95
|
| Rate for Payer: Humana Commercial |
$19,108.85
|
| Rate for Payer: Humana KY Medicaid |
$7,731.22
|
| Rate for Payer: Kentucky WC Medicaid |
$7,809.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,434.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,590.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,744.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,886.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,783.28
|
| Rate for Payer: Ohio Health Group HMO |
$16,860.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,984.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,558.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,511.89
|
| Rate for Payer: PHCS Commercial |
$21,581.76
|
| Rate for Payer: United Healthcare All Payer |
$19,783.28
|
|
|
RESTOR PS 5/15 BOWD CTD 233MML
|
Facility
|
IP
|
$24,101.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,230.30 |
| Max. Negotiated Rate |
$23,136.96 |
| Rate for Payer: Aetna Commercial |
$18,557.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,798.78
|
| Rate for Payer: Cash Price |
$12,050.50
|
| Rate for Payer: Cigna Commercial |
$20,003.83
|
| Rate for Payer: First Health Commercial |
$22,895.95
|
| Rate for Payer: Humana Commercial |
$20,485.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,762.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,786.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,230.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,208.88
|
| Rate for Payer: Ohio Health Group HMO |
$18,075.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,280.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,967.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,629.69
|
| Rate for Payer: PHCS Commercial |
$23,136.96
|
| Rate for Payer: United Healthcare All Payer |
$21,208.88
|
|
|
RESTOR PS 5/15 BOWD CTD 233MML
|
Facility
|
OP
|
$24,101.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,230.30 |
| Max. Negotiated Rate |
$23,136.96 |
| Rate for Payer: Aetna Commercial |
$18,557.77
|
| Rate for Payer: Anthem Medicaid |
$8,288.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,798.78
|
| Rate for Payer: Cash Price |
$12,050.50
|
| Rate for Payer: Cigna Commercial |
$20,003.83
|
| Rate for Payer: First Health Commercial |
$22,895.95
|
| Rate for Payer: Humana Commercial |
$20,485.85
|
| Rate for Payer: Humana KY Medicaid |
$8,288.33
|
| Rate for Payer: Kentucky WC Medicaid |
$8,372.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,762.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,786.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,230.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,454.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,208.88
|
| Rate for Payer: Ohio Health Group HMO |
$18,075.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,280.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,967.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,629.69
|
| Rate for Payer: PHCS Commercial |
$23,136.96
|
| Rate for Payer: United Healthcare All Payer |
$21,208.88
|
|
|
RESTOR PS 5/15 BOWD CTD 233MMR
|
Facility
|
IP
|
$24,101.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,230.30 |
| Max. Negotiated Rate |
$23,136.96 |
| Rate for Payer: Aetna Commercial |
$18,557.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,798.78
|
| Rate for Payer: Cash Price |
$12,050.50
|
| Rate for Payer: Cigna Commercial |
$20,003.83
|
| Rate for Payer: First Health Commercial |
$22,895.95
|
| Rate for Payer: Humana Commercial |
$20,485.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,762.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,786.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,230.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,208.88
|
| Rate for Payer: Ohio Health Group HMO |
$18,075.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,280.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,967.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,629.69
|
| Rate for Payer: PHCS Commercial |
$23,136.96
|
| Rate for Payer: United Healthcare All Payer |
$21,208.88
|
|
|
RESTOR PS 5/15 BOWD CTD 233MMR
|
Facility
|
OP
|
$24,101.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,230.30 |
| Max. Negotiated Rate |
$23,136.96 |
| Rate for Payer: Aetna Commercial |
$18,557.77
|
| Rate for Payer: Anthem Medicaid |
$8,288.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,798.78
|
| Rate for Payer: Cash Price |
$12,050.50
|
| Rate for Payer: Cigna Commercial |
$20,003.83
|
| Rate for Payer: First Health Commercial |
$22,895.95
|
| Rate for Payer: Humana Commercial |
$20,485.85
|
| Rate for Payer: Humana KY Medicaid |
$8,288.33
|
| Rate for Payer: Kentucky WC Medicaid |
$8,372.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,762.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,786.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,230.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,454.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,208.88
|
| Rate for Payer: Ohio Health Group HMO |
$18,075.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,280.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,967.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,629.69
|
| Rate for Payer: PHCS Commercial |
$23,136.96
|
| Rate for Payer: United Healthcare All Payer |
$21,208.88
|
|
|
RESTOR PS 5/17 165M RVHIP STEM
|
Facility
|
IP
|
$21,185.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,355.50 |
| Max. Negotiated Rate |
$20,337.60 |
| Rate for Payer: Aetna Commercial |
$16,312.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,524.30
|
| Rate for Payer: Cash Price |
$10,592.50
|
| Rate for Payer: Cigna Commercial |
$17,583.55
|
| Rate for Payer: First Health Commercial |
$20,125.75
|
| Rate for Payer: Humana Commercial |
$18,007.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,371.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,634.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,355.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,642.80
|
| Rate for Payer: Ohio Health Group HMO |
$15,888.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,430.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,617.65
|
| Rate for Payer: PHCS Commercial |
$20,337.60
|
| Rate for Payer: United Healthcare All Payer |
$18,642.80
|
|
|
RESTOR PS 5/17 165M RVHIP STEM
|
Facility
|
OP
|
$21,185.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,355.50 |
| Max. Negotiated Rate |
$20,337.60 |
| Rate for Payer: Aetna Commercial |
$16,312.45
|
| Rate for Payer: Anthem Medicaid |
$7,285.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,524.30
|
| Rate for Payer: Cash Price |
$10,592.50
|
| Rate for Payer: Cigna Commercial |
$17,583.55
|
| Rate for Payer: First Health Commercial |
$20,125.75
|
| Rate for Payer: Humana Commercial |
$18,007.25
|
| Rate for Payer: Humana KY Medicaid |
$7,285.52
|
| Rate for Payer: Kentucky WC Medicaid |
$7,359.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,371.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,634.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,355.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,431.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,642.80
|
| Rate for Payer: Ohio Health Group HMO |
$15,888.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,430.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,617.65
|
| Rate for Payer: PHCS Commercial |
$20,337.60
|
| Rate for Payer: United Healthcare All Payer |
$18,642.80
|
|
|
RESTOR PS 5/17 203M RVHIP STEM
|
Facility
|
IP
|
$22,481.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,744.30 |
| Max. Negotiated Rate |
$21,581.76 |
| Rate for Payer: Aetna Commercial |
$17,310.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,535.18
|
| Rate for Payer: Cash Price |
$11,240.50
|
| Rate for Payer: Cigna Commercial |
$18,659.23
|
| Rate for Payer: First Health Commercial |
$21,356.95
|
| Rate for Payer: Humana Commercial |
$19,108.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,434.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,590.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,744.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,783.28
|
| Rate for Payer: Ohio Health Group HMO |
$16,860.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,984.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,558.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,511.89
|
| Rate for Payer: PHCS Commercial |
$21,581.76
|
| Rate for Payer: United Healthcare All Payer |
$19,783.28
|
|
|
RESTOR PS 5/17 203M RVHIP STEM
|
Facility
|
OP
|
$22,481.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,744.30 |
| Max. Negotiated Rate |
$21,581.76 |
| Rate for Payer: Aetna Commercial |
$17,310.37
|
| Rate for Payer: Anthem Medicaid |
$7,731.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,535.18
|
| Rate for Payer: Cash Price |
$11,240.50
|
| Rate for Payer: Cigna Commercial |
$18,659.23
|
| Rate for Payer: First Health Commercial |
$21,356.95
|
| Rate for Payer: Humana Commercial |
$19,108.85
|
| Rate for Payer: Humana KY Medicaid |
$7,731.22
|
| Rate for Payer: Kentucky WC Medicaid |
$7,809.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,434.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,590.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,744.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,886.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,783.28
|
| Rate for Payer: Ohio Health Group HMO |
$16,860.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,984.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,558.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,511.89
|
| Rate for Payer: PHCS Commercial |
$21,581.76
|
| Rate for Payer: United Healthcare All Payer |
$19,783.28
|
|
|
RESTOR PS 6/16 165M RVHIP STEM
|
Facility
|
IP
|
$21,185.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,355.50 |
| Max. Negotiated Rate |
$20,337.60 |
| Rate for Payer: Aetna Commercial |
$16,312.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,524.30
|
| Rate for Payer: Cash Price |
$10,592.50
|
| Rate for Payer: Cigna Commercial |
$17,583.55
|
| Rate for Payer: First Health Commercial |
$20,125.75
|
| Rate for Payer: Humana Commercial |
$18,007.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,371.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,634.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,355.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,642.80
|
| Rate for Payer: Ohio Health Group HMO |
$15,888.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,430.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,617.65
|
| Rate for Payer: PHCS Commercial |
$20,337.60
|
| Rate for Payer: United Healthcare All Payer |
$18,642.80
|
|
|
RESTOR PS 6/16 165M RVHIP STEM
|
Facility
|
OP
|
$21,185.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,355.50 |
| Max. Negotiated Rate |
$20,337.60 |
| Rate for Payer: Aetna Commercial |
$16,312.45
|
| Rate for Payer: Anthem Medicaid |
$7,285.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,524.30
|
| Rate for Payer: Cash Price |
$10,592.50
|
| Rate for Payer: Cigna Commercial |
$17,583.55
|
| Rate for Payer: First Health Commercial |
$20,125.75
|
| Rate for Payer: Humana Commercial |
$18,007.25
|
| Rate for Payer: Humana KY Medicaid |
$7,285.52
|
| Rate for Payer: Kentucky WC Medicaid |
$7,359.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,371.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,634.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,355.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,431.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,642.80
|
| Rate for Payer: Ohio Health Group HMO |
$15,888.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,430.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,617.65
|
| Rate for Payer: PHCS Commercial |
$20,337.60
|
| Rate for Payer: United Healthcare All Payer |
$18,642.80
|
|
|
RESTOR PS 6/16 203M RVHIP STEM
|
Facility
|
IP
|
$22,481.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,744.30 |
| Max. Negotiated Rate |
$21,581.76 |
| Rate for Payer: Aetna Commercial |
$17,310.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,535.18
|
| Rate for Payer: Cash Price |
$11,240.50
|
| Rate for Payer: Cigna Commercial |
$18,659.23
|
| Rate for Payer: First Health Commercial |
$21,356.95
|
| Rate for Payer: Humana Commercial |
$19,108.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,434.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,590.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,744.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,783.28
|
| Rate for Payer: Ohio Health Group HMO |
$16,860.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,984.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,558.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,511.89
|
| Rate for Payer: PHCS Commercial |
$21,581.76
|
| Rate for Payer: United Healthcare All Payer |
$19,783.28
|
|
|
RESTOR PS 6/16 203M RVHIP STEM
|
Facility
|
OP
|
$22,481.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,744.30 |
| Max. Negotiated Rate |
$21,581.76 |
| Rate for Payer: Aetna Commercial |
$17,310.37
|
| Rate for Payer: Anthem Medicaid |
$7,731.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,535.18
|
| Rate for Payer: Cash Price |
$11,240.50
|
| Rate for Payer: Cigna Commercial |
$18,659.23
|
| Rate for Payer: First Health Commercial |
$21,356.95
|
| Rate for Payer: Humana Commercial |
$19,108.85
|
| Rate for Payer: Humana KY Medicaid |
$7,731.22
|
| Rate for Payer: Kentucky WC Medicaid |
$7,809.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,434.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,590.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,744.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,886.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,783.28
|
| Rate for Payer: Ohio Health Group HMO |
$16,860.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,984.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,558.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,511.89
|
| Rate for Payer: PHCS Commercial |
$21,581.76
|
| Rate for Payer: United Healthcare All Payer |
$19,783.28
|
|
|
RESTOR PS 6/16 BOWD CTD 234MML
|
Facility
|
IP
|
$24,101.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,230.30 |
| Max. Negotiated Rate |
$23,136.96 |
| Rate for Payer: Aetna Commercial |
$18,557.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,798.78
|
| Rate for Payer: Cash Price |
$12,050.50
|
| Rate for Payer: Cigna Commercial |
$20,003.83
|
| Rate for Payer: First Health Commercial |
$22,895.95
|
| Rate for Payer: Humana Commercial |
$20,485.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,762.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,786.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,230.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,208.88
|
| Rate for Payer: Ohio Health Group HMO |
$18,075.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,280.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,967.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,629.69
|
| Rate for Payer: PHCS Commercial |
$23,136.96
|
| Rate for Payer: United Healthcare All Payer |
$21,208.88
|
|
|
RESTOR PS 6/16 BOWD CTD 234MML
|
Facility
|
OP
|
$24,101.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,230.30 |
| Max. Negotiated Rate |
$23,136.96 |
| Rate for Payer: Aetna Commercial |
$18,557.77
|
| Rate for Payer: Anthem Medicaid |
$8,288.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,798.78
|
| Rate for Payer: Cash Price |
$12,050.50
|
| Rate for Payer: Cigna Commercial |
$20,003.83
|
| Rate for Payer: First Health Commercial |
$22,895.95
|
| Rate for Payer: Humana Commercial |
$20,485.85
|
| Rate for Payer: Humana KY Medicaid |
$8,288.33
|
| Rate for Payer: Kentucky WC Medicaid |
$8,372.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,762.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,786.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,230.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,454.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,208.88
|
| Rate for Payer: Ohio Health Group HMO |
$18,075.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,280.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,967.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,629.69
|
| Rate for Payer: PHCS Commercial |
$23,136.96
|
| Rate for Payer: United Healthcare All Payer |
$21,208.88
|
|
|
RESTOR PS 6/16 BOWD CTD 234MMR
|
Facility
|
OP
|
$24,101.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,230.30 |
| Max. Negotiated Rate |
$23,136.96 |
| Rate for Payer: Aetna Commercial |
$18,557.77
|
| Rate for Payer: Anthem Medicaid |
$8,288.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,798.78
|
| Rate for Payer: Cash Price |
$12,050.50
|
| Rate for Payer: Cigna Commercial |
$20,003.83
|
| Rate for Payer: First Health Commercial |
$22,895.95
|
| Rate for Payer: Humana Commercial |
$20,485.85
|
| Rate for Payer: Humana KY Medicaid |
$8,288.33
|
| Rate for Payer: Kentucky WC Medicaid |
$8,372.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,762.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,786.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,230.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,454.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,208.88
|
| Rate for Payer: Ohio Health Group HMO |
$18,075.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,280.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,967.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,629.69
|
| Rate for Payer: PHCS Commercial |
$23,136.96
|
| Rate for Payer: United Healthcare All Payer |
$21,208.88
|
|
|
RESTOR PS 6/16 BOWD CTD 234MMR
|
Facility
|
IP
|
$24,101.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,230.30 |
| Max. Negotiated Rate |
$23,136.96 |
| Rate for Payer: Aetna Commercial |
$18,557.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,798.78
|
| Rate for Payer: Cash Price |
$12,050.50
|
| Rate for Payer: Cigna Commercial |
$20,003.83
|
| Rate for Payer: First Health Commercial |
$22,895.95
|
| Rate for Payer: Humana Commercial |
$20,485.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,762.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,786.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,230.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,208.88
|
| Rate for Payer: Ohio Health Group HMO |
$18,075.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,280.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,967.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,629.69
|
| Rate for Payer: PHCS Commercial |
$23,136.96
|
| Rate for Payer: United Healthcare All Payer |
$21,208.88
|
|
|
RESTOR PS 6/18 165M RVHIP STEM
|
Facility
|
OP
|
$21,185.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,355.50 |
| Max. Negotiated Rate |
$20,337.60 |
| Rate for Payer: Aetna Commercial |
$16,312.45
|
| Rate for Payer: Anthem Medicaid |
$7,285.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,524.30
|
| Rate for Payer: Cash Price |
$10,592.50
|
| Rate for Payer: Cigna Commercial |
$17,583.55
|
| Rate for Payer: First Health Commercial |
$20,125.75
|
| Rate for Payer: Humana Commercial |
$18,007.25
|
| Rate for Payer: Humana KY Medicaid |
$7,285.52
|
| Rate for Payer: Kentucky WC Medicaid |
$7,359.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,371.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,634.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,355.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,431.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,642.80
|
| Rate for Payer: Ohio Health Group HMO |
$15,888.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,430.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,617.65
|
| Rate for Payer: PHCS Commercial |
$20,337.60
|
| Rate for Payer: United Healthcare All Payer |
$18,642.80
|
|
|
RESTOR PS 6/18 165M RVHIP STEM
|
Facility
|
IP
|
$21,185.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,355.50 |
| Max. Negotiated Rate |
$20,337.60 |
| Rate for Payer: Aetna Commercial |
$16,312.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,524.30
|
| Rate for Payer: Cash Price |
$10,592.50
|
| Rate for Payer: Cigna Commercial |
$17,583.55
|
| Rate for Payer: First Health Commercial |
$20,125.75
|
| Rate for Payer: Humana Commercial |
$18,007.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,371.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,634.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,355.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,642.80
|
| Rate for Payer: Ohio Health Group HMO |
$15,888.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,430.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,617.65
|
| Rate for Payer: PHCS Commercial |
$20,337.60
|
| Rate for Payer: United Healthcare All Payer |
$18,642.80
|
|
|
RESTOR PS 6/18 203M RVHIP STEM
|
Facility
|
IP
|
$22,481.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,744.30 |
| Max. Negotiated Rate |
$21,581.76 |
| Rate for Payer: Aetna Commercial |
$17,310.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,535.18
|
| Rate for Payer: Cash Price |
$11,240.50
|
| Rate for Payer: Cigna Commercial |
$18,659.23
|
| Rate for Payer: First Health Commercial |
$21,356.95
|
| Rate for Payer: Humana Commercial |
$19,108.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,434.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,590.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,744.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,783.28
|
| Rate for Payer: Ohio Health Group HMO |
$16,860.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,984.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,558.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,511.89
|
| Rate for Payer: PHCS Commercial |
$21,581.76
|
| Rate for Payer: United Healthcare All Payer |
$19,783.28
|
|
|
RESTOR PS 6/18 203M RVHIP STEM
|
Facility
|
OP
|
$22,481.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,744.30 |
| Max. Negotiated Rate |
$21,581.76 |
| Rate for Payer: Aetna Commercial |
$17,310.37
|
| Rate for Payer: Anthem Medicaid |
$7,731.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,535.18
|
| Rate for Payer: Cash Price |
$11,240.50
|
| Rate for Payer: Cigna Commercial |
$18,659.23
|
| Rate for Payer: First Health Commercial |
$21,356.95
|
| Rate for Payer: Humana Commercial |
$19,108.85
|
| Rate for Payer: Humana KY Medicaid |
$7,731.22
|
| Rate for Payer: Kentucky WC Medicaid |
$7,809.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,434.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,590.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,744.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,886.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,783.28
|
| Rate for Payer: Ohio Health Group HMO |
$16,860.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,984.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,558.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,511.89
|
| Rate for Payer: PHCS Commercial |
$21,581.76
|
| Rate for Payer: United Healthcare All Payer |
$19,783.28
|
|
