|
RESTOR PS 8/20 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 8/20 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 8/20 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 8/20 BOWD CTD 251MML
|
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 8/20 BOWD CTD 251MML
|
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 8/20 BOWD CTD 251MMR
|
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 8/20 BOWD CTD 251MMR
|
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 9/21 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 9/21 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 921 203M REVHIP 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 921 203M REVHIP 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 9/21 BOWD CTD 250MML
|
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 9/21 BOWD CTD 250MML
|
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 9/21 BOWD CTD 250MMR
|
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 9/21 BOWD CTD 250MMR
|
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
|
|
|
REST PLASM DSTAL STEM 12*127 S
|
Facility
|
OP
|
$14,228.14
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,268.44 |
| Max. Negotiated Rate |
$13,659.01 |
| Rate for Payer: Aetna Commercial |
$10,955.67
|
| Rate for Payer: Anthem Medicaid |
$4,893.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,097.95
|
| Rate for Payer: Cash Price |
$7,114.07
|
| Rate for Payer: Cigna Commercial |
$11,809.36
|
| Rate for Payer: First Health Commercial |
$13,516.73
|
| Rate for Payer: Humana Commercial |
$12,093.92
|
| Rate for Payer: Humana KY Medicaid |
$4,893.06
|
| Rate for Payer: Kentucky WC Medicaid |
$4,942.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,667.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,500.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,268.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,991.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,520.76
|
| Rate for Payer: Ohio Health Group HMO |
$10,671.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,382.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,378.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,817.42
|
| Rate for Payer: PHCS Commercial |
$13,659.01
|
| Rate for Payer: United Healthcare All Payer |
$12,520.76
|
|
|
REST PLASM DSTAL STEM 12*127 S
|
Facility
|
IP
|
$14,228.14
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,268.44 |
| Max. Negotiated Rate |
$13,659.01 |
| Rate for Payer: Aetna Commercial |
$10,955.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,097.95
|
| Rate for Payer: Cash Price |
$7,114.07
|
| Rate for Payer: Cigna Commercial |
$11,809.36
|
| Rate for Payer: First Health Commercial |
$13,516.73
|
| Rate for Payer: Humana Commercial |
$12,093.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,667.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,500.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,268.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,520.76
|
| Rate for Payer: Ohio Health Group HMO |
$10,671.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,382.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,378.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,817.42
|
| Rate for Payer: PHCS Commercial |
$13,659.01
|
| Rate for Payer: United Healthcare All Payer |
$12,520.76
|
|
|
REST PLASM DSTAL STEM 13*127 S
|
Facility
|
IP
|
$14,228.14
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,268.44 |
| Max. Negotiated Rate |
$13,659.01 |
| Rate for Payer: Aetna Commercial |
$10,955.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,097.95
|
| Rate for Payer: Cash Price |
$7,114.07
|
| Rate for Payer: Cigna Commercial |
$11,809.36
|
| Rate for Payer: First Health Commercial |
$13,516.73
|
| Rate for Payer: Humana Commercial |
$12,093.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,667.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,500.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,268.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,520.76
|
| Rate for Payer: Ohio Health Group HMO |
$10,671.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,382.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,378.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,817.42
|
| Rate for Payer: PHCS Commercial |
$13,659.01
|
| Rate for Payer: United Healthcare All Payer |
$12,520.76
|
|
|
REST PLASM DSTAL STEM 13*127 S
|
Facility
|
OP
|
$14,228.14
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,268.44 |
| Max. Negotiated Rate |
$13,659.01 |
| Rate for Payer: Aetna Commercial |
$10,955.67
|
| Rate for Payer: Anthem Medicaid |
$4,893.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,097.95
|
| Rate for Payer: Cash Price |
$7,114.07
|
| Rate for Payer: Cigna Commercial |
$11,809.36
|
| Rate for Payer: First Health Commercial |
$13,516.73
|
| Rate for Payer: Humana Commercial |
$12,093.92
|
| Rate for Payer: Humana KY Medicaid |
$4,893.06
|
| Rate for Payer: Kentucky WC Medicaid |
$4,942.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,667.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,500.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,268.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,991.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,520.76
|
| Rate for Payer: Ohio Health Group HMO |
$10,671.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,382.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,378.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,817.42
|
| Rate for Payer: PHCS Commercial |
$13,659.01
|
| Rate for Payer: United Healthcare All Payer |
$12,520.76
|
|
|
RESTRICTOR MED UNIV CEMENT
|
Facility
|
OP
|
$1,851.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.30 |
| Max. Negotiated Rate |
$1,776.96 |
| Rate for Payer: Aetna Commercial |
$1,425.27
|
| Rate for Payer: Anthem Medicaid |
$636.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,443.78
|
| Rate for Payer: Cash Price |
$925.50
|
| Rate for Payer: Cigna Commercial |
$1,536.33
|
| Rate for Payer: First Health Commercial |
$1,758.45
|
| Rate for Payer: Humana Commercial |
$1,573.35
|
| Rate for Payer: Humana KY Medicaid |
$636.56
|
| Rate for Payer: Kentucky WC Medicaid |
$643.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,517.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,366.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$649.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,628.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,388.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,480.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,610.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,277.19
|
| Rate for Payer: PHCS Commercial |
$1,776.96
|
| Rate for Payer: United Healthcare All Payer |
$1,628.88
|
|
|
RESTRICTOR MED UNIV CEMENT
|
Facility
|
IP
|
$1,851.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.30 |
| Max. Negotiated Rate |
$1,776.96 |
| Rate for Payer: Aetna Commercial |
$1,425.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,443.78
|
| Rate for Payer: Cash Price |
$925.50
|
| Rate for Payer: Cigna Commercial |
$1,536.33
|
| Rate for Payer: First Health Commercial |
$1,758.45
|
| Rate for Payer: Humana Commercial |
$1,573.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,517.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,366.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,628.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,388.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,480.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,610.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,277.19
|
| Rate for Payer: PHCS Commercial |
$1,776.96
|
| Rate for Payer: United Healthcare All Payer |
$1,628.88
|
|
|
RESTYLANE CONTOUR
|
Professional
|
Both
|
$650.00
|
|
| Hospital Charge Code |
22200785
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$455.00 |
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Multiplan PHCS |
$390.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$455.00
|
| Rate for Payer: UHCCP Medicaid |
$227.50
|
|
|
RESTYLANE L
|
Facility
|
OP
|
$600.00
|
|
| Hospital Charge Code |
22200024
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$180.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Aetna Commercial |
$462.00
|
| Rate for Payer: Anthem Medicaid |
$206.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$498.00
|
| Rate for Payer: First Health Commercial |
$570.00
|
| Rate for Payer: Humana Commercial |
$510.00
|
| Rate for Payer: Humana KY Medicaid |
$206.34
|
| Rate for Payer: Kentucky WC Medicaid |
$208.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$442.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$210.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$414.00
|
| Rate for Payer: PHCS Commercial |
$576.00
|
| Rate for Payer: United Healthcare All Payer |
$528.00
|
|
|
RESTYLANE L
|
Facility
|
IP
|
$600.00
|
|
| Hospital Charge Code |
22200024
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$180.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Aetna Commercial |
$462.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$498.00
|
| Rate for Payer: First Health Commercial |
$570.00
|
| Rate for Payer: Humana Commercial |
$510.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$442.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$414.00
|
| Rate for Payer: PHCS Commercial |
$576.00
|
| Rate for Payer: United Healthcare All Payer |
$528.00
|
|
|
RESTYLANE L
|
Professional
|
Both
|
$600.00
|
|
| Hospital Charge Code |
22200024
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$210.00 |
| Max. Negotiated Rate |
$420.00 |
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$210.00
|
|
