|
PLATE 2&3 ST TARSOMETATRSAL 4H
|
Facility
|
OP
|
$3,582.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$465.72 |
| Max. Negotiated Rate |
$3,439.20 |
| Rate for Payer: Humana Commercial |
$3,045.12
|
| Rate for Payer: Humana KY Medicaid |
$1,232.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,244.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,937.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,643.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,074.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,256.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,152.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,686.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$716.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$465.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,110.58
|
| Rate for Payer: PHCS Commercial |
$3,439.20
|
| Rate for Payer: United Healthcare All Payer |
$3,152.60
|
| Rate for Payer: Aetna Commercial |
$2,758.52
|
| Rate for Payer: Anthem Medicaid |
$1,232.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,794.35
|
| Rate for Payer: Cash Price |
$1,791.25
|
| Rate for Payer: Cigna Commercial |
$2,973.48
|
| Rate for Payer: First Health Commercial |
$3,403.38
|
|
|
PLATE 2&3 ST TARSOMETATRSAL 4H
|
Facility
|
IP
|
$3,582.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$465.72 |
| Max. Negotiated Rate |
$3,439.20 |
| Rate for Payer: Aetna Commercial |
$2,758.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,794.35
|
| Rate for Payer: Cash Price |
$1,791.25
|
| Rate for Payer: Cigna Commercial |
$2,973.48
|
| Rate for Payer: First Health Commercial |
$3,403.38
|
| Rate for Payer: Humana Commercial |
$3,045.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,937.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,643.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,074.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,152.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,686.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$716.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$465.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,110.58
|
| Rate for Payer: PHCS Commercial |
$3,439.20
|
| Rate for Payer: United Healthcare All Payer |
$3,152.60
|
|
|
PLATE 2.4 VOL DRP N 3H LT
|
Facility
|
OP
|
$4,982.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$647.72 |
| Max. Negotiated Rate |
$4,783.20 |
| Rate for Payer: Aetna Commercial |
$3,836.52
|
| Rate for Payer: Anthem Medicaid |
$1,713.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,886.35
|
| Rate for Payer: Cash Price |
$2,491.25
|
| Rate for Payer: Cigna Commercial |
$4,135.48
|
| Rate for Payer: First Health Commercial |
$4,733.38
|
| Rate for Payer: Humana Commercial |
$4,235.12
|
| Rate for Payer: Humana KY Medicaid |
$1,713.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1,730.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,085.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,677.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,494.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,747.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,384.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,736.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$996.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$647.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,544.58
|
| Rate for Payer: PHCS Commercial |
$4,783.20
|
| Rate for Payer: United Healthcare All Payer |
$4,384.60
|
|
|
PLATE 2.4 VOL DRP N 3H LT
|
Facility
|
IP
|
$4,982.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$647.72 |
| Max. Negotiated Rate |
$4,783.20 |
| Rate for Payer: Aetna Commercial |
$3,836.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,886.35
|
| Rate for Payer: Cash Price |
$2,491.25
|
| Rate for Payer: Cigna Commercial |
$4,135.48
|
| Rate for Payer: First Health Commercial |
$4,733.38
|
| Rate for Payer: Humana Commercial |
$4,235.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,085.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,677.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,494.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,384.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,736.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$996.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$647.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,544.58
|
| Rate for Payer: PHCS Commercial |
$4,783.20
|
| Rate for Payer: United Healthcare All Payer |
$4,384.60
|
|
|
PLATE 2.7/3.5 POST DST HM 9H L
|
Facility
|
OP
|
$7,198.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$935.77 |
| Max. Negotiated Rate |
$6,910.32 |
| Rate for Payer: Aetna Commercial |
$5,542.65
|
| Rate for Payer: Anthem Medicaid |
$2,475.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,614.64
|
| Rate for Payer: Cash Price |
$3,599.12
|
| Rate for Payer: Cigna Commercial |
$5,974.55
|
| Rate for Payer: First Health Commercial |
$6,838.34
|
| Rate for Payer: Humana Commercial |
$6,118.51
|
| Rate for Payer: Humana KY Medicaid |
$2,475.48
|
| Rate for Payer: Kentucky WC Medicaid |
$2,500.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,902.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,312.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,159.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,525.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,334.46
|
| Rate for Payer: Ohio Health Group HMO |
$5,398.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,439.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$935.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,231.46
|
| Rate for Payer: PHCS Commercial |
$6,910.32
|
| Rate for Payer: United Healthcare All Payer |
$6,334.46
|
|
|
PLATE 2.7/3.5 POST DST HM 9H L
|
Facility
|
IP
|
$7,198.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$935.77 |
| Max. Negotiated Rate |
$6,910.32 |
| Rate for Payer: Aetna Commercial |
$5,542.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,614.64
|
| Rate for Payer: Cash Price |
$3,599.12
|
| Rate for Payer: Cigna Commercial |
$5,974.55
|
| Rate for Payer: First Health Commercial |
$6,838.34
|
| Rate for Payer: Humana Commercial |
$6,118.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,902.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,312.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,159.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,334.46
|
| Rate for Payer: Ohio Health Group HMO |
$5,398.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,439.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$935.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,231.46
|
| Rate for Payer: PHCS Commercial |
$6,910.32
|
| Rate for Payer: United Healthcare All Payer |
$6,334.46
|
|
|
PLATE 2.7/3.5 VA ANTEROLT 6H R
|
Facility
|
IP
|
$8,914.19
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,158.84 |
| Max. Negotiated Rate |
$8,557.62 |
| Rate for Payer: Aetna Commercial |
$6,863.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,953.07
|
| Rate for Payer: Cash Price |
$4,457.09
|
| Rate for Payer: Cigna Commercial |
$7,398.78
|
| Rate for Payer: First Health Commercial |
$8,468.48
|
| Rate for Payer: Humana Commercial |
$7,577.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,309.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,578.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,674.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,844.49
|
| Rate for Payer: Ohio Health Group HMO |
$6,685.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,782.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,158.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,763.40
|
| Rate for Payer: PHCS Commercial |
$8,557.62
|
| Rate for Payer: United Healthcare All Payer |
$7,844.49
|
|
|
PLATE 2.7/3.5 VA ANTEROLT 6H R
|
Facility
|
OP
|
$8,914.19
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,158.84 |
| Max. Negotiated Rate |
$8,557.62 |
| Rate for Payer: Aetna Commercial |
$6,863.93
|
| Rate for Payer: Anthem Medicaid |
$3,065.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,953.07
|
| Rate for Payer: Cash Price |
$4,457.09
|
| Rate for Payer: Cigna Commercial |
$7,398.78
|
| Rate for Payer: First Health Commercial |
$8,468.48
|
| Rate for Payer: Humana Commercial |
$7,577.06
|
| Rate for Payer: Humana KY Medicaid |
$3,065.59
|
| Rate for Payer: Kentucky WC Medicaid |
$3,096.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,309.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,578.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,674.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,127.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,844.49
|
| Rate for Payer: Ohio Health Group HMO |
$6,685.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,782.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,158.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,763.40
|
| Rate for Payer: PHCS Commercial |
$8,557.62
|
| Rate for Payer: United Healthcare All Payer |
$7,844.49
|
|
|
PLATE 2.7/3.5 VA ANTEROLT 8H R
|
Facility
|
IP
|
$8,979.08
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,167.28 |
| Max. Negotiated Rate |
$8,619.92 |
| Rate for Payer: Aetna Commercial |
$6,913.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,003.68
|
| Rate for Payer: Cash Price |
$4,489.54
|
| Rate for Payer: Cigna Commercial |
$7,452.64
|
| Rate for Payer: First Health Commercial |
$8,530.13
|
| Rate for Payer: Humana Commercial |
$7,632.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,362.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,626.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,693.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,901.59
|
| Rate for Payer: Ohio Health Group HMO |
$6,734.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,795.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,167.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,783.51
|
| Rate for Payer: PHCS Commercial |
$8,619.92
|
| Rate for Payer: United Healthcare All Payer |
$7,901.59
|
|
|
PLATE 2.7/3.5 VA ANTEROLT 8H R
|
Facility
|
OP
|
$8,979.08
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,167.28 |
| Max. Negotiated Rate |
$8,619.92 |
| Rate for Payer: Aetna Commercial |
$6,913.89
|
| Rate for Payer: Anthem Medicaid |
$3,087.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,003.68
|
| Rate for Payer: Cash Price |
$4,489.54
|
| Rate for Payer: Cigna Commercial |
$7,452.64
|
| Rate for Payer: First Health Commercial |
$8,530.13
|
| Rate for Payer: Humana Commercial |
$7,632.22
|
| Rate for Payer: Humana KY Medicaid |
$3,087.91
|
| Rate for Payer: Kentucky WC Medicaid |
$3,119.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,362.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,626.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,693.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,149.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,901.59
|
| Rate for Payer: Ohio Health Group HMO |
$6,734.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,795.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,167.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,783.51
|
| Rate for Payer: PHCS Commercial |
$8,619.92
|
| Rate for Payer: United Healthcare All Payer |
$7,901.59
|
|
|
PLATE 2.7MM 7 HOLE LEFT LARGE
|
Facility
|
IP
|
$1,997.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$259.68 |
| Max. Negotiated Rate |
$1,917.60 |
| Rate for Payer: Aetna Commercial |
$1,538.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,558.05
|
| Rate for Payer: Cash Price |
$998.75
|
| Rate for Payer: Cigna Commercial |
$1,657.92
|
| Rate for Payer: First Health Commercial |
$1,897.62
|
| Rate for Payer: Humana Commercial |
$1,697.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,637.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,474.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$599.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,757.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,498.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$399.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$259.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$619.22
|
| Rate for Payer: PHCS Commercial |
$1,917.60
|
| Rate for Payer: United Healthcare All Payer |
$1,757.80
|
|
|
PLATE 2.7MM 7 HOLE LEFT LARGE
|
Facility
|
OP
|
$1,997.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$259.68 |
| Max. Negotiated Rate |
$1,917.60 |
| Rate for Payer: Aetna Commercial |
$1,538.08
|
| Rate for Payer: Anthem Medicaid |
$686.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,558.05
|
| Rate for Payer: Cash Price |
$998.75
|
| Rate for Payer: Cigna Commercial |
$1,657.92
|
| Rate for Payer: First Health Commercial |
$1,897.62
|
| Rate for Payer: Humana Commercial |
$1,697.88
|
| Rate for Payer: Humana KY Medicaid |
$686.94
|
| Rate for Payer: Kentucky WC Medicaid |
$693.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,637.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,474.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$599.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$700.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,757.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,498.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$399.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$259.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$619.22
|
| Rate for Payer: PHCS Commercial |
$1,917.60
|
| Rate for Payer: United Healthcare All Payer |
$1,757.80
|
|
|
PLATE 2.7MM HOLE RIGHT LARGE
|
Facility
|
IP
|
$1,997.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$259.68 |
| Max. Negotiated Rate |
$1,917.60 |
| Rate for Payer: Aetna Commercial |
$1,538.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,558.05
|
| Rate for Payer: Cash Price |
$998.75
|
| Rate for Payer: Cigna Commercial |
$1,657.92
|
| Rate for Payer: First Health Commercial |
$1,897.62
|
| Rate for Payer: Humana Commercial |
$1,697.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,637.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,474.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$599.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,757.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,498.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$399.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$259.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$619.22
|
| Rate for Payer: PHCS Commercial |
$1,917.60
|
| Rate for Payer: United Healthcare All Payer |
$1,757.80
|
|
|
PLATE 2.7MM HOLE RIGHT LARGE
|
Facility
|
OP
|
$1,997.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$259.68 |
| Max. Negotiated Rate |
$1,917.60 |
| Rate for Payer: Aetna Commercial |
$1,538.08
|
| Rate for Payer: Anthem Medicaid |
$686.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,558.05
|
| Rate for Payer: Cash Price |
$998.75
|
| Rate for Payer: Cigna Commercial |
$1,657.92
|
| Rate for Payer: First Health Commercial |
$1,897.62
|
| Rate for Payer: Humana Commercial |
$1,697.88
|
| Rate for Payer: Humana KY Medicaid |
$686.94
|
| Rate for Payer: Kentucky WC Medicaid |
$693.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,637.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,474.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$599.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$700.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,757.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,498.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$399.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$259.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$619.22
|
| Rate for Payer: PHCS Commercial |
$1,917.60
|
| Rate for Payer: United Healthcare All Payer |
$1,757.80
|
|
|
PLATE 2H STR
|
Facility
|
IP
|
$4,090.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$531.70 |
| Max. Negotiated Rate |
$3,926.40 |
| Rate for Payer: Aetna Commercial |
$3,149.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,190.20
|
| Rate for Payer: Cash Price |
$2,045.00
|
| Rate for Payer: Cigna Commercial |
$3,394.70
|
| Rate for Payer: First Health Commercial |
$3,885.50
|
| Rate for Payer: Humana Commercial |
$3,476.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,353.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,018.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,227.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,599.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,067.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$818.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$531.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,267.90
|
| Rate for Payer: PHCS Commercial |
$3,926.40
|
| Rate for Payer: United Healthcare All Payer |
$3,599.20
|
|
|
PLATE 2H STR
|
Facility
|
OP
|
$4,090.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$531.70 |
| Max. Negotiated Rate |
$3,926.40 |
| Rate for Payer: Aetna Commercial |
$3,149.30
|
| Rate for Payer: Anthem Medicaid |
$1,406.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,190.20
|
| Rate for Payer: Cash Price |
$2,045.00
|
| Rate for Payer: Cigna Commercial |
$3,394.70
|
| Rate for Payer: First Health Commercial |
$3,885.50
|
| Rate for Payer: Humana Commercial |
$3,476.50
|
| Rate for Payer: Humana KY Medicaid |
$1,406.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1,420.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,353.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,018.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,227.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,434.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,599.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,067.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$818.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$531.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,267.90
|
| Rate for Payer: PHCS Commercial |
$3,926.40
|
| Rate for Payer: United Healthcare All Payer |
$3,599.20
|
|
|
PLATE 2H STR W/COMP
|
Facility
|
OP
|
$4,090.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$531.70 |
| Max. Negotiated Rate |
$3,926.40 |
| Rate for Payer: Aetna Commercial |
$3,149.30
|
| Rate for Payer: Anthem Medicaid |
$1,406.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,190.20
|
| Rate for Payer: Cash Price |
$2,045.00
|
| Rate for Payer: Cigna Commercial |
$3,394.70
|
| Rate for Payer: First Health Commercial |
$3,885.50
|
| Rate for Payer: Humana Commercial |
$3,476.50
|
| Rate for Payer: Humana KY Medicaid |
$1,406.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1,420.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,353.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,018.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,227.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,434.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,599.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,067.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$818.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$531.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,267.90
|
| Rate for Payer: PHCS Commercial |
$3,926.40
|
| Rate for Payer: United Healthcare All Payer |
$3,599.20
|
|
|
PLATE 2H STR W/COMP
|
Facility
|
IP
|
$4,090.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$531.70 |
| Max. Negotiated Rate |
$3,926.40 |
| Rate for Payer: Aetna Commercial |
$3,149.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,190.20
|
| Rate for Payer: Cash Price |
$2,045.00
|
| Rate for Payer: Cigna Commercial |
$3,394.70
|
| Rate for Payer: First Health Commercial |
$3,885.50
|
| Rate for Payer: Humana Commercial |
$3,476.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,353.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,018.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,227.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,599.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,067.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$818.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$531.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,267.90
|
| Rate for Payer: PHCS Commercial |
$3,926.40
|
| Rate for Payer: United Healthcare All Payer |
$3,599.20
|
|
|
PLATE 3.5 MED COL LG L
|
Facility
|
OP
|
$8,256.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,073.38 |
| Max. Negotiated Rate |
$7,926.48 |
| Rate for Payer: Anthem Medicaid |
$2,839.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,440.26
|
| Rate for Payer: Cash Price |
$4,128.38
|
| Rate for Payer: Cigna Commercial |
$6,853.10
|
| Rate for Payer: First Health Commercial |
$7,843.91
|
| Rate for Payer: Humana Commercial |
$7,018.24
|
| Rate for Payer: Humana KY Medicaid |
$2,839.50
|
| Rate for Payer: Kentucky WC Medicaid |
$2,868.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,770.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,093.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,477.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,896.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,265.94
|
| Rate for Payer: Ohio Health Group HMO |
$6,192.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,651.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,073.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,559.59
|
| Rate for Payer: PHCS Commercial |
$7,926.48
|
| Rate for Payer: United Healthcare All Payer |
$7,265.94
|
| Rate for Payer: Aetna Commercial |
$6,357.70
|
|
|
PLATE 3.5 MED COL LG L
|
Facility
|
IP
|
$8,256.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,073.38 |
| Max. Negotiated Rate |
$7,926.48 |
| Rate for Payer: Aetna Commercial |
$6,357.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,440.26
|
| Rate for Payer: Cash Price |
$4,128.38
|
| Rate for Payer: Cigna Commercial |
$6,853.10
|
| Rate for Payer: First Health Commercial |
$7,843.91
|
| Rate for Payer: Humana Commercial |
$7,018.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,770.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,093.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,477.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,265.94
|
| Rate for Payer: Ohio Health Group HMO |
$6,192.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,651.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,073.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,559.59
|
| Rate for Payer: PHCS Commercial |
$7,926.48
|
| Rate for Payer: United Healthcare All Payer |
$7,265.94
|
|
|
PLATE 3.5 MED COL LG R
|
Facility
|
OP
|
$8,256.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,073.38 |
| Max. Negotiated Rate |
$7,926.48 |
| Rate for Payer: Aetna Commercial |
$6,357.70
|
| Rate for Payer: Anthem Medicaid |
$2,839.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,440.26
|
| Rate for Payer: Cash Price |
$4,128.38
|
| Rate for Payer: Cigna Commercial |
$6,853.10
|
| Rate for Payer: First Health Commercial |
$7,843.91
|
| Rate for Payer: Humana Commercial |
$7,018.24
|
| Rate for Payer: Humana KY Medicaid |
$2,839.50
|
| Rate for Payer: Kentucky WC Medicaid |
$2,868.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,770.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,093.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,477.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,896.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,265.94
|
| Rate for Payer: Ohio Health Group HMO |
$6,192.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,651.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,073.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,559.59
|
| Rate for Payer: PHCS Commercial |
$7,926.48
|
| Rate for Payer: United Healthcare All Payer |
$7,265.94
|
|
|
PLATE 3.5 MED COL LG R
|
Facility
|
IP
|
$8,256.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,073.38 |
| Max. Negotiated Rate |
$7,926.48 |
| Rate for Payer: Aetna Commercial |
$6,357.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,440.26
|
| Rate for Payer: Cash Price |
$4,128.38
|
| Rate for Payer: Cigna Commercial |
$6,853.10
|
| Rate for Payer: First Health Commercial |
$7,843.91
|
| Rate for Payer: Humana Commercial |
$7,018.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,770.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,093.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,477.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,265.94
|
| Rate for Payer: Ohio Health Group HMO |
$6,192.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,651.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,073.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,559.59
|
| Rate for Payer: PHCS Commercial |
$7,926.48
|
| Rate for Payer: United Healthcare All Payer |
$7,265.94
|
|
|
PLATE 3.5 MED COL MED L
|
Facility
|
IP
|
$8,256.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,073.38 |
| Max. Negotiated Rate |
$7,926.48 |
| Rate for Payer: Aetna Commercial |
$6,357.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,440.26
|
| Rate for Payer: Cash Price |
$4,128.38
|
| Rate for Payer: Cigna Commercial |
$6,853.10
|
| Rate for Payer: First Health Commercial |
$7,843.91
|
| Rate for Payer: Humana Commercial |
$7,018.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,770.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,093.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,477.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,265.94
|
| Rate for Payer: Ohio Health Group HMO |
$6,192.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,651.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,073.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,559.59
|
| Rate for Payer: PHCS Commercial |
$7,926.48
|
| Rate for Payer: United Healthcare All Payer |
$7,265.94
|
|
|
PLATE 3.5 MED COL MED L
|
Facility
|
OP
|
$8,256.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,073.38 |
| Max. Negotiated Rate |
$7,926.48 |
| Rate for Payer: Aetna Commercial |
$6,357.70
|
| Rate for Payer: Anthem Medicaid |
$2,839.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,440.26
|
| Rate for Payer: Cash Price |
$4,128.38
|
| Rate for Payer: Cigna Commercial |
$6,853.10
|
| Rate for Payer: First Health Commercial |
$7,843.91
|
| Rate for Payer: Humana Commercial |
$7,018.24
|
| Rate for Payer: Humana KY Medicaid |
$2,839.50
|
| Rate for Payer: Kentucky WC Medicaid |
$2,868.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,770.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,093.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,477.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,896.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,265.94
|
| Rate for Payer: Ohio Health Group HMO |
$6,192.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,651.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,073.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,559.59
|
| Rate for Payer: PHCS Commercial |
$7,926.48
|
| Rate for Payer: United Healthcare All Payer |
$7,265.94
|
|
|
PLATE 3.5 MED COL MED R
|
Facility
|
OP
|
$8,256.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,073.38 |
| Max. Negotiated Rate |
$7,926.48 |
| Rate for Payer: Aetna Commercial |
$6,357.70
|
| Rate for Payer: Anthem Medicaid |
$2,839.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,440.26
|
| Rate for Payer: Cash Price |
$4,128.38
|
| Rate for Payer: Cigna Commercial |
$6,853.10
|
| Rate for Payer: First Health Commercial |
$7,843.91
|
| Rate for Payer: Humana Commercial |
$7,018.24
|
| Rate for Payer: Humana KY Medicaid |
$2,839.50
|
| Rate for Payer: Kentucky WC Medicaid |
$2,868.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,770.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,093.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,477.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,896.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,265.94
|
| Rate for Payer: Ohio Health Group HMO |
$6,192.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,651.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,073.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,559.59
|
| Rate for Payer: PHCS Commercial |
$7,926.48
|
| Rate for Payer: United Healthcare All Payer |
$7,265.94
|
|
