|
PLATE DIST FEM 21 HOLE R
|
Facility
|
IP
|
$11,184.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,453.92 |
| Max. Negotiated Rate |
$10,736.64 |
| Rate for Payer: Aetna Commercial |
$8,611.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,723.52
|
| Rate for Payer: Cash Price |
$5,592.00
|
| Rate for Payer: Cigna Commercial |
$9,282.72
|
| Rate for Payer: First Health Commercial |
$10,624.80
|
| Rate for Payer: Humana Commercial |
$9,506.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,170.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,253.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,355.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,841.92
|
| Rate for Payer: Ohio Health Group HMO |
$8,388.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,236.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,453.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,467.04
|
| Rate for Payer: PHCS Commercial |
$10,736.64
|
| Rate for Payer: United Healthcare All Payer |
$9,841.92
|
|
|
PLATE DIST FEM 21 HOLE R
|
Facility
|
OP
|
$11,184.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,453.92 |
| Max. Negotiated Rate |
$10,736.64 |
| Rate for Payer: Aetna Commercial |
$8,611.68
|
| Rate for Payer: Anthem Medicaid |
$3,846.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,723.52
|
| Rate for Payer: Cash Price |
$5,592.00
|
| Rate for Payer: Cigna Commercial |
$9,282.72
|
| Rate for Payer: First Health Commercial |
$10,624.80
|
| Rate for Payer: Humana Commercial |
$9,506.40
|
| Rate for Payer: Humana KY Medicaid |
$3,846.18
|
| Rate for Payer: Kentucky WC Medicaid |
$3,885.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,170.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,253.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,355.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,923.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,841.92
|
| Rate for Payer: Ohio Health Group HMO |
$8,388.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,236.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,453.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,467.04
|
| Rate for Payer: PHCS Commercial |
$10,736.64
|
| Rate for Payer: United Healthcare All Payer |
$9,841.92
|
|
|
PLATE DIST FEM 9 HOLE L
|
Facility
|
IP
|
$11,184.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,453.92 |
| Max. Negotiated Rate |
$10,736.64 |
| Rate for Payer: Aetna Commercial |
$8,611.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,723.52
|
| Rate for Payer: Cash Price |
$5,592.00
|
| Rate for Payer: Cigna Commercial |
$9,282.72
|
| Rate for Payer: First Health Commercial |
$10,624.80
|
| Rate for Payer: Humana Commercial |
$9,506.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,170.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,253.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,355.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,841.92
|
| Rate for Payer: Ohio Health Group HMO |
$8,388.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,236.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,453.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,467.04
|
| Rate for Payer: PHCS Commercial |
$10,736.64
|
| Rate for Payer: United Healthcare All Payer |
$9,841.92
|
|
|
PLATE DIST FEM 9 HOLE L
|
Facility
|
OP
|
$11,184.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,453.92 |
| Max. Negotiated Rate |
$10,736.64 |
| Rate for Payer: Anthem Medicaid |
$3,846.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,723.52
|
| Rate for Payer: Cash Price |
$5,592.00
|
| Rate for Payer: Cigna Commercial |
$9,282.72
|
| Rate for Payer: First Health Commercial |
$10,624.80
|
| Rate for Payer: Humana Commercial |
$9,506.40
|
| Rate for Payer: Humana KY Medicaid |
$3,846.18
|
| Rate for Payer: Kentucky WC Medicaid |
$3,885.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,170.88
|
| Rate for Payer: Aetna Commercial |
$8,611.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,253.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,355.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,923.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,841.92
|
| Rate for Payer: Ohio Health Group HMO |
$8,388.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,236.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,453.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,467.04
|
| Rate for Payer: PHCS Commercial |
$10,736.64
|
| Rate for Payer: United Healthcare All Payer |
$9,841.92
|
|
|
PLATE DIST FEM 9 HOLE R
|
Facility
|
IP
|
$11,184.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,453.92 |
| Max. Negotiated Rate |
$10,736.64 |
| Rate for Payer: Aetna Commercial |
$8,611.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,723.52
|
| Rate for Payer: Cash Price |
$5,592.00
|
| Rate for Payer: Cigna Commercial |
$9,282.72
|
| Rate for Payer: First Health Commercial |
$10,624.80
|
| Rate for Payer: Humana Commercial |
$9,506.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,170.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,253.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,355.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,841.92
|
| Rate for Payer: Ohio Health Group HMO |
$8,388.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,236.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,453.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,467.04
|
| Rate for Payer: PHCS Commercial |
$10,736.64
|
| Rate for Payer: United Healthcare All Payer |
$9,841.92
|
|
|
PLATE DIST FEM 9 HOLE R
|
Facility
|
OP
|
$11,184.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,453.92 |
| Max. Negotiated Rate |
$10,736.64 |
| Rate for Payer: Aetna Commercial |
$8,611.68
|
| Rate for Payer: Anthem Medicaid |
$3,846.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,723.52
|
| Rate for Payer: Cash Price |
$5,592.00
|
| Rate for Payer: Cigna Commercial |
$9,282.72
|
| Rate for Payer: First Health Commercial |
$10,624.80
|
| Rate for Payer: Humana Commercial |
$9,506.40
|
| Rate for Payer: Humana KY Medicaid |
$3,846.18
|
| Rate for Payer: Kentucky WC Medicaid |
$3,885.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,170.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,253.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,355.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,923.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,841.92
|
| Rate for Payer: Ohio Health Group HMO |
$8,388.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,236.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,453.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,467.04
|
| Rate for Payer: PHCS Commercial |
$10,736.64
|
| Rate for Payer: United Healthcare All Payer |
$9,841.92
|
|
|
PLATE DIST FEM NCB PP R/L 238M
|
Facility
|
IP
|
$9,516.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,237.08 |
| Max. Negotiated Rate |
$9,135.36 |
| Rate for Payer: Aetna Commercial |
$7,327.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,422.48
|
| Rate for Payer: Cash Price |
$4,758.00
|
| Rate for Payer: Cigna Commercial |
$7,898.28
|
| Rate for Payer: First Health Commercial |
$9,040.20
|
| Rate for Payer: Humana Commercial |
$8,088.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,803.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,022.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,854.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,374.08
|
| Rate for Payer: Ohio Health Group HMO |
$7,137.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,903.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,237.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,949.96
|
| Rate for Payer: PHCS Commercial |
$9,135.36
|
| Rate for Payer: United Healthcare All Payer |
$8,374.08
|
|
|
PLATE DIST FEM NCB PP R/L 238M
|
Facility
|
OP
|
$9,516.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,237.08 |
| Max. Negotiated Rate |
$9,135.36 |
| Rate for Payer: Aetna Commercial |
$7,327.32
|
| Rate for Payer: Anthem Medicaid |
$3,272.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,422.48
|
| Rate for Payer: Cash Price |
$4,758.00
|
| Rate for Payer: Cigna Commercial |
$7,898.28
|
| Rate for Payer: First Health Commercial |
$9,040.20
|
| Rate for Payer: Humana Commercial |
$8,088.60
|
| Rate for Payer: Humana KY Medicaid |
$3,272.55
|
| Rate for Payer: Kentucky WC Medicaid |
$3,305.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,803.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,022.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,854.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,338.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,374.08
|
| Rate for Payer: Ohio Health Group HMO |
$7,137.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,903.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,237.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,949.96
|
| Rate for Payer: PHCS Commercial |
$9,135.36
|
| Rate for Payer: United Healthcare All Payer |
$8,374.08
|
|
|
PLATE DIST FEM NCB PP R/L 393M
|
Facility
|
OP
|
$11,972.40
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,556.41 |
| Max. Negotiated Rate |
$11,493.50 |
| Rate for Payer: Aetna Commercial |
$9,218.75
|
| Rate for Payer: Anthem Medicaid |
$4,117.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,338.47
|
| Rate for Payer: Cash Price |
$5,986.20
|
| Rate for Payer: Cigna Commercial |
$9,937.09
|
| Rate for Payer: First Health Commercial |
$11,373.78
|
| Rate for Payer: Humana Commercial |
$10,176.54
|
| Rate for Payer: Humana KY Medicaid |
$4,117.31
|
| Rate for Payer: Kentucky WC Medicaid |
$4,159.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,817.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,835.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,591.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,199.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,535.71
|
| Rate for Payer: Ohio Health Group HMO |
$8,979.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,394.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,556.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,711.44
|
| Rate for Payer: PHCS Commercial |
$11,493.50
|
| Rate for Payer: United Healthcare All Payer |
$10,535.71
|
|
|
PLATE DIST FEM NCB PP R/L 393M
|
Facility
|
IP
|
$11,972.40
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,556.41 |
| Max. Negotiated Rate |
$11,493.50 |
| Rate for Payer: Aetna Commercial |
$9,218.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,338.47
|
| Rate for Payer: Cash Price |
$5,986.20
|
| Rate for Payer: Cigna Commercial |
$9,937.09
|
| Rate for Payer: First Health Commercial |
$11,373.78
|
| Rate for Payer: Humana Commercial |
$10,176.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,817.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,835.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,591.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,535.71
|
| Rate for Payer: Ohio Health Group HMO |
$8,979.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,394.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,556.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,711.44
|
| Rate for Payer: PHCS Commercial |
$11,493.50
|
| Rate for Payer: United Healthcare All Payer |
$10,535.71
|
|
|
PLATE DIST HUM LK MD 5H L 79M
|
Facility
|
IP
|
$6,682.69
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$868.75 |
| Max. Negotiated Rate |
$6,415.38 |
| Rate for Payer: Aetna Commercial |
$5,145.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,212.50
|
| Rate for Payer: Cash Price |
$3,341.34
|
| Rate for Payer: Cigna Commercial |
$5,546.63
|
| Rate for Payer: First Health Commercial |
$6,348.56
|
| Rate for Payer: Humana Commercial |
$5,680.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,479.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,931.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,004.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,880.77
|
| Rate for Payer: Ohio Health Group HMO |
$5,012.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,336.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$868.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,071.63
|
| Rate for Payer: PHCS Commercial |
$6,415.38
|
| Rate for Payer: United Healthcare All Payer |
$5,880.77
|
|
|
PLATE DIST HUM LK MD 5H L 79M
|
Facility
|
OP
|
$6,682.69
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$868.75 |
| Max. Negotiated Rate |
$6,415.38 |
| Rate for Payer: Aetna Commercial |
$5,145.67
|
| Rate for Payer: Anthem Medicaid |
$2,298.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,212.50
|
| Rate for Payer: Cash Price |
$3,341.34
|
| Rate for Payer: Cigna Commercial |
$5,546.63
|
| Rate for Payer: First Health Commercial |
$6,348.56
|
| Rate for Payer: Humana Commercial |
$5,680.29
|
| Rate for Payer: Humana KY Medicaid |
$2,298.18
|
| Rate for Payer: Kentucky WC Medicaid |
$2,321.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,479.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,931.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,004.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,344.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,880.77
|
| Rate for Payer: Ohio Health Group HMO |
$5,012.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,336.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$868.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,071.63
|
| Rate for Payer: PHCS Commercial |
$6,415.38
|
| Rate for Payer: United Healthcare All Payer |
$5,880.77
|
|
|
PLATE DIST HUM LK MD 7H L 130M
|
Facility
|
OP
|
$7,128.35
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$926.69 |
| Max. Negotiated Rate |
$6,843.22 |
| Rate for Payer: Aetna Commercial |
$5,488.83
|
| Rate for Payer: Anthem Medicaid |
$2,451.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,560.11
|
| Rate for Payer: Cash Price |
$3,564.18
|
| Rate for Payer: Cigna Commercial |
$5,916.53
|
| Rate for Payer: First Health Commercial |
$6,771.93
|
| Rate for Payer: Humana Commercial |
$6,059.10
|
| Rate for Payer: Humana KY Medicaid |
$2,451.44
|
| Rate for Payer: Kentucky WC Medicaid |
$2,476.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,845.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,260.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,138.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,500.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,272.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,346.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,425.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$926.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,209.79
|
| Rate for Payer: PHCS Commercial |
$6,843.22
|
| Rate for Payer: United Healthcare All Payer |
$6,272.95
|
|
|
PLATE DIST HUM LK MD 7H L 130M
|
Facility
|
IP
|
$7,128.35
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$926.69 |
| Max. Negotiated Rate |
$6,843.22 |
| Rate for Payer: Aetna Commercial |
$5,488.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,560.11
|
| Rate for Payer: Cash Price |
$3,564.18
|
| Rate for Payer: Cigna Commercial |
$5,916.53
|
| Rate for Payer: First Health Commercial |
$6,771.93
|
| Rate for Payer: Humana Commercial |
$6,059.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,845.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,260.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,138.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,272.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,346.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,425.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$926.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,209.79
|
| Rate for Payer: PHCS Commercial |
$6,843.22
|
| Rate for Payer: United Healthcare All Payer |
$6,272.95
|
|
|
PLATE DIST HUM LK MD 9H L 127M
|
Facility
|
IP
|
$7,452.47
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$968.82 |
| Max. Negotiated Rate |
$7,154.37 |
| Rate for Payer: Aetna Commercial |
$5,738.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,812.93
|
| Rate for Payer: Cash Price |
$3,726.24
|
| Rate for Payer: Cigna Commercial |
$6,185.55
|
| Rate for Payer: First Health Commercial |
$7,079.85
|
| Rate for Payer: Humana Commercial |
$6,334.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,111.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,499.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,235.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,558.17
|
| Rate for Payer: Ohio Health Group HMO |
$5,589.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,490.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$968.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,310.27
|
| Rate for Payer: PHCS Commercial |
$7,154.37
|
| Rate for Payer: United Healthcare All Payer |
$6,558.17
|
|
|
PLATE DIST HUM LK MD 9H L 127M
|
Facility
|
OP
|
$7,452.47
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$968.82 |
| Max. Negotiated Rate |
$7,154.37 |
| Rate for Payer: Aetna Commercial |
$5,738.40
|
| Rate for Payer: Anthem Medicaid |
$2,562.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,812.93
|
| Rate for Payer: Cash Price |
$3,726.24
|
| Rate for Payer: Cigna Commercial |
$6,185.55
|
| Rate for Payer: First Health Commercial |
$7,079.85
|
| Rate for Payer: Humana Commercial |
$6,334.60
|
| Rate for Payer: Humana KY Medicaid |
$2,562.90
|
| Rate for Payer: Kentucky WC Medicaid |
$2,588.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,111.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,499.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,235.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,614.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,558.17
|
| Rate for Payer: Ohio Health Group HMO |
$5,589.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,490.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$968.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,310.27
|
| Rate for Payer: PHCS Commercial |
$7,154.37
|
| Rate for Payer: United Healthcare All Payer |
$6,558.17
|
|
|
PLATE DISTL ANTEROLATERAL L 4H
|
Facility
|
IP
|
$6,888.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$895.44 |
| Max. Negotiated Rate |
$6,612.48 |
| Rate for Payer: Aetna Commercial |
$5,303.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,372.64
|
| Rate for Payer: Cash Price |
$3,444.00
|
| Rate for Payer: Cigna Commercial |
$5,717.04
|
| Rate for Payer: First Health Commercial |
$6,543.60
|
| Rate for Payer: Humana Commercial |
$5,854.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,648.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,083.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,066.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,061.44
|
| Rate for Payer: Ohio Health Group HMO |
$5,166.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,377.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$895.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,135.28
|
| Rate for Payer: PHCS Commercial |
$6,612.48
|
| Rate for Payer: United Healthcare All Payer |
$6,061.44
|
|
|
PLATE DISTL ANTEROLATERAL L 4H
|
Facility
|
OP
|
$6,888.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$895.44 |
| Max. Negotiated Rate |
$6,612.48 |
| Rate for Payer: Aetna Commercial |
$5,303.76
|
| Rate for Payer: Anthem Medicaid |
$2,368.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,372.64
|
| Rate for Payer: Cash Price |
$3,444.00
|
| Rate for Payer: Cigna Commercial |
$5,717.04
|
| Rate for Payer: First Health Commercial |
$6,543.60
|
| Rate for Payer: Humana Commercial |
$5,854.80
|
| Rate for Payer: Humana KY Medicaid |
$2,368.78
|
| Rate for Payer: Kentucky WC Medicaid |
$2,392.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,648.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,083.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,066.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,416.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,061.44
|
| Rate for Payer: Ohio Health Group HMO |
$5,166.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,377.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$895.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,135.28
|
| Rate for Payer: PHCS Commercial |
$6,612.48
|
| Rate for Payer: United Healthcare All Payer |
$6,061.44
|
|
|
PLATE DISTL ANTEROLATERAL L 6H
|
Facility
|
OP
|
$6,888.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$895.44 |
| Max. Negotiated Rate |
$6,612.48 |
| Rate for Payer: Aetna Commercial |
$5,303.76
|
| Rate for Payer: Anthem Medicaid |
$2,368.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,372.64
|
| Rate for Payer: Cash Price |
$3,444.00
|
| Rate for Payer: Cigna Commercial |
$5,717.04
|
| Rate for Payer: First Health Commercial |
$6,543.60
|
| Rate for Payer: Humana Commercial |
$5,854.80
|
| Rate for Payer: Humana KY Medicaid |
$2,368.78
|
| Rate for Payer: Kentucky WC Medicaid |
$2,392.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,648.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,083.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,066.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,416.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,061.44
|
| Rate for Payer: Ohio Health Group HMO |
$5,166.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,377.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$895.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,135.28
|
| Rate for Payer: PHCS Commercial |
$6,612.48
|
| Rate for Payer: United Healthcare All Payer |
$6,061.44
|
|
|
PLATE DISTL ANTEROLATERAL L 6H
|
Facility
|
IP
|
$6,888.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$895.44 |
| Max. Negotiated Rate |
$6,612.48 |
| Rate for Payer: Aetna Commercial |
$5,303.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,372.64
|
| Rate for Payer: Cash Price |
$3,444.00
|
| Rate for Payer: Cigna Commercial |
$5,717.04
|
| Rate for Payer: First Health Commercial |
$6,543.60
|
| Rate for Payer: Humana Commercial |
$5,854.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,648.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,083.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,066.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,061.44
|
| Rate for Payer: Ohio Health Group HMO |
$5,166.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,377.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$895.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,135.28
|
| Rate for Payer: PHCS Commercial |
$6,612.48
|
| Rate for Payer: United Healthcare All Payer |
$6,061.44
|
|
|
PLATE DISTL ANTEROLATERAL L 8H
|
Facility
|
OP
|
$6,888.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$895.44 |
| Max. Negotiated Rate |
$6,612.48 |
| Rate for Payer: Aetna Commercial |
$5,303.76
|
| Rate for Payer: Anthem Medicaid |
$2,368.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,372.64
|
| Rate for Payer: Cash Price |
$3,444.00
|
| Rate for Payer: Cigna Commercial |
$5,717.04
|
| Rate for Payer: First Health Commercial |
$6,543.60
|
| Rate for Payer: Humana Commercial |
$5,854.80
|
| Rate for Payer: Humana KY Medicaid |
$2,368.78
|
| Rate for Payer: Kentucky WC Medicaid |
$2,392.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,648.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,083.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,066.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,416.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,061.44
|
| Rate for Payer: Ohio Health Group HMO |
$5,166.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,377.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$895.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,135.28
|
| Rate for Payer: PHCS Commercial |
$6,612.48
|
| Rate for Payer: United Healthcare All Payer |
$6,061.44
|
|
|
PLATE DISTL ANTEROLATERAL L 8H
|
Facility
|
IP
|
$6,888.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$895.44 |
| Max. Negotiated Rate |
$6,612.48 |
| Rate for Payer: Aetna Commercial |
$5,303.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,372.64
|
| Rate for Payer: Cash Price |
$3,444.00
|
| Rate for Payer: Cigna Commercial |
$5,717.04
|
| Rate for Payer: First Health Commercial |
$6,543.60
|
| Rate for Payer: Humana Commercial |
$5,854.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,648.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,083.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,066.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,061.44
|
| Rate for Payer: Ohio Health Group HMO |
$5,166.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,377.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$895.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,135.28
|
| Rate for Payer: PHCS Commercial |
$6,612.48
|
| Rate for Payer: United Healthcare All Payer |
$6,061.44
|
|
|
PLATE DISTL ANTEROLATERAL R 4H
|
Facility
|
OP
|
$6,888.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$895.44 |
| Max. Negotiated Rate |
$6,612.48 |
| Rate for Payer: Anthem Medicaid |
$2,368.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,372.64
|
| Rate for Payer: Cash Price |
$3,444.00
|
| Rate for Payer: Cigna Commercial |
$5,717.04
|
| Rate for Payer: First Health Commercial |
$6,543.60
|
| Rate for Payer: Humana Commercial |
$5,854.80
|
| Rate for Payer: Humana KY Medicaid |
$2,368.78
|
| Rate for Payer: Kentucky WC Medicaid |
$2,392.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,648.16
|
| Rate for Payer: Aetna Commercial |
$5,303.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,083.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,066.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,416.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,061.44
|
| Rate for Payer: Ohio Health Group HMO |
$5,166.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,377.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$895.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,135.28
|
| Rate for Payer: PHCS Commercial |
$6,612.48
|
| Rate for Payer: United Healthcare All Payer |
$6,061.44
|
|
|
PLATE DISTL ANTEROLATERAL R 4H
|
Facility
|
IP
|
$6,888.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$895.44 |
| Max. Negotiated Rate |
$6,612.48 |
| Rate for Payer: Aetna Commercial |
$5,303.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,372.64
|
| Rate for Payer: Cash Price |
$3,444.00
|
| Rate for Payer: Cigna Commercial |
$5,717.04
|
| Rate for Payer: First Health Commercial |
$6,543.60
|
| Rate for Payer: Humana Commercial |
$5,854.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,648.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,083.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,066.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,061.44
|
| Rate for Payer: Ohio Health Group HMO |
$5,166.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,377.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$895.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,135.28
|
| Rate for Payer: PHCS Commercial |
$6,612.48
|
| Rate for Payer: United Healthcare All Payer |
$6,061.44
|
|
|
PLATE DISTL ANTEROLATERAL R 6H
|
Facility
|
IP
|
$6,888.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$895.44 |
| Max. Negotiated Rate |
$6,612.48 |
| Rate for Payer: Aetna Commercial |
$5,303.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,372.64
|
| Rate for Payer: Cash Price |
$3,444.00
|
| Rate for Payer: Cigna Commercial |
$5,717.04
|
| Rate for Payer: First Health Commercial |
$6,543.60
|
| Rate for Payer: Humana Commercial |
$5,854.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,648.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,083.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,066.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,061.44
|
| Rate for Payer: Ohio Health Group HMO |
$5,166.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,377.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$895.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,135.28
|
| Rate for Payer: PHCS Commercial |
$6,612.48
|
| Rate for Payer: United Healthcare All Payer |
$6,061.44
|
|
