|
PLATE DOR DIS RD 2H 2.4*37 -90
|
Facility
|
OP
|
$4,008.73
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$521.13 |
| Max. Negotiated Rate |
$3,848.38 |
| Rate for Payer: Aetna Commercial |
$3,086.72
|
| Rate for Payer: Anthem Medicaid |
$1,378.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,126.81
|
| Rate for Payer: Cash Price |
$2,004.37
|
| Rate for Payer: Cigna Commercial |
$3,327.25
|
| Rate for Payer: First Health Commercial |
$3,808.29
|
| Rate for Payer: Humana Commercial |
$3,407.42
|
| Rate for Payer: Humana KY Medicaid |
$1,378.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1,392.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,287.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,958.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,202.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,406.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,527.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,006.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$801.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$521.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,242.71
|
| Rate for Payer: PHCS Commercial |
$3,848.38
|
| Rate for Payer: United Healthcare All Payer |
$3,527.68
|
|
|
PLATE DOR DIS RD 2H 2.4*51 +90
|
Facility
|
OP
|
$4,099.45
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$532.93 |
| Max. Negotiated Rate |
$3,935.47 |
| Rate for Payer: Aetna Commercial |
$3,156.58
|
| Rate for Payer: Anthem Medicaid |
$1,409.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,197.57
|
| Rate for Payer: Cash Price |
$2,049.72
|
| Rate for Payer: Cigna Commercial |
$3,402.54
|
| Rate for Payer: First Health Commercial |
$3,894.48
|
| Rate for Payer: Humana Commercial |
$3,484.53
|
| Rate for Payer: Humana KY Medicaid |
$1,409.80
|
| Rate for Payer: Kentucky WC Medicaid |
$1,424.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,361.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,025.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,229.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,438.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,607.52
|
| Rate for Payer: Ohio Health Group HMO |
$3,074.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$819.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$532.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,270.83
|
| Rate for Payer: PHCS Commercial |
$3,935.47
|
| Rate for Payer: United Healthcare All Payer |
$3,607.52
|
|
|
PLATE DOR DIS RD 2H 2.4*51 +90
|
Facility
|
IP
|
$4,099.45
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$532.93 |
| Max. Negotiated Rate |
$3,935.47 |
| Rate for Payer: Aetna Commercial |
$3,156.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,197.57
|
| Rate for Payer: Cash Price |
$2,049.72
|
| Rate for Payer: Cigna Commercial |
$3,402.54
|
| Rate for Payer: First Health Commercial |
$3,894.48
|
| Rate for Payer: Humana Commercial |
$3,484.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,361.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,025.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,229.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,607.52
|
| Rate for Payer: Ohio Health Group HMO |
$3,074.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$819.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$532.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,270.83
|
| Rate for Payer: PHCS Commercial |
$3,935.47
|
| Rate for Payer: United Healthcare All Payer |
$3,607.52
|
|
|
PLATE DOR DIS RD 2H 2.4*51 -90
|
Facility
|
OP
|
$4,099.45
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$532.93 |
| Max. Negotiated Rate |
$3,935.47 |
| Rate for Payer: Anthem Medicaid |
$1,409.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,197.57
|
| Rate for Payer: Cash Price |
$2,049.72
|
| Rate for Payer: Cigna Commercial |
$3,402.54
|
| Rate for Payer: First Health Commercial |
$3,894.48
|
| Rate for Payer: Humana Commercial |
$3,484.53
|
| Rate for Payer: Humana KY Medicaid |
$1,409.80
|
| Rate for Payer: Kentucky WC Medicaid |
$1,424.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,361.55
|
| Rate for Payer: Aetna Commercial |
$3,156.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,025.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,229.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,438.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,607.52
|
| Rate for Payer: Ohio Health Group HMO |
$3,074.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$819.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$532.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,270.83
|
| Rate for Payer: PHCS Commercial |
$3,935.47
|
| Rate for Payer: United Healthcare All Payer |
$3,607.52
|
|
|
PLATE DOR DIS RD 2H 2.4*51 -90
|
Facility
|
IP
|
$4,099.45
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$532.93 |
| Max. Negotiated Rate |
$3,935.47 |
| Rate for Payer: Aetna Commercial |
$3,156.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,197.57
|
| Rate for Payer: Cash Price |
$2,049.72
|
| Rate for Payer: Cigna Commercial |
$3,402.54
|
| Rate for Payer: First Health Commercial |
$3,894.48
|
| Rate for Payer: Humana Commercial |
$3,484.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,361.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,025.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,229.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,607.52
|
| Rate for Payer: Ohio Health Group HMO |
$3,074.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$819.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$532.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,270.83
|
| Rate for Payer: PHCS Commercial |
$3,935.47
|
| Rate for Payer: United Healthcare All Payer |
$3,607.52
|
|
|
PLATE DOR DIS RD 3H 2.4*37 +90
|
Facility
|
OP
|
$4,264.09
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$554.33 |
| Max. Negotiated Rate |
$4,093.53 |
| Rate for Payer: Aetna Commercial |
$3,283.35
|
| Rate for Payer: Anthem Medicaid |
$1,466.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,325.99
|
| Rate for Payer: Cash Price |
$2,132.04
|
| Rate for Payer: Cigna Commercial |
$3,539.19
|
| Rate for Payer: First Health Commercial |
$4,050.89
|
| Rate for Payer: Humana Commercial |
$3,624.48
|
| Rate for Payer: Humana KY Medicaid |
$1,466.42
|
| Rate for Payer: Kentucky WC Medicaid |
$1,481.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,496.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,146.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,279.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,495.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,752.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,198.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$852.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$554.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,321.87
|
| Rate for Payer: PHCS Commercial |
$4,093.53
|
| Rate for Payer: United Healthcare All Payer |
$3,752.40
|
|
|
PLATE DOR DIS RD 3H 2.4*37 +90
|
Facility
|
IP
|
$4,264.09
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$554.33 |
| Max. Negotiated Rate |
$4,093.53 |
| Rate for Payer: Aetna Commercial |
$3,283.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,325.99
|
| Rate for Payer: Cash Price |
$2,132.04
|
| Rate for Payer: Cigna Commercial |
$3,539.19
|
| Rate for Payer: First Health Commercial |
$4,050.89
|
| Rate for Payer: Humana Commercial |
$3,624.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,496.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,146.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,279.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,752.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,198.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$852.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$554.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,321.87
|
| Rate for Payer: PHCS Commercial |
$4,093.53
|
| Rate for Payer: United Healthcare All Payer |
$3,752.40
|
|
|
PLATE DOR DIS RD 3H 2.4*37 -90
|
Facility
|
OP
|
$4,008.73
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$521.13 |
| Max. Negotiated Rate |
$3,848.38 |
| Rate for Payer: Aetna Commercial |
$3,086.72
|
| Rate for Payer: Anthem Medicaid |
$1,378.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,126.81
|
| Rate for Payer: Cash Price |
$2,004.37
|
| Rate for Payer: Cigna Commercial |
$3,327.25
|
| Rate for Payer: First Health Commercial |
$3,808.29
|
| Rate for Payer: Humana Commercial |
$3,407.42
|
| Rate for Payer: Humana KY Medicaid |
$1,378.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1,392.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,287.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,958.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,202.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,406.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,527.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,006.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$801.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$521.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,242.71
|
| Rate for Payer: PHCS Commercial |
$3,848.38
|
| Rate for Payer: United Healthcare All Payer |
$3,527.68
|
|
|
PLATE DOR DIS RD 3H 2.4*37 -90
|
Facility
|
IP
|
$4,008.73
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$521.13 |
| Max. Negotiated Rate |
$3,848.38 |
| Rate for Payer: Aetna Commercial |
$3,086.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,126.81
|
| Rate for Payer: Cash Price |
$2,004.37
|
| Rate for Payer: Cigna Commercial |
$3,327.25
|
| Rate for Payer: First Health Commercial |
$3,808.29
|
| Rate for Payer: Humana Commercial |
$3,407.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,287.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,958.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,202.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,527.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,006.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$801.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$521.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,242.71
|
| Rate for Payer: PHCS Commercial |
$3,848.38
|
| Rate for Payer: United Healthcare All Payer |
$3,527.68
|
|
|
PLATE DOR DIS RD 3H 2.4*41 +20
|
Facility
|
IP
|
$4,008.73
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$521.13 |
| Max. Negotiated Rate |
$3,848.38 |
| Rate for Payer: Aetna Commercial |
$3,086.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,126.81
|
| Rate for Payer: Cash Price |
$2,004.37
|
| Rate for Payer: Cigna Commercial |
$3,327.25
|
| Rate for Payer: First Health Commercial |
$3,808.29
|
| Rate for Payer: Humana Commercial |
$3,407.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,287.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,958.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,202.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,527.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,006.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$801.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$521.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,242.71
|
| Rate for Payer: PHCS Commercial |
$3,848.38
|
| Rate for Payer: United Healthcare All Payer |
$3,527.68
|
|
|
PLATE DOR DIS RD 3H 2.4*41 +20
|
Facility
|
OP
|
$4,008.73
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$521.13 |
| Max. Negotiated Rate |
$3,848.38 |
| Rate for Payer: Anthem Medicaid |
$1,378.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,126.81
|
| Rate for Payer: Cash Price |
$2,004.37
|
| Rate for Payer: Cigna Commercial |
$3,327.25
|
| Rate for Payer: First Health Commercial |
$3,808.29
|
| Rate for Payer: Humana Commercial |
$3,407.42
|
| Rate for Payer: Humana KY Medicaid |
$1,378.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1,392.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,287.16
|
| Rate for Payer: Aetna Commercial |
$3,086.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,958.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,202.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,406.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,527.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,006.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$801.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$521.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,242.71
|
| Rate for Payer: PHCS Commercial |
$3,848.38
|
| Rate for Payer: United Healthcare All Payer |
$3,527.68
|
|
|
PLATE DOR DIS RD 3H 2.4*41 -20
|
Facility
|
OP
|
$4,008.73
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$521.13 |
| Max. Negotiated Rate |
$3,848.38 |
| Rate for Payer: Aetna Commercial |
$3,086.72
|
| Rate for Payer: Anthem Medicaid |
$1,378.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,126.81
|
| Rate for Payer: Cash Price |
$2,004.37
|
| Rate for Payer: Cigna Commercial |
$3,327.25
|
| Rate for Payer: First Health Commercial |
$3,808.29
|
| Rate for Payer: Humana Commercial |
$3,407.42
|
| Rate for Payer: Humana KY Medicaid |
$1,378.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1,392.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,287.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,958.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,202.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,406.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,527.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,006.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$801.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$521.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,242.71
|
| Rate for Payer: PHCS Commercial |
$3,848.38
|
| Rate for Payer: United Healthcare All Payer |
$3,527.68
|
|
|
PLATE DOR DIS RD 3H 2.4*41 -20
|
Facility
|
IP
|
$4,008.73
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$521.13 |
| Max. Negotiated Rate |
$3,848.38 |
| Rate for Payer: Aetna Commercial |
$3,086.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,126.81
|
| Rate for Payer: Cash Price |
$2,004.37
|
| Rate for Payer: Cigna Commercial |
$3,327.25
|
| Rate for Payer: First Health Commercial |
$3,808.29
|
| Rate for Payer: Humana Commercial |
$3,407.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,287.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,958.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,202.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,527.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,006.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$801.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$521.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,242.71
|
| Rate for Payer: PHCS Commercial |
$3,848.38
|
| Rate for Payer: United Healthcare All Payer |
$3,527.68
|
|
|
PLATE DOR DIS RD 5H 2.4*51 +90
|
Facility
|
IP
|
$4,099.45
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$532.93 |
| Max. Negotiated Rate |
$3,935.47 |
| Rate for Payer: Aetna Commercial |
$3,156.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,197.57
|
| Rate for Payer: Cash Price |
$2,049.72
|
| Rate for Payer: Cigna Commercial |
$3,402.54
|
| Rate for Payer: First Health Commercial |
$3,894.48
|
| Rate for Payer: Humana Commercial |
$3,484.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,361.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,025.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,229.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,607.52
|
| Rate for Payer: Ohio Health Group HMO |
$3,074.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$819.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$532.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,270.83
|
| Rate for Payer: PHCS Commercial |
$3,935.47
|
| Rate for Payer: United Healthcare All Payer |
$3,607.52
|
|
|
PLATE DOR DIS RD 5H 2.4*51 +90
|
Facility
|
OP
|
$4,099.45
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$532.93 |
| Max. Negotiated Rate |
$3,935.47 |
| Rate for Payer: Aetna Commercial |
$3,156.58
|
| Rate for Payer: Anthem Medicaid |
$1,409.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,197.57
|
| Rate for Payer: Cash Price |
$2,049.72
|
| Rate for Payer: Cigna Commercial |
$3,402.54
|
| Rate for Payer: First Health Commercial |
$3,894.48
|
| Rate for Payer: Humana Commercial |
$3,484.53
|
| Rate for Payer: Humana KY Medicaid |
$1,409.80
|
| Rate for Payer: Kentucky WC Medicaid |
$1,424.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,361.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,025.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,229.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,438.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,607.52
|
| Rate for Payer: Ohio Health Group HMO |
$3,074.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$819.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$532.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,270.83
|
| Rate for Payer: PHCS Commercial |
$3,935.47
|
| Rate for Payer: United Healthcare All Payer |
$3,607.52
|
|
|
PLATE DOR DIS RD 5H 2.4*51 -90
|
Facility
|
IP
|
$4,099.45
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$532.93 |
| Max. Negotiated Rate |
$3,935.47 |
| Rate for Payer: Aetna Commercial |
$3,156.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,197.57
|
| Rate for Payer: Cash Price |
$2,049.72
|
| Rate for Payer: Cigna Commercial |
$3,402.54
|
| Rate for Payer: First Health Commercial |
$3,894.48
|
| Rate for Payer: Humana Commercial |
$3,484.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,361.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,025.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,229.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,607.52
|
| Rate for Payer: Ohio Health Group HMO |
$3,074.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$819.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$532.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,270.83
|
| Rate for Payer: PHCS Commercial |
$3,935.47
|
| Rate for Payer: United Healthcare All Payer |
$3,607.52
|
|
|
PLATE DOR DIS RD 5H 2.4*51 -90
|
Facility
|
OP
|
$4,099.45
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$532.93 |
| Max. Negotiated Rate |
$3,935.47 |
| Rate for Payer: Aetna Commercial |
$3,156.58
|
| Rate for Payer: Anthem Medicaid |
$1,409.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,197.57
|
| Rate for Payer: Cash Price |
$2,049.72
|
| Rate for Payer: Cigna Commercial |
$3,402.54
|
| Rate for Payer: First Health Commercial |
$3,894.48
|
| Rate for Payer: Humana Commercial |
$3,484.53
|
| Rate for Payer: Humana KY Medicaid |
$1,409.80
|
| Rate for Payer: Kentucky WC Medicaid |
$1,424.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,361.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,025.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,229.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,438.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,607.52
|
| Rate for Payer: Ohio Health Group HMO |
$3,074.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$819.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$532.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,270.83
|
| Rate for Payer: PHCS Commercial |
$3,935.47
|
| Rate for Payer: United Healthcare All Payer |
$3,607.52
|
|
|
PLATE DOR DIS RD 5H 2.4*55 +20
|
Facility
|
OP
|
$4,099.45
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$532.93 |
| Max. Negotiated Rate |
$3,935.47 |
| Rate for Payer: Aetna Commercial |
$3,156.58
|
| Rate for Payer: Anthem Medicaid |
$1,409.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,197.57
|
| Rate for Payer: Cash Price |
$2,049.72
|
| Rate for Payer: Cigna Commercial |
$3,402.54
|
| Rate for Payer: First Health Commercial |
$3,894.48
|
| Rate for Payer: Humana Commercial |
$3,484.53
|
| Rate for Payer: Humana KY Medicaid |
$1,409.80
|
| Rate for Payer: Kentucky WC Medicaid |
$1,424.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,361.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,025.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,229.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,438.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,607.52
|
| Rate for Payer: Ohio Health Group HMO |
$3,074.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$819.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$532.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,270.83
|
| Rate for Payer: PHCS Commercial |
$3,935.47
|
| Rate for Payer: United Healthcare All Payer |
$3,607.52
|
|
|
PLATE DOR DIS RD 5H 2.4*55 +20
|
Facility
|
IP
|
$4,099.45
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$532.93 |
| Max. Negotiated Rate |
$3,935.47 |
| Rate for Payer: Aetna Commercial |
$3,156.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,197.57
|
| Rate for Payer: Cash Price |
$2,049.72
|
| Rate for Payer: Cigna Commercial |
$3,402.54
|
| Rate for Payer: First Health Commercial |
$3,894.48
|
| Rate for Payer: Humana Commercial |
$3,484.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,361.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,025.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,229.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,607.52
|
| Rate for Payer: Ohio Health Group HMO |
$3,074.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$819.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$532.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,270.83
|
| Rate for Payer: PHCS Commercial |
$3,935.47
|
| Rate for Payer: United Healthcare All Payer |
$3,607.52
|
|
|
PLATE DOR DIS RD 5H 2.4*55 -20
|
Facility
|
OP
|
$4,099.45
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$532.93 |
| Max. Negotiated Rate |
$3,935.47 |
| Rate for Payer: Aetna Commercial |
$3,156.58
|
| Rate for Payer: Anthem Medicaid |
$1,409.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,197.57
|
| Rate for Payer: Cash Price |
$2,049.72
|
| Rate for Payer: Cigna Commercial |
$3,402.54
|
| Rate for Payer: First Health Commercial |
$3,894.48
|
| Rate for Payer: Humana Commercial |
$3,484.53
|
| Rate for Payer: Humana KY Medicaid |
$1,409.80
|
| Rate for Payer: Kentucky WC Medicaid |
$1,424.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,361.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,025.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,229.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,438.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,607.52
|
| Rate for Payer: Ohio Health Group HMO |
$3,074.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$819.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$532.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,270.83
|
| Rate for Payer: PHCS Commercial |
$3,935.47
|
| Rate for Payer: United Healthcare All Payer |
$3,607.52
|
|
|
PLATE DOR DIS RD 5H 2.4*55 -20
|
Facility
|
IP
|
$4,099.45
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$532.93 |
| Max. Negotiated Rate |
$3,935.47 |
| Rate for Payer: Aetna Commercial |
$3,156.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,197.57
|
| Rate for Payer: Cash Price |
$2,049.72
|
| Rate for Payer: Cigna Commercial |
$3,402.54
|
| Rate for Payer: First Health Commercial |
$3,894.48
|
| Rate for Payer: Humana Commercial |
$3,484.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,361.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,025.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,229.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,607.52
|
| Rate for Payer: Ohio Health Group HMO |
$3,074.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$819.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$532.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,270.83
|
| Rate for Payer: PHCS Commercial |
$3,935.47
|
| Rate for Payer: United Healthcare All Payer |
$3,607.52
|
|
|
PLATE DOR DIST RAD TI NAR R 4H
|
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: 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: Aetna Commercial |
$3,836.52
|
| 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 DOR DIST RAD TI NAR R 4H
|
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 DOR DIST RAD TI STD L 4H
|
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 DOR DIST RAD TI STD L 4H
|
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
|
|
