|
PLATE EVOS VL 7H WDE TI 105M L
|
Facility
|
IP
|
$8,930.91
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,161.02 |
| Max. Negotiated Rate |
$8,573.67 |
| Rate for Payer: Aetna Commercial |
$6,876.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,966.11
|
| Rate for Payer: Cash Price |
$4,465.45
|
| Rate for Payer: Cigna Commercial |
$7,412.66
|
| Rate for Payer: First Health Commercial |
$8,484.36
|
| Rate for Payer: Humana Commercial |
$7,591.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,323.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,591.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,679.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,859.20
|
| Rate for Payer: Ohio Health Group HMO |
$6,698.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,786.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,161.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,768.58
|
| Rate for Payer: PHCS Commercial |
$8,573.67
|
| Rate for Payer: United Healthcare All Payer |
$7,859.20
|
|
|
PLATE EVOS VL 7H WDE TI 105M L
|
Facility
|
OP
|
$8,930.91
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,161.02 |
| Max. Negotiated Rate |
$8,573.67 |
| Rate for Payer: Aetna Commercial |
$6,876.80
|
| Rate for Payer: Anthem Medicaid |
$3,071.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,966.11
|
| Rate for Payer: Cash Price |
$4,465.45
|
| Rate for Payer: Cigna Commercial |
$7,412.66
|
| Rate for Payer: First Health Commercial |
$8,484.36
|
| Rate for Payer: Humana Commercial |
$7,591.27
|
| Rate for Payer: Humana KY Medicaid |
$3,071.34
|
| Rate for Payer: Kentucky WC Medicaid |
$3,102.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,323.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,591.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,679.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,132.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,859.20
|
| Rate for Payer: Ohio Health Group HMO |
$6,698.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,786.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,161.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,768.58
|
| Rate for Payer: PHCS Commercial |
$8,573.67
|
| Rate for Payer: United Healthcare All Payer |
$7,859.20
|
|
|
PLATE EVOS VL 7H WDE TI 105M R
|
Facility
|
IP
|
$8,930.91
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,161.02 |
| Max. Negotiated Rate |
$8,573.67 |
| Rate for Payer: Aetna Commercial |
$6,876.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,966.11
|
| Rate for Payer: Cash Price |
$4,465.45
|
| Rate for Payer: Cigna Commercial |
$7,412.66
|
| Rate for Payer: First Health Commercial |
$8,484.36
|
| Rate for Payer: Humana Commercial |
$7,591.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,323.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,591.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,679.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,859.20
|
| Rate for Payer: Ohio Health Group HMO |
$6,698.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,786.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,161.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,768.58
|
| Rate for Payer: PHCS Commercial |
$8,573.67
|
| Rate for Payer: United Healthcare All Payer |
$7,859.20
|
|
|
PLATE EVOS VL 7H WDE TI 105M R
|
Facility
|
OP
|
$8,930.91
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,161.02 |
| Max. Negotiated Rate |
$8,573.67 |
| Rate for Payer: Aetna Commercial |
$6,876.80
|
| Rate for Payer: Anthem Medicaid |
$3,071.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,966.11
|
| Rate for Payer: Cash Price |
$4,465.45
|
| Rate for Payer: Cigna Commercial |
$7,412.66
|
| Rate for Payer: First Health Commercial |
$8,484.36
|
| Rate for Payer: Humana Commercial |
$7,591.27
|
| Rate for Payer: Humana KY Medicaid |
$3,071.34
|
| Rate for Payer: Kentucky WC Medicaid |
$3,102.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,323.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,591.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,679.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,132.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,859.20
|
| Rate for Payer: Ohio Health Group HMO |
$6,698.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,786.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,161.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,768.58
|
| Rate for Payer: PHCS Commercial |
$8,573.67
|
| Rate for Payer: United Healthcare All Payer |
$7,859.20
|
|
|
PLATE EVOS VOL 3H WDE TI 48M L
|
Facility
|
IP
|
$5,549.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$721.44 |
| Max. Negotiated Rate |
$5,327.52 |
| Rate for Payer: Aetna Commercial |
$4,273.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,328.61
|
| Rate for Payer: Cash Price |
$2,774.75
|
| Rate for Payer: Cigna Commercial |
$4,606.08
|
| Rate for Payer: First Health Commercial |
$5,272.02
|
| Rate for Payer: Humana Commercial |
$4,717.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,550.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,095.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,664.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,883.56
|
| Rate for Payer: Ohio Health Group HMO |
$4,162.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,109.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$721.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,720.34
|
| Rate for Payer: PHCS Commercial |
$5,327.52
|
| Rate for Payer: United Healthcare All Payer |
$4,883.56
|
|
|
PLATE EVOS VOL 3H WDE TI 48M L
|
Facility
|
OP
|
$5,549.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$721.44 |
| Max. Negotiated Rate |
$5,327.52 |
| Rate for Payer: Aetna Commercial |
$4,273.12
|
| Rate for Payer: Anthem Medicaid |
$1,908.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,328.61
|
| Rate for Payer: Cash Price |
$2,774.75
|
| Rate for Payer: Cigna Commercial |
$4,606.08
|
| Rate for Payer: First Health Commercial |
$5,272.02
|
| Rate for Payer: Humana Commercial |
$4,717.08
|
| Rate for Payer: Humana KY Medicaid |
$1,908.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1,927.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,550.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,095.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,664.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,946.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,883.56
|
| Rate for Payer: Ohio Health Group HMO |
$4,162.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,109.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$721.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,720.34
|
| Rate for Payer: PHCS Commercial |
$5,327.52
|
| Rate for Payer: United Healthcare All Payer |
$4,883.56
|
|
|
PLATE EVOS VOL 3H WDE TI 48M R
|
Facility
|
OP
|
$5,616.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$730.08 |
| Max. Negotiated Rate |
$5,391.36 |
| Rate for Payer: Anthem Medicaid |
$1,931.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,380.48
|
| Rate for Payer: Cash Price |
$2,808.00
|
| Rate for Payer: Cigna Commercial |
$4,661.28
|
| Rate for Payer: First Health Commercial |
$5,335.20
|
| Rate for Payer: Humana Commercial |
$4,773.60
|
| Rate for Payer: Humana KY Medicaid |
$1,931.34
|
| Rate for Payer: Kentucky WC Medicaid |
$1,951.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,605.12
|
| Rate for Payer: Aetna Commercial |
$4,324.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,144.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,684.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,970.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,942.08
|
| Rate for Payer: Ohio Health Group HMO |
$4,212.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,123.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$730.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,740.96
|
| Rate for Payer: PHCS Commercial |
$5,391.36
|
| Rate for Payer: United Healthcare All Payer |
$4,942.08
|
|
|
PLATE EVOS VOL 3H WDE TI 48M R
|
Facility
|
IP
|
$5,616.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$730.08 |
| Max. Negotiated Rate |
$5,391.36 |
| Rate for Payer: Aetna Commercial |
$4,324.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,380.48
|
| Rate for Payer: Cash Price |
$2,808.00
|
| Rate for Payer: Cigna Commercial |
$4,661.28
|
| Rate for Payer: First Health Commercial |
$5,335.20
|
| Rate for Payer: Humana Commercial |
$4,773.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,605.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,144.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,684.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,942.08
|
| Rate for Payer: Ohio Health Group HMO |
$4,212.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,123.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$730.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,740.96
|
| Rate for Payer: PHCS Commercial |
$5,391.36
|
| Rate for Payer: United Healthcare All Payer |
$4,942.08
|
|
|
PLATE EVOS VOL 4H STD TI 56M R
|
Facility
|
IP
|
$6,461.68
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$840.02 |
| Max. Negotiated Rate |
$6,203.21 |
| Rate for Payer: Aetna Commercial |
$4,975.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,040.11
|
| Rate for Payer: Cash Price |
$3,230.84
|
| Rate for Payer: Cigna Commercial |
$5,363.19
|
| Rate for Payer: First Health Commercial |
$6,138.60
|
| Rate for Payer: Humana Commercial |
$5,492.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,298.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,768.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,938.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,686.28
|
| Rate for Payer: Ohio Health Group HMO |
$4,846.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,292.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$840.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,003.12
|
| Rate for Payer: PHCS Commercial |
$6,203.21
|
| Rate for Payer: United Healthcare All Payer |
$5,686.28
|
|
|
PLATE EVOS VOL 4H STD TI 56M R
|
Facility
|
OP
|
$6,461.68
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$840.02 |
| Max. Negotiated Rate |
$6,203.21 |
| Rate for Payer: Aetna Commercial |
$4,975.49
|
| Rate for Payer: Anthem Medicaid |
$2,222.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,040.11
|
| Rate for Payer: Cash Price |
$3,230.84
|
| Rate for Payer: Cigna Commercial |
$5,363.19
|
| Rate for Payer: First Health Commercial |
$6,138.60
|
| Rate for Payer: Humana Commercial |
$5,492.43
|
| Rate for Payer: Humana KY Medicaid |
$2,222.17
|
| Rate for Payer: Kentucky WC Medicaid |
$2,244.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,298.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,768.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,938.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,266.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,686.28
|
| Rate for Payer: Ohio Health Group HMO |
$4,846.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,292.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$840.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,003.12
|
| Rate for Payer: PHCS Commercial |
$6,203.21
|
| Rate for Payer: United Healthcare All Payer |
$5,686.28
|
|
|
PLATE EVOS VOL 4H WDE TI 56M L
|
Facility
|
OP
|
$6,762.80
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$879.16 |
| Max. Negotiated Rate |
$6,492.29 |
| Rate for Payer: Aetna Commercial |
$5,207.36
|
| Rate for Payer: Anthem Medicaid |
$2,325.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,274.98
|
| Rate for Payer: Cash Price |
$3,381.40
|
| Rate for Payer: Cigna Commercial |
$5,613.12
|
| Rate for Payer: First Health Commercial |
$6,424.66
|
| Rate for Payer: Humana Commercial |
$5,748.38
|
| Rate for Payer: Humana KY Medicaid |
$2,325.73
|
| Rate for Payer: Kentucky WC Medicaid |
$2,349.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,545.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,990.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,372.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,951.26
|
| Rate for Payer: Ohio Health Group HMO |
$5,072.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,352.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$879.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,096.47
|
| Rate for Payer: PHCS Commercial |
$6,492.29
|
| Rate for Payer: United Healthcare All Payer |
$5,951.26
|
|
|
PLATE EVOS VOL 4H WDE TI 56M L
|
Facility
|
IP
|
$6,762.80
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$879.16 |
| Max. Negotiated Rate |
$6,492.29 |
| Rate for Payer: Aetna Commercial |
$5,207.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,274.98
|
| Rate for Payer: Cash Price |
$3,381.40
|
| Rate for Payer: Cigna Commercial |
$5,613.12
|
| Rate for Payer: First Health Commercial |
$6,424.66
|
| Rate for Payer: Humana Commercial |
$5,748.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,545.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,990.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,951.26
|
| Rate for Payer: Ohio Health Group HMO |
$5,072.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,352.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$879.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,096.47
|
| Rate for Payer: PHCS Commercial |
$6,492.29
|
| Rate for Payer: United Healthcare All Payer |
$5,951.26
|
|
|
PLATE EVOS VOL 4H WDE TI 56M R
|
Facility
|
IP
|
$6,461.68
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$840.02 |
| Max. Negotiated Rate |
$6,203.21 |
| Rate for Payer: Aetna Commercial |
$4,975.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,040.11
|
| Rate for Payer: Cash Price |
$3,230.84
|
| Rate for Payer: Cigna Commercial |
$5,363.19
|
| Rate for Payer: First Health Commercial |
$6,138.60
|
| Rate for Payer: Humana Commercial |
$5,492.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,298.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,768.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,938.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,686.28
|
| Rate for Payer: Ohio Health Group HMO |
$4,846.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,292.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$840.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,003.12
|
| Rate for Payer: PHCS Commercial |
$6,203.21
|
| Rate for Payer: United Healthcare All Payer |
$5,686.28
|
|
|
PLATE EVOS VOL 4H WDE TI 56M R
|
Facility
|
OP
|
$6,461.68
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$840.02 |
| Max. Negotiated Rate |
$6,203.21 |
| Rate for Payer: Aetna Commercial |
$4,975.49
|
| Rate for Payer: Anthem Medicaid |
$2,222.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,040.11
|
| Rate for Payer: Cash Price |
$3,230.84
|
| Rate for Payer: Cigna Commercial |
$5,363.19
|
| Rate for Payer: First Health Commercial |
$6,138.60
|
| Rate for Payer: Humana Commercial |
$5,492.43
|
| Rate for Payer: Humana KY Medicaid |
$2,222.17
|
| Rate for Payer: Kentucky WC Medicaid |
$2,244.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,298.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,768.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,938.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,266.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,686.28
|
| Rate for Payer: Ohio Health Group HMO |
$4,846.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,292.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$840.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,003.12
|
| Rate for Payer: PHCS Commercial |
$6,203.21
|
| Rate for Payer: United Healthcare All Payer |
$5,686.28
|
|
|
PLATE EVOS VOL 5H STD TI 81M R
|
Facility
|
OP
|
$8,605.69
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,118.74 |
| Max. Negotiated Rate |
$8,261.46 |
| Rate for Payer: Aetna Commercial |
$6,626.38
|
| Rate for Payer: Anthem Medicaid |
$2,959.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,712.44
|
| Rate for Payer: Cash Price |
$4,302.84
|
| Rate for Payer: Cigna Commercial |
$7,142.72
|
| Rate for Payer: First Health Commercial |
$8,175.41
|
| Rate for Payer: Humana Commercial |
$7,314.84
|
| Rate for Payer: Humana KY Medicaid |
$2,959.50
|
| Rate for Payer: Kentucky WC Medicaid |
$2,989.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,056.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,351.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,581.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,018.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,573.01
|
| Rate for Payer: Ohio Health Group HMO |
$6,454.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,721.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,118.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,667.76
|
| Rate for Payer: PHCS Commercial |
$8,261.46
|
| Rate for Payer: United Healthcare All Payer |
$7,573.01
|
|
|
PLATE EVOS VOL 5H STD TI 81M R
|
Facility
|
IP
|
$8,605.69
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,118.74 |
| Max. Negotiated Rate |
$8,261.46 |
| Rate for Payer: Aetna Commercial |
$6,626.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,712.44
|
| Rate for Payer: Cash Price |
$4,302.84
|
| Rate for Payer: Cigna Commercial |
$7,142.72
|
| Rate for Payer: First Health Commercial |
$8,175.41
|
| Rate for Payer: Humana Commercial |
$7,314.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,056.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,351.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,581.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,573.01
|
| Rate for Payer: Ohio Health Group HMO |
$6,454.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,721.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,118.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,667.76
|
| Rate for Payer: PHCS Commercial |
$8,261.46
|
| Rate for Payer: United Healthcare All Payer |
$7,573.01
|
|
|
PLATE EVOS VOL 5H WDE TI 83M L
|
Facility
|
OP
|
$8,762.27
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,139.10 |
| Max. Negotiated Rate |
$8,411.78 |
| Rate for Payer: Anthem Medicaid |
$3,013.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,834.57
|
| Rate for Payer: Cash Price |
$4,381.14
|
| Rate for Payer: Cigna Commercial |
$7,272.68
|
| Rate for Payer: First Health Commercial |
$8,324.16
|
| Rate for Payer: Humana Commercial |
$7,447.93
|
| Rate for Payer: Humana KY Medicaid |
$3,013.34
|
| Rate for Payer: Kentucky WC Medicaid |
$3,044.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,185.06
|
| Rate for Payer: Aetna Commercial |
$6,746.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,466.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,628.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,073.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,710.80
|
| Rate for Payer: Ohio Health Group HMO |
$6,571.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,752.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,139.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,716.30
|
| Rate for Payer: PHCS Commercial |
$8,411.78
|
| Rate for Payer: United Healthcare All Payer |
$7,710.80
|
|
|
PLATE EVOS VOL 5H WDE TI 83M L
|
Facility
|
IP
|
$8,762.27
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,139.10 |
| Max. Negotiated Rate |
$8,411.78 |
| Rate for Payer: Aetna Commercial |
$6,746.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,834.57
|
| Rate for Payer: Cash Price |
$4,381.14
|
| Rate for Payer: Cigna Commercial |
$7,272.68
|
| Rate for Payer: First Health Commercial |
$8,324.16
|
| Rate for Payer: Humana Commercial |
$7,447.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,185.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,466.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,628.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,710.80
|
| Rate for Payer: Ohio Health Group HMO |
$6,571.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,752.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,139.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,716.30
|
| Rate for Payer: PHCS Commercial |
$8,411.78
|
| Rate for Payer: United Healthcare All Payer |
$7,710.80
|
|
|
PLATE EVOS VOL 5H WDE TI 83M R
|
Facility
|
OP
|
$8,581.60
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,115.61 |
| Max. Negotiated Rate |
$8,238.34 |
| Rate for Payer: Aetna Commercial |
$6,607.83
|
| Rate for Payer: Anthem Medicaid |
$2,951.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,693.65
|
| Rate for Payer: Cash Price |
$4,290.80
|
| Rate for Payer: Cigna Commercial |
$7,122.73
|
| Rate for Payer: First Health Commercial |
$8,152.52
|
| Rate for Payer: Humana Commercial |
$7,294.36
|
| Rate for Payer: Humana KY Medicaid |
$2,951.21
|
| Rate for Payer: Kentucky WC Medicaid |
$2,981.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,036.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,333.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,574.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,010.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,551.81
|
| Rate for Payer: Ohio Health Group HMO |
$6,436.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,716.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,115.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,660.30
|
| Rate for Payer: PHCS Commercial |
$8,238.34
|
| Rate for Payer: United Healthcare All Payer |
$7,551.81
|
|
|
PLATE EVOS VOL 5H WDE TI 83M R
|
Facility
|
IP
|
$8,581.60
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,115.61 |
| Max. Negotiated Rate |
$8,238.34 |
| Rate for Payer: Aetna Commercial |
$6,607.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,693.65
|
| Rate for Payer: Cash Price |
$4,290.80
|
| Rate for Payer: Cigna Commercial |
$7,122.73
|
| Rate for Payer: First Health Commercial |
$8,152.52
|
| Rate for Payer: Humana Commercial |
$7,294.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,036.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,333.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,574.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,551.81
|
| Rate for Payer: Ohio Health Group HMO |
$6,436.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,716.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,115.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,660.30
|
| Rate for Payer: PHCS Commercial |
$8,238.34
|
| Rate for Payer: United Healthcare All Payer |
$7,551.81
|
|
|
PLATE EVOS VOLAR 4H 56MM R
|
Facility
|
IP
|
$6,461.68
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$840.02 |
| Max. Negotiated Rate |
$6,203.21 |
| Rate for Payer: Aetna Commercial |
$4,975.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,040.11
|
| Rate for Payer: Cash Price |
$3,230.84
|
| Rate for Payer: Cigna Commercial |
$5,363.19
|
| Rate for Payer: First Health Commercial |
$6,138.60
|
| Rate for Payer: Humana Commercial |
$5,492.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,298.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,768.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,938.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,686.28
|
| Rate for Payer: Ohio Health Group HMO |
$4,846.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,292.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$840.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,003.12
|
| Rate for Payer: PHCS Commercial |
$6,203.21
|
| Rate for Payer: United Healthcare All Payer |
$5,686.28
|
|
|
PLATE EVOS VOLAR 4H 56MM R
|
Facility
|
OP
|
$6,461.68
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$840.02 |
| Max. Negotiated Rate |
$6,203.21 |
| Rate for Payer: Aetna Commercial |
$4,975.49
|
| Rate for Payer: Anthem Medicaid |
$2,222.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,040.11
|
| Rate for Payer: Cash Price |
$3,230.84
|
| Rate for Payer: Cigna Commercial |
$5,363.19
|
| Rate for Payer: First Health Commercial |
$6,138.60
|
| Rate for Payer: Humana Commercial |
$5,492.43
|
| Rate for Payer: Humana KY Medicaid |
$2,222.17
|
| Rate for Payer: Kentucky WC Medicaid |
$2,244.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,298.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,768.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,938.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,266.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,686.28
|
| Rate for Payer: Ohio Health Group HMO |
$4,846.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,292.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$840.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,003.12
|
| Rate for Payer: PHCS Commercial |
$6,203.21
|
| Rate for Payer: United Healthcare All Payer |
$5,686.28
|
|
|
PLATE EVS INTL 4H WDE TI 54M L
|
Facility
|
IP
|
$6,630.31
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$861.94 |
| Max. Negotiated Rate |
$6,365.10 |
| Rate for Payer: Aetna Commercial |
$5,105.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,171.64
|
| Rate for Payer: Cash Price |
$3,315.16
|
| Rate for Payer: Cigna Commercial |
$5,503.16
|
| Rate for Payer: First Health Commercial |
$6,298.79
|
| Rate for Payer: Humana Commercial |
$5,635.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,436.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,893.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,989.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,834.67
|
| Rate for Payer: Ohio Health Group HMO |
$4,972.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,326.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$861.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,055.40
|
| Rate for Payer: PHCS Commercial |
$6,365.10
|
| Rate for Payer: United Healthcare All Payer |
$5,834.67
|
|
|
PLATE EVS INTL 4H WDE TI 54M L
|
Facility
|
OP
|
$6,630.31
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$861.94 |
| Max. Negotiated Rate |
$6,365.10 |
| Rate for Payer: Aetna Commercial |
$5,105.34
|
| Rate for Payer: Anthem Medicaid |
$2,280.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,171.64
|
| Rate for Payer: Cash Price |
$3,315.16
|
| Rate for Payer: Cigna Commercial |
$5,503.16
|
| Rate for Payer: First Health Commercial |
$6,298.79
|
| Rate for Payer: Humana Commercial |
$5,635.76
|
| Rate for Payer: Humana KY Medicaid |
$2,280.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,303.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,436.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,893.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,989.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,325.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,834.67
|
| Rate for Payer: Ohio Health Group HMO |
$4,972.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,326.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$861.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,055.40
|
| Rate for Payer: PHCS Commercial |
$6,365.10
|
| Rate for Payer: United Healthcare All Payer |
$5,834.67
|
|
|
PLATE EVS INTL 4H WDE TI 57M L
|
Facility
|
OP
|
$7,268.70
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$944.93 |
| Max. Negotiated Rate |
$6,977.95 |
| Rate for Payer: Aetna Commercial |
$5,596.90
|
| Rate for Payer: Anthem Medicaid |
$2,499.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,669.59
|
| Rate for Payer: Cash Price |
$3,634.35
|
| Rate for Payer: Cigna Commercial |
$6,033.02
|
| Rate for Payer: First Health Commercial |
$6,905.26
|
| Rate for Payer: Humana Commercial |
$6,178.40
|
| Rate for Payer: Humana KY Medicaid |
$2,499.71
|
| Rate for Payer: Kentucky WC Medicaid |
$2,525.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,960.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,364.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,180.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,549.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,396.46
|
| Rate for Payer: Ohio Health Group HMO |
$5,451.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,453.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$944.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,253.30
|
| Rate for Payer: PHCS Commercial |
$6,977.95
|
| Rate for Payer: United Healthcare All Payer |
$6,396.46
|
|
