|
PLATE ACU-LOC 2 VDR STD LONG R
|
Facility
|
IP
|
$5,172.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,551.75 |
| Max. Negotiated Rate |
$4,965.60 |
| Rate for Payer: Aetna Commercial |
$3,982.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,034.55
|
| Rate for Payer: Cash Price |
$2,586.25
|
| Rate for Payer: Cigna Commercial |
$4,293.18
|
| Rate for Payer: First Health Commercial |
$4,913.88
|
| Rate for Payer: Humana Commercial |
$4,396.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,241.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,817.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,551.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,551.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,879.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,138.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,500.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,569.03
|
| Rate for Payer: PHCS Commercial |
$4,965.60
|
| Rate for Payer: United Healthcare All Payer |
$4,551.80
|
|
|
PLATE ACU-LOC 2 VDR STD R
|
Facility
|
IP
|
$5,172.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,551.75 |
| Max. Negotiated Rate |
$4,965.60 |
| Rate for Payer: Aetna Commercial |
$3,982.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,034.55
|
| Rate for Payer: Cash Price |
$2,586.25
|
| Rate for Payer: Cigna Commercial |
$4,293.18
|
| Rate for Payer: First Health Commercial |
$4,913.88
|
| Rate for Payer: Humana Commercial |
$4,396.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,241.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,817.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,551.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,551.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,879.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,138.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,500.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,569.03
|
| Rate for Payer: PHCS Commercial |
$4,965.60
|
| Rate for Payer: United Healthcare All Payer |
$4,551.80
|
|
|
PLATE ACU-LOC 2 VDR STD R
|
Facility
|
OP
|
$5,172.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,551.75 |
| Max. Negotiated Rate |
$4,965.60 |
| Rate for Payer: Aetna Commercial |
$3,982.82
|
| Rate for Payer: Anthem Medicaid |
$1,778.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,034.55
|
| Rate for Payer: Cash Price |
$2,586.25
|
| Rate for Payer: Cigna Commercial |
$4,293.18
|
| Rate for Payer: First Health Commercial |
$4,913.88
|
| Rate for Payer: Humana Commercial |
$4,396.62
|
| Rate for Payer: Humana KY Medicaid |
$1,778.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,796.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,241.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,817.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,551.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,814.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,551.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,879.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,138.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,500.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,569.03
|
| Rate for Payer: PHCS Commercial |
$4,965.60
|
| Rate for Payer: United Healthcare All Payer |
$4,551.80
|
|
|
PLATE ACU-LOC 2 VDR WIDE L
|
Facility
|
IP
|
$5,172.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,551.75 |
| Max. Negotiated Rate |
$4,965.60 |
| Rate for Payer: Aetna Commercial |
$3,982.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,034.55
|
| Rate for Payer: Cash Price |
$2,586.25
|
| Rate for Payer: Cigna Commercial |
$4,293.18
|
| Rate for Payer: First Health Commercial |
$4,913.88
|
| Rate for Payer: Humana Commercial |
$4,396.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,241.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,817.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,551.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,551.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,879.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,138.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,500.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,569.03
|
| Rate for Payer: PHCS Commercial |
$4,965.60
|
| Rate for Payer: United Healthcare All Payer |
$4,551.80
|
|
|
PLATE ACU-LOC 2 VDR WIDE L
|
Facility
|
OP
|
$5,172.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,551.75 |
| Max. Negotiated Rate |
$4,965.60 |
| Rate for Payer: Aetna Commercial |
$3,982.82
|
| Rate for Payer: Anthem Medicaid |
$1,778.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,034.55
|
| Rate for Payer: Cash Price |
$2,586.25
|
| Rate for Payer: Cigna Commercial |
$4,293.18
|
| Rate for Payer: First Health Commercial |
$4,913.88
|
| Rate for Payer: Humana Commercial |
$4,396.62
|
| Rate for Payer: Humana KY Medicaid |
$1,778.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,796.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,241.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,817.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,551.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,814.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,551.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,879.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,138.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,500.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,569.03
|
| Rate for Payer: PHCS Commercial |
$4,965.60
|
| Rate for Payer: United Healthcare All Payer |
$4,551.80
|
|
|
PLATE ACU-LOC 2 VDR WIDE R
|
Facility
|
IP
|
$5,172.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,551.75 |
| Max. Negotiated Rate |
$4,965.60 |
| Rate for Payer: Aetna Commercial |
$3,982.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,034.55
|
| Rate for Payer: Cash Price |
$2,586.25
|
| Rate for Payer: Cigna Commercial |
$4,293.18
|
| Rate for Payer: First Health Commercial |
$4,913.88
|
| Rate for Payer: Humana Commercial |
$4,396.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,241.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,817.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,551.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,551.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,879.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,138.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,500.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,569.03
|
| Rate for Payer: PHCS Commercial |
$4,965.60
|
| Rate for Payer: United Healthcare All Payer |
$4,551.80
|
|
|
PLATE ACU-LOC 2 VDR WIDE R
|
Facility
|
OP
|
$5,172.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,551.75 |
| Max. Negotiated Rate |
$4,965.60 |
| Rate for Payer: Aetna Commercial |
$3,982.82
|
| Rate for Payer: Anthem Medicaid |
$1,778.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,034.55
|
| Rate for Payer: Cash Price |
$2,586.25
|
| Rate for Payer: Cigna Commercial |
$4,293.18
|
| Rate for Payer: First Health Commercial |
$4,913.88
|
| Rate for Payer: Humana Commercial |
$4,396.62
|
| Rate for Payer: Humana KY Medicaid |
$1,778.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,796.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,241.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,817.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,551.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,814.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,551.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,879.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,138.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,500.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,569.03
|
| Rate for Payer: PHCS Commercial |
$4,965.60
|
| Rate for Payer: United Healthcare All Payer |
$4,551.80
|
|
|
PLATE ACU-LOC DORSAL NAR LEFT
|
Facility
|
OP
|
$4,542.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,362.75 |
| Max. Negotiated Rate |
$4,360.80 |
| Rate for Payer: Aetna Commercial |
$3,497.72
|
| Rate for Payer: Anthem Medicaid |
$1,562.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,543.15
|
| Rate for Payer: Cash Price |
$2,271.25
|
| Rate for Payer: Cigna Commercial |
$3,770.28
|
| Rate for Payer: First Health Commercial |
$4,315.38
|
| Rate for Payer: Humana Commercial |
$3,861.12
|
| Rate for Payer: Humana KY Medicaid |
$1,562.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,578.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,724.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,352.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,362.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,593.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,997.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,406.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,634.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,951.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,134.32
|
| Rate for Payer: PHCS Commercial |
$4,360.80
|
| Rate for Payer: United Healthcare All Payer |
$3,997.40
|
|
|
PLATE ACU-LOC DORSAL NAR LEFT
|
Facility
|
IP
|
$4,542.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,362.75 |
| Max. Negotiated Rate |
$4,360.80 |
| Rate for Payer: Aetna Commercial |
$3,497.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,543.15
|
| Rate for Payer: Cash Price |
$2,271.25
|
| Rate for Payer: Cigna Commercial |
$3,770.28
|
| Rate for Payer: First Health Commercial |
$4,315.38
|
| Rate for Payer: Humana Commercial |
$3,861.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,724.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,352.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,362.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,997.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,406.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,634.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,951.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,134.32
|
| Rate for Payer: PHCS Commercial |
$4,360.80
|
| Rate for Payer: United Healthcare All Payer |
$3,997.40
|
|
|
PLATE ACU-LOC DORSAL NAR RIGHT
|
Facility
|
OP
|
$4,542.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,362.75 |
| Max. Negotiated Rate |
$4,360.80 |
| Rate for Payer: Aetna Commercial |
$3,497.72
|
| Rate for Payer: Anthem Medicaid |
$1,562.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,543.15
|
| Rate for Payer: Cash Price |
$2,271.25
|
| Rate for Payer: Cigna Commercial |
$3,770.28
|
| Rate for Payer: First Health Commercial |
$4,315.38
|
| Rate for Payer: Humana Commercial |
$3,861.12
|
| Rate for Payer: Humana KY Medicaid |
$1,562.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,578.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,724.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,352.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,362.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,593.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,997.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,406.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,634.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,951.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,134.32
|
| Rate for Payer: PHCS Commercial |
$4,360.80
|
| Rate for Payer: United Healthcare All Payer |
$3,997.40
|
|
|
PLATE ACU-LOC DORSAL NAR RIGHT
|
Facility
|
IP
|
$4,542.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,362.75 |
| Max. Negotiated Rate |
$4,360.80 |
| Rate for Payer: Aetna Commercial |
$3,497.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,543.15
|
| Rate for Payer: Cash Price |
$2,271.25
|
| Rate for Payer: Cigna Commercial |
$3,770.28
|
| Rate for Payer: First Health Commercial |
$4,315.38
|
| Rate for Payer: Humana Commercial |
$3,861.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,724.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,352.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,362.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,997.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,406.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,634.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,951.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,134.32
|
| Rate for Payer: PHCS Commercial |
$4,360.80
|
| Rate for Payer: United Healthcare All Payer |
$3,997.40
|
|
|
PLATE ACU-LOC DORSAL STD LEFT
|
Facility
|
OP
|
$4,542.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,362.75 |
| Max. Negotiated Rate |
$4,360.80 |
| Rate for Payer: Aetna Commercial |
$3,497.72
|
| Rate for Payer: Anthem Medicaid |
$1,562.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,543.15
|
| Rate for Payer: Cash Price |
$2,271.25
|
| Rate for Payer: Cigna Commercial |
$3,770.28
|
| Rate for Payer: First Health Commercial |
$4,315.38
|
| Rate for Payer: Humana Commercial |
$3,861.12
|
| Rate for Payer: Humana KY Medicaid |
$1,562.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,578.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,724.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,352.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,362.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,593.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,997.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,406.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,634.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,951.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,134.32
|
| Rate for Payer: PHCS Commercial |
$4,360.80
|
| Rate for Payer: United Healthcare All Payer |
$3,997.40
|
|
|
PLATE ACU-LOC DORSAL STD LEFT
|
Facility
|
IP
|
$4,542.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,362.75 |
| Max. Negotiated Rate |
$4,360.80 |
| Rate for Payer: Aetna Commercial |
$3,497.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,543.15
|
| Rate for Payer: Cash Price |
$2,271.25
|
| Rate for Payer: Cigna Commercial |
$3,770.28
|
| Rate for Payer: First Health Commercial |
$4,315.38
|
| Rate for Payer: Humana Commercial |
$3,861.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,724.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,352.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,362.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,997.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,406.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,634.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,951.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,134.32
|
| Rate for Payer: PHCS Commercial |
$4,360.80
|
| Rate for Payer: United Healthcare All Payer |
$3,997.40
|
|
|
PLATE ACU-LOC DORSAL STD RIGHT
|
Facility
|
IP
|
$4,542.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,362.75 |
| Max. Negotiated Rate |
$4,360.80 |
| Rate for Payer: Aetna Commercial |
$3,497.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,543.15
|
| Rate for Payer: Cash Price |
$2,271.25
|
| Rate for Payer: Cigna Commercial |
$3,770.28
|
| Rate for Payer: First Health Commercial |
$4,315.38
|
| Rate for Payer: Humana Commercial |
$3,861.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,724.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,352.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,362.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,997.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,406.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,634.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,951.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,134.32
|
| Rate for Payer: PHCS Commercial |
$4,360.80
|
| Rate for Payer: United Healthcare All Payer |
$3,997.40
|
|
|
PLATE ACU-LOC DORSAL STD RIGHT
|
Facility
|
OP
|
$4,542.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,362.75 |
| Max. Negotiated Rate |
$4,360.80 |
| Rate for Payer: Aetna Commercial |
$3,497.72
|
| Rate for Payer: Anthem Medicaid |
$1,562.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,543.15
|
| Rate for Payer: Cash Price |
$2,271.25
|
| Rate for Payer: Cigna Commercial |
$3,770.28
|
| Rate for Payer: First Health Commercial |
$4,315.38
|
| Rate for Payer: Humana Commercial |
$3,861.12
|
| Rate for Payer: Humana KY Medicaid |
$1,562.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,578.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,724.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,352.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,362.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,593.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,997.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,406.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,634.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,951.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,134.32
|
| Rate for Payer: PHCS Commercial |
$4,360.80
|
| Rate for Payer: United Healthcare All Payer |
$3,997.40
|
|
|
PLATE ACU-LOC VDU LEFT LONG
|
Facility
|
IP
|
$4,542.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,362.75 |
| Max. Negotiated Rate |
$4,360.80 |
| Rate for Payer: Aetna Commercial |
$3,497.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,543.15
|
| Rate for Payer: Cash Price |
$2,271.25
|
| Rate for Payer: Cigna Commercial |
$3,770.28
|
| Rate for Payer: First Health Commercial |
$4,315.38
|
| Rate for Payer: Humana Commercial |
$3,861.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,724.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,352.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,362.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,997.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,406.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,634.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,951.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,134.32
|
| Rate for Payer: PHCS Commercial |
$4,360.80
|
| Rate for Payer: United Healthcare All Payer |
$3,997.40
|
|
|
PLATE ACU-LOC VDU LEFT LONG
|
Facility
|
OP
|
$4,542.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,362.75 |
| Max. Negotiated Rate |
$4,360.80 |
| Rate for Payer: Aetna Commercial |
$3,497.72
|
| Rate for Payer: Anthem Medicaid |
$1,562.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,543.15
|
| Rate for Payer: Cash Price |
$2,271.25
|
| Rate for Payer: Cigna Commercial |
$3,770.28
|
| Rate for Payer: First Health Commercial |
$4,315.38
|
| Rate for Payer: Humana Commercial |
$3,861.12
|
| Rate for Payer: Humana KY Medicaid |
$1,562.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,578.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,724.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,352.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,362.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,593.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,997.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,406.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,634.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,951.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,134.32
|
| Rate for Payer: PHCS Commercial |
$4,360.80
|
| Rate for Payer: United Healthcare All Payer |
$3,997.40
|
|
|
PLATE ACU-LOC VDU LEFT STD
|
Facility
|
IP
|
$4,542.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,362.75 |
| Max. Negotiated Rate |
$4,360.80 |
| Rate for Payer: Aetna Commercial |
$3,497.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,543.15
|
| Rate for Payer: Cash Price |
$2,271.25
|
| Rate for Payer: Cigna Commercial |
$3,770.28
|
| Rate for Payer: First Health Commercial |
$4,315.38
|
| Rate for Payer: Humana Commercial |
$3,861.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,724.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,352.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,362.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,997.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,406.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,634.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,951.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,134.32
|
| Rate for Payer: PHCS Commercial |
$4,360.80
|
| Rate for Payer: United Healthcare All Payer |
$3,997.40
|
|
|
PLATE ACU-LOC VDU LEFT STD
|
Facility
|
OP
|
$4,542.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,362.75 |
| Max. Negotiated Rate |
$4,360.80 |
| Rate for Payer: Aetna Commercial |
$3,497.72
|
| Rate for Payer: Anthem Medicaid |
$1,562.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,543.15
|
| Rate for Payer: Cash Price |
$2,271.25
|
| Rate for Payer: Cigna Commercial |
$3,770.28
|
| Rate for Payer: First Health Commercial |
$4,315.38
|
| Rate for Payer: Humana Commercial |
$3,861.12
|
| Rate for Payer: Humana KY Medicaid |
$1,562.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,578.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,724.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,352.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,362.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,593.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,997.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,406.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,634.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,951.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,134.32
|
| Rate for Payer: PHCS Commercial |
$4,360.80
|
| Rate for Payer: United Healthcare All Payer |
$3,997.40
|
|
|
PLATE ACU-LOC VDU RIGHT LONG
|
Facility
|
IP
|
$4,542.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,362.75 |
| Max. Negotiated Rate |
$4,360.80 |
| Rate for Payer: Aetna Commercial |
$3,497.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,543.15
|
| Rate for Payer: Cash Price |
$2,271.25
|
| Rate for Payer: Cigna Commercial |
$3,770.28
|
| Rate for Payer: First Health Commercial |
$4,315.38
|
| Rate for Payer: Humana Commercial |
$3,861.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,724.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,352.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,362.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,997.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,406.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,634.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,951.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,134.32
|
| Rate for Payer: PHCS Commercial |
$4,360.80
|
| Rate for Payer: United Healthcare All Payer |
$3,997.40
|
|
|
PLATE ACU-LOC VDU RIGHT LONG
|
Facility
|
OP
|
$4,542.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,362.75 |
| Max. Negotiated Rate |
$4,360.80 |
| Rate for Payer: Aetna Commercial |
$3,497.72
|
| Rate for Payer: Anthem Medicaid |
$1,562.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,543.15
|
| Rate for Payer: Cash Price |
$2,271.25
|
| Rate for Payer: Cigna Commercial |
$3,770.28
|
| Rate for Payer: First Health Commercial |
$4,315.38
|
| Rate for Payer: Humana Commercial |
$3,861.12
|
| Rate for Payer: Humana KY Medicaid |
$1,562.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,578.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,724.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,352.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,362.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,593.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,997.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,406.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,634.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,951.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,134.32
|
| Rate for Payer: PHCS Commercial |
$4,360.80
|
| Rate for Payer: United Healthcare All Payer |
$3,997.40
|
|
|
PLATE ACU-LOC VDU RIGHT STD
|
Facility
|
IP
|
$4,542.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,362.75 |
| Max. Negotiated Rate |
$4,360.80 |
| Rate for Payer: Aetna Commercial |
$3,497.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,543.15
|
| Rate for Payer: Cash Price |
$2,271.25
|
| Rate for Payer: Cigna Commercial |
$3,770.28
|
| Rate for Payer: First Health Commercial |
$4,315.38
|
| Rate for Payer: Humana Commercial |
$3,861.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,724.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,352.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,362.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,997.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,406.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,634.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,951.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,134.32
|
| Rate for Payer: PHCS Commercial |
$4,360.80
|
| Rate for Payer: United Healthcare All Payer |
$3,997.40
|
|
|
PLATE ACU-LOC VDU RIGHT STD
|
Facility
|
OP
|
$4,542.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,362.75 |
| Max. Negotiated Rate |
$4,360.80 |
| Rate for Payer: Aetna Commercial |
$3,497.72
|
| Rate for Payer: Anthem Medicaid |
$1,562.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,543.15
|
| Rate for Payer: Cash Price |
$2,271.25
|
| Rate for Payer: Cigna Commercial |
$3,770.28
|
| Rate for Payer: First Health Commercial |
$4,315.38
|
| Rate for Payer: Humana Commercial |
$3,861.12
|
| Rate for Payer: Humana KY Medicaid |
$1,562.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,578.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,724.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,352.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,362.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,593.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,997.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,406.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,634.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,951.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,134.32
|
| Rate for Payer: PHCS Commercial |
$4,360.80
|
| Rate for Payer: United Healthcare All Payer |
$3,997.40
|
|
|
PLATE ADULT BLD 95 50/124 7H
|
Facility
|
IP
|
$4,698.31
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,409.49 |
| Max. Negotiated Rate |
$4,510.38 |
| Rate for Payer: Aetna Commercial |
$3,617.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,664.68
|
| Rate for Payer: Cash Price |
$2,349.16
|
| Rate for Payer: Cigna Commercial |
$3,899.60
|
| Rate for Payer: First Health Commercial |
$4,463.39
|
| Rate for Payer: Humana Commercial |
$3,993.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,852.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,467.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,409.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,134.51
|
| Rate for Payer: Ohio Health Group HMO |
$3,523.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,758.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,087.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,241.83
|
| Rate for Payer: PHCS Commercial |
$4,510.38
|
| Rate for Payer: United Healthcare All Payer |
$4,134.51
|
|
|
PLATE ADULT BLD 95 50/124 7H
|
Facility
|
OP
|
$4,698.31
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,409.49 |
| Max. Negotiated Rate |
$4,510.38 |
| Rate for Payer: Aetna Commercial |
$3,617.70
|
| Rate for Payer: Anthem Medicaid |
$1,615.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,664.68
|
| Rate for Payer: Cash Price |
$2,349.16
|
| Rate for Payer: Cigna Commercial |
$3,899.60
|
| Rate for Payer: First Health Commercial |
$4,463.39
|
| Rate for Payer: Humana Commercial |
$3,993.56
|
| Rate for Payer: Humana KY Medicaid |
$1,615.75
|
| Rate for Payer: Kentucky WC Medicaid |
$1,632.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,852.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,467.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,409.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,648.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,134.51
|
| Rate for Payer: Ohio Health Group HMO |
$3,523.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,758.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,087.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,241.83
|
| Rate for Payer: PHCS Commercial |
$4,510.38
|
| Rate for Payer: United Healthcare All Payer |
$4,134.51
|
|
