|
PLATE CHIN 6H 4MM
|
Facility
|
OP
|
$2,176.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$652.86 |
| Max. Negotiated Rate |
$2,089.15 |
| Rate for Payer: Aetna Commercial |
$1,675.67
|
| Rate for Payer: Anthem Medicaid |
$748.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,697.44
|
| Rate for Payer: Cash Price |
$1,088.10
|
| Rate for Payer: Cigna Commercial |
$1,806.25
|
| Rate for Payer: First Health Commercial |
$2,067.39
|
| Rate for Payer: Humana Commercial |
$1,849.77
|
| Rate for Payer: Humana KY Medicaid |
$748.40
|
| Rate for Payer: Kentucky WC Medicaid |
$756.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,784.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,606.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$652.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$763.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,915.06
|
| Rate for Payer: Ohio Health Group HMO |
$1,632.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,740.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,893.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,501.58
|
| Rate for Payer: PHCS Commercial |
$2,089.15
|
| Rate for Payer: United Healthcare All Payer |
$1,915.06
|
|
|
PLATE CHS SHORT BARREL 145^ 5H
|
Facility
|
OP
|
$2,155.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$646.50 |
| Max. Negotiated Rate |
$2,068.80 |
| Rate for Payer: Aetna Commercial |
$1,659.35
|
| Rate for Payer: Anthem Medicaid |
$741.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,680.90
|
| Rate for Payer: Cash Price |
$1,077.50
|
| Rate for Payer: Cigna Commercial |
$1,788.65
|
| Rate for Payer: First Health Commercial |
$2,047.25
|
| Rate for Payer: Humana Commercial |
$1,831.75
|
| Rate for Payer: Humana KY Medicaid |
$741.10
|
| Rate for Payer: Kentucky WC Medicaid |
$748.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,767.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,590.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$646.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$755.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,896.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,616.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,724.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,874.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,486.95
|
| Rate for Payer: PHCS Commercial |
$2,068.80
|
| Rate for Payer: United Healthcare All Payer |
$1,896.40
|
|
|
PLATE CHS SHORT BARREL 145^ 5H
|
Facility
|
IP
|
$2,155.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$646.50 |
| Max. Negotiated Rate |
$2,068.80 |
| Rate for Payer: Aetna Commercial |
$1,659.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,680.90
|
| Rate for Payer: Cash Price |
$1,077.50
|
| Rate for Payer: Cigna Commercial |
$1,788.65
|
| Rate for Payer: First Health Commercial |
$2,047.25
|
| Rate for Payer: Humana Commercial |
$1,831.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,767.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,590.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$646.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,896.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,616.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,724.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,874.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,486.95
|
| Rate for Payer: PHCS Commercial |
$2,068.80
|
| Rate for Payer: United Healthcare All Payer |
$1,896.40
|
|
|
PLATE CHS SHORT BARREL 150^ 5H
|
Facility
|
OP
|
$2,155.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$646.50 |
| Max. Negotiated Rate |
$2,068.80 |
| Rate for Payer: Aetna Commercial |
$1,659.35
|
| Rate for Payer: Anthem Medicaid |
$741.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,680.90
|
| Rate for Payer: Cash Price |
$1,077.50
|
| Rate for Payer: Cigna Commercial |
$1,788.65
|
| Rate for Payer: First Health Commercial |
$2,047.25
|
| Rate for Payer: Humana Commercial |
$1,831.75
|
| Rate for Payer: Humana KY Medicaid |
$741.10
|
| Rate for Payer: Kentucky WC Medicaid |
$748.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,767.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,590.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$646.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$755.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,896.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,616.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,724.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,874.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,486.95
|
| Rate for Payer: PHCS Commercial |
$2,068.80
|
| Rate for Payer: United Healthcare All Payer |
$1,896.40
|
|
|
PLATE CHS SHORT BARREL 150^ 5H
|
Facility
|
IP
|
$2,155.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$646.50 |
| Max. Negotiated Rate |
$2,068.80 |
| Rate for Payer: Aetna Commercial |
$1,659.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,680.90
|
| Rate for Payer: Cash Price |
$1,077.50
|
| Rate for Payer: Cigna Commercial |
$1,788.65
|
| Rate for Payer: First Health Commercial |
$2,047.25
|
| Rate for Payer: Humana Commercial |
$1,831.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,767.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,590.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$646.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,896.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,616.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,724.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,874.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,486.95
|
| Rate for Payer: PHCS Commercial |
$2,068.80
|
| Rate for Payer: United Healthcare All Payer |
$1,896.40
|
|
|
PLATE CLASSIC 10 SLOT 130^ 220
|
Facility
|
IP
|
$4,813.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.09 |
| Max. Negotiated Rate |
$4,621.08 |
| Rate for Payer: Aetna Commercial |
$3,706.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,754.62
|
| Rate for Payer: Cash Price |
$2,406.81
|
| Rate for Payer: Cigna Commercial |
$3,995.30
|
| Rate for Payer: First Health Commercial |
$4,572.94
|
| Rate for Payer: Humana Commercial |
$4,091.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,947.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,552.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,444.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.99
|
| Rate for Payer: Ohio Health Group HMO |
$3,610.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,187.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,321.40
|
| Rate for Payer: PHCS Commercial |
$4,621.08
|
| Rate for Payer: United Healthcare All Payer |
$4,235.99
|
|
|
PLATE CLASSIC 10 SLOT 130^ 220
|
Facility
|
OP
|
$4,813.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.09 |
| Max. Negotiated Rate |
$4,621.08 |
| Rate for Payer: Aetna Commercial |
$3,706.49
|
| Rate for Payer: Anthem Medicaid |
$1,655.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,754.62
|
| Rate for Payer: Cash Price |
$2,406.81
|
| Rate for Payer: Cigna Commercial |
$3,995.30
|
| Rate for Payer: First Health Commercial |
$4,572.94
|
| Rate for Payer: Humana Commercial |
$4,091.58
|
| Rate for Payer: Humana KY Medicaid |
$1,655.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,672.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,947.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,552.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,444.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,688.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.99
|
| Rate for Payer: Ohio Health Group HMO |
$3,610.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,187.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,321.40
|
| Rate for Payer: PHCS Commercial |
$4,621.08
|
| Rate for Payer: United Healthcare All Payer |
$4,235.99
|
|
|
PLATE CLASSIC 10 SLOT 145^ 220
|
Facility
|
OP
|
$4,813.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.09 |
| Max. Negotiated Rate |
$4,621.08 |
| Rate for Payer: Aetna Commercial |
$3,706.49
|
| Rate for Payer: Anthem Medicaid |
$1,655.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,754.62
|
| Rate for Payer: Cash Price |
$2,406.81
|
| Rate for Payer: Cigna Commercial |
$3,995.30
|
| Rate for Payer: First Health Commercial |
$4,572.94
|
| Rate for Payer: Humana Commercial |
$4,091.58
|
| Rate for Payer: Humana KY Medicaid |
$1,655.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,672.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,947.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,552.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,444.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,688.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.99
|
| Rate for Payer: Ohio Health Group HMO |
$3,610.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,187.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,321.40
|
| Rate for Payer: PHCS Commercial |
$4,621.08
|
| Rate for Payer: United Healthcare All Payer |
$4,235.99
|
|
|
PLATE CLASSIC 10 SLOT 145^ 220
|
Facility
|
IP
|
$4,813.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.09 |
| Max. Negotiated Rate |
$4,621.08 |
| Rate for Payer: Aetna Commercial |
$3,706.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,754.62
|
| Rate for Payer: Cash Price |
$2,406.81
|
| Rate for Payer: Cigna Commercial |
$3,995.30
|
| Rate for Payer: First Health Commercial |
$4,572.94
|
| Rate for Payer: Humana Commercial |
$4,091.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,947.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,552.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,444.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.99
|
| Rate for Payer: Ohio Health Group HMO |
$3,610.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,187.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,321.40
|
| Rate for Payer: PHCS Commercial |
$4,621.08
|
| Rate for Payer: United Healthcare All Payer |
$4,235.99
|
|
|
PLATE CLASSIC 10 SLOT 150^ 220
|
Facility
|
IP
|
$4,813.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.09 |
| Max. Negotiated Rate |
$4,621.08 |
| Rate for Payer: Aetna Commercial |
$3,706.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,754.62
|
| Rate for Payer: Cash Price |
$2,406.81
|
| Rate for Payer: Cigna Commercial |
$3,995.30
|
| Rate for Payer: First Health Commercial |
$4,572.94
|
| Rate for Payer: Humana Commercial |
$4,091.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,947.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,552.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,444.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.99
|
| Rate for Payer: Ohio Health Group HMO |
$3,610.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,187.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,321.40
|
| Rate for Payer: PHCS Commercial |
$4,621.08
|
| Rate for Payer: United Healthcare All Payer |
$4,235.99
|
|
|
PLATE CLASSIC 10 SLOT 150^ 220
|
Facility
|
OP
|
$4,813.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.09 |
| Max. Negotiated Rate |
$4,621.08 |
| Rate for Payer: Aetna Commercial |
$3,706.49
|
| Rate for Payer: Anthem Medicaid |
$1,655.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,754.62
|
| Rate for Payer: Cash Price |
$2,406.81
|
| Rate for Payer: Cigna Commercial |
$3,995.30
|
| Rate for Payer: First Health Commercial |
$4,572.94
|
| Rate for Payer: Humana Commercial |
$4,091.58
|
| Rate for Payer: Humana KY Medicaid |
$1,655.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,672.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,947.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,552.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,444.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,688.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.99
|
| Rate for Payer: Ohio Health Group HMO |
$3,610.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,187.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,321.40
|
| Rate for Payer: PHCS Commercial |
$4,621.08
|
| Rate for Payer: United Healthcare All Payer |
$4,235.99
|
|
|
PLATE CLASSIC 10 SLOT 90^
|
Facility
|
IP
|
$4,690.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,407.19 |
| Max. Negotiated Rate |
$4,503.00 |
| Rate for Payer: Aetna Commercial |
$3,611.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,658.68
|
| Rate for Payer: Cash Price |
$2,345.31
|
| Rate for Payer: Cigna Commercial |
$3,893.21
|
| Rate for Payer: First Health Commercial |
$4,456.09
|
| Rate for Payer: Humana Commercial |
$3,987.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,846.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,461.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,407.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,127.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,517.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,752.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,080.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,236.53
|
| Rate for Payer: PHCS Commercial |
$4,503.00
|
| Rate for Payer: United Healthcare All Payer |
$4,127.75
|
|
|
PLATE CLASSIC 10 SLOT 90^
|
Facility
|
OP
|
$4,690.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,407.19 |
| Max. Negotiated Rate |
$4,503.00 |
| Rate for Payer: Aetna Commercial |
$3,611.78
|
| Rate for Payer: Anthem Medicaid |
$1,613.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,658.68
|
| Rate for Payer: Cash Price |
$2,345.31
|
| Rate for Payer: Cigna Commercial |
$3,893.21
|
| Rate for Payer: First Health Commercial |
$4,456.09
|
| Rate for Payer: Humana Commercial |
$3,987.03
|
| Rate for Payer: Humana KY Medicaid |
$1,613.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,629.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,846.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,461.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,407.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,645.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,127.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,517.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,752.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,080.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,236.53
|
| Rate for Payer: PHCS Commercial |
$4,503.00
|
| Rate for Payer: United Healthcare All Payer |
$4,127.75
|
|
|
PLATE CLASSIC 10 SLOT 95^
|
Facility
|
IP
|
$4,690.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,407.19 |
| Max. Negotiated Rate |
$4,503.00 |
| Rate for Payer: Aetna Commercial |
$3,611.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,658.68
|
| Rate for Payer: Cash Price |
$2,345.31
|
| Rate for Payer: Cigna Commercial |
$3,893.21
|
| Rate for Payer: First Health Commercial |
$4,456.09
|
| Rate for Payer: Humana Commercial |
$3,987.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,846.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,461.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,407.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,127.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,517.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,752.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,080.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,236.53
|
| Rate for Payer: PHCS Commercial |
$4,503.00
|
| Rate for Payer: United Healthcare All Payer |
$4,127.75
|
|
|
PLATE CLASSIC 10 SLOT 95^
|
Facility
|
OP
|
$4,690.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,407.19 |
| Max. Negotiated Rate |
$4,503.00 |
| Rate for Payer: Aetna Commercial |
$3,611.78
|
| Rate for Payer: Anthem Medicaid |
$1,613.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,658.68
|
| Rate for Payer: Cash Price |
$2,345.31
|
| Rate for Payer: Cigna Commercial |
$3,893.21
|
| Rate for Payer: First Health Commercial |
$4,456.09
|
| Rate for Payer: Humana Commercial |
$3,987.03
|
| Rate for Payer: Humana KY Medicaid |
$1,613.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,629.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,846.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,461.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,407.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,645.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,127.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,517.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,752.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,080.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,236.53
|
| Rate for Payer: PHCS Commercial |
$4,503.00
|
| Rate for Payer: United Healthcare All Payer |
$4,127.75
|
|
|
PLATE CLASSIC 12 SLOT 145^ 260
|
Facility
|
IP
|
$5,005.81
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,501.74 |
| Max. Negotiated Rate |
$4,805.58 |
| Rate for Payer: Aetna Commercial |
$3,854.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,904.53
|
| Rate for Payer: Cash Price |
$2,502.91
|
| Rate for Payer: Cigna Commercial |
$4,154.82
|
| Rate for Payer: First Health Commercial |
$4,755.52
|
| Rate for Payer: Humana Commercial |
$4,254.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,104.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,694.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,501.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,405.11
|
| Rate for Payer: Ohio Health Group HMO |
$3,754.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,004.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,355.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,454.01
|
| Rate for Payer: PHCS Commercial |
$4,805.58
|
| Rate for Payer: United Healthcare All Payer |
$4,405.11
|
|
|
PLATE CLASSIC 12 SLOT 145^ 260
|
Facility
|
OP
|
$5,005.81
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,501.74 |
| Max. Negotiated Rate |
$4,805.58 |
| Rate for Payer: Aetna Commercial |
$3,854.47
|
| Rate for Payer: Anthem Medicaid |
$1,721.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,904.53
|
| Rate for Payer: Cash Price |
$2,502.91
|
| Rate for Payer: Cigna Commercial |
$4,154.82
|
| Rate for Payer: First Health Commercial |
$4,755.52
|
| Rate for Payer: Humana Commercial |
$4,254.94
|
| Rate for Payer: Humana KY Medicaid |
$1,721.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,739.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,104.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,694.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,501.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,756.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,405.11
|
| Rate for Payer: Ohio Health Group HMO |
$3,754.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,004.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,355.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,454.01
|
| Rate for Payer: PHCS Commercial |
$4,805.58
|
| Rate for Payer: United Healthcare All Payer |
$4,405.11
|
|
|
PLATE CLASSIC 12 SLOT 95^
|
Facility
|
OP
|
$5,028.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,508.66 |
| Max. Negotiated Rate |
$4,827.72 |
| Rate for Payer: Aetna Commercial |
$3,872.24
|
| Rate for Payer: Anthem Medicaid |
$1,729.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,922.53
|
| Rate for Payer: Cash Price |
$2,514.44
|
| Rate for Payer: Cigna Commercial |
$4,173.97
|
| Rate for Payer: First Health Commercial |
$4,777.44
|
| Rate for Payer: Humana Commercial |
$4,274.55
|
| Rate for Payer: Humana KY Medicaid |
$1,729.43
|
| Rate for Payer: Kentucky WC Medicaid |
$1,747.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,123.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,711.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,508.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,764.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,425.41
|
| Rate for Payer: Ohio Health Group HMO |
$3,771.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,023.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,375.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,469.93
|
| Rate for Payer: PHCS Commercial |
$4,827.72
|
| Rate for Payer: United Healthcare All Payer |
$4,425.41
|
|
|
PLATE CLASSIC 12 SLOT 95^
|
Facility
|
IP
|
$5,028.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,508.66 |
| Max. Negotiated Rate |
$4,827.72 |
| Rate for Payer: Aetna Commercial |
$3,872.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,922.53
|
| Rate for Payer: Cash Price |
$2,514.44
|
| Rate for Payer: Cigna Commercial |
$4,173.97
|
| Rate for Payer: First Health Commercial |
$4,777.44
|
| Rate for Payer: Humana Commercial |
$4,274.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,123.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,711.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,508.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,425.41
|
| Rate for Payer: Ohio Health Group HMO |
$3,771.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,023.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,375.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,469.93
|
| Rate for Payer: PHCS Commercial |
$4,827.72
|
| Rate for Payer: United Healthcare All Payer |
$4,425.41
|
|
|
PLATE CLASSIC 14 SLOT 145^ 300
|
Facility
|
OP
|
$3,937.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,181.17 |
| Max. Negotiated Rate |
$3,779.76 |
| Rate for Payer: Aetna Commercial |
$3,031.68
|
| Rate for Payer: Anthem Medicaid |
$1,354.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,071.05
|
| Rate for Payer: Cash Price |
$1,968.62
|
| Rate for Payer: Cigna Commercial |
$3,267.92
|
| Rate for Payer: First Health Commercial |
$3,740.39
|
| Rate for Payer: Humana Commercial |
$3,346.66
|
| Rate for Payer: Humana KY Medicaid |
$1,354.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,367.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,228.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,905.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,181.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,381.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,464.78
|
| Rate for Payer: Ohio Health Group HMO |
$2,952.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,149.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,425.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,716.70
|
| Rate for Payer: PHCS Commercial |
$3,779.76
|
| Rate for Payer: United Healthcare All Payer |
$3,464.78
|
|
|
PLATE CLASSIC 14 SLOT 145^ 300
|
Facility
|
IP
|
$3,937.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,181.17 |
| Max. Negotiated Rate |
$3,779.76 |
| Rate for Payer: Aetna Commercial |
$3,031.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,071.05
|
| Rate for Payer: Cash Price |
$1,968.62
|
| Rate for Payer: Cigna Commercial |
$3,267.92
|
| Rate for Payer: First Health Commercial |
$3,740.39
|
| Rate for Payer: Humana Commercial |
$3,346.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,228.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,905.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,181.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,464.78
|
| Rate for Payer: Ohio Health Group HMO |
$2,952.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,149.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,425.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,716.70
|
| Rate for Payer: PHCS Commercial |
$3,779.76
|
| Rate for Payer: United Healthcare All Payer |
$3,464.78
|
|
|
PLATE CLASSIC 2 SLOT 130^
|
Facility
|
IP
|
$3,722.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,116.60 |
| Max. Negotiated Rate |
$3,573.12 |
| Rate for Payer: Aetna Commercial |
$2,865.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,903.16
|
| Rate for Payer: Cash Price |
$1,861.00
|
| Rate for Payer: Cigna Commercial |
$3,089.26
|
| Rate for Payer: First Health Commercial |
$3,535.90
|
| Rate for Payer: Humana Commercial |
$3,163.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,052.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,746.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,116.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,275.36
|
| Rate for Payer: Ohio Health Group HMO |
$2,791.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,977.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,238.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,568.18
|
| Rate for Payer: PHCS Commercial |
$3,573.12
|
| Rate for Payer: United Healthcare All Payer |
$3,275.36
|
|
|
PLATE CLASSIC 2 SLOT 130^
|
Facility
|
OP
|
$3,722.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,116.60 |
| Max. Negotiated Rate |
$3,573.12 |
| Rate for Payer: Aetna Commercial |
$2,865.94
|
| Rate for Payer: Anthem Medicaid |
$1,280.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,903.16
|
| Rate for Payer: Cash Price |
$1,861.00
|
| Rate for Payer: Cigna Commercial |
$3,089.26
|
| Rate for Payer: First Health Commercial |
$3,535.90
|
| Rate for Payer: Humana Commercial |
$3,163.70
|
| Rate for Payer: Humana KY Medicaid |
$1,280.00
|
| Rate for Payer: Kentucky WC Medicaid |
$1,293.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,052.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,746.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,116.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,305.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,275.36
|
| Rate for Payer: Ohio Health Group HMO |
$2,791.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,977.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,238.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,568.18
|
| Rate for Payer: PHCS Commercial |
$3,573.12
|
| Rate for Payer: United Healthcare All Payer |
$3,275.36
|
|
|
PLATE CLASSIC 2 SLOT 135^
|
Facility
|
IP
|
$3,722.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,116.60 |
| Max. Negotiated Rate |
$3,573.12 |
| Rate for Payer: Aetna Commercial |
$2,865.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,903.16
|
| Rate for Payer: Cash Price |
$1,861.00
|
| Rate for Payer: Cigna Commercial |
$3,089.26
|
| Rate for Payer: First Health Commercial |
$3,535.90
|
| Rate for Payer: Humana Commercial |
$3,163.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,052.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,746.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,116.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,275.36
|
| Rate for Payer: Ohio Health Group HMO |
$2,791.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,977.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,238.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,568.18
|
| Rate for Payer: PHCS Commercial |
$3,573.12
|
| Rate for Payer: United Healthcare All Payer |
$3,275.36
|
|
|
PLATE CLASSIC 2 SLOT 135^
|
Facility
|
OP
|
$3,722.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,116.60 |
| Max. Negotiated Rate |
$3,573.12 |
| Rate for Payer: Aetna Commercial |
$2,865.94
|
| Rate for Payer: Anthem Medicaid |
$1,280.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,903.16
|
| Rate for Payer: Cash Price |
$1,861.00
|
| Rate for Payer: Cigna Commercial |
$3,089.26
|
| Rate for Payer: First Health Commercial |
$3,535.90
|
| Rate for Payer: Humana Commercial |
$3,163.70
|
| Rate for Payer: Humana KY Medicaid |
$1,280.00
|
| Rate for Payer: Kentucky WC Medicaid |
$1,293.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,052.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,746.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,116.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,305.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,275.36
|
| Rate for Payer: Ohio Health Group HMO |
$2,791.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,977.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,238.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,568.18
|
| Rate for Payer: PHCS Commercial |
$3,573.12
|
| Rate for Payer: United Healthcare All Payer |
$3,275.36
|
|
