|
PLATE LP MET OPN WDG TI R 5MM
|
Facility
|
OP
|
$4,982.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$647.72 |
| Max. Negotiated Rate |
$4,783.20 |
| Rate for Payer: Aetna Commercial |
$3,836.52
|
| Rate for Payer: Anthem Medicaid |
$1,713.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,886.35
|
| Rate for Payer: Cash Price |
$2,491.25
|
| Rate for Payer: Cigna Commercial |
$4,135.48
|
| Rate for Payer: First Health Commercial |
$4,733.38
|
| Rate for Payer: Humana Commercial |
$4,235.12
|
| Rate for Payer: Humana KY Medicaid |
$1,713.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1,730.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,085.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,677.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,494.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,747.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,384.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,736.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$996.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$647.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,544.58
|
| Rate for Payer: PHCS Commercial |
$4,783.20
|
| Rate for Payer: United Healthcare All Payer |
$4,384.60
|
|
|
PLATE LP MET OPN WDG TI R 6.5M
|
Facility
|
OP
|
$4,982.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$647.72 |
| Max. Negotiated Rate |
$4,783.20 |
| Rate for Payer: Aetna Commercial |
$3,836.52
|
| Rate for Payer: Anthem Medicaid |
$1,713.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,886.35
|
| Rate for Payer: Cash Price |
$2,491.25
|
| Rate for Payer: Cigna Commercial |
$4,135.48
|
| Rate for Payer: First Health Commercial |
$4,733.38
|
| Rate for Payer: Humana Commercial |
$4,235.12
|
| Rate for Payer: Humana KY Medicaid |
$1,713.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1,730.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,085.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,677.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,494.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,747.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,384.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,736.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$996.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$647.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,544.58
|
| Rate for Payer: PHCS Commercial |
$4,783.20
|
| Rate for Payer: United Healthcare All Payer |
$4,384.60
|
|
|
PLATE LP MET OPN WDG TI R 6.5M
|
Facility
|
IP
|
$4,982.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$647.72 |
| Max. Negotiated Rate |
$4,783.20 |
| Rate for Payer: Aetna Commercial |
$3,836.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,886.35
|
| Rate for Payer: Cash Price |
$2,491.25
|
| Rate for Payer: Cigna Commercial |
$4,135.48
|
| Rate for Payer: First Health Commercial |
$4,733.38
|
| Rate for Payer: Humana Commercial |
$4,235.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,085.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,677.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,494.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,384.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,736.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$996.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$647.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,544.58
|
| Rate for Payer: PHCS Commercial |
$4,783.20
|
| Rate for Payer: United Healthcare All Payer |
$4,384.60
|
|
|
PLATE LP MET OPN WDG TI R 6MM
|
Facility
|
OP
|
$4,982.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$647.72 |
| Max. Negotiated Rate |
$4,783.20 |
| Rate for Payer: Aetna Commercial |
$3,836.52
|
| Rate for Payer: Anthem Medicaid |
$1,713.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,886.35
|
| Rate for Payer: Cash Price |
$2,491.25
|
| Rate for Payer: Cigna Commercial |
$4,135.48
|
| Rate for Payer: First Health Commercial |
$4,733.38
|
| Rate for Payer: Humana Commercial |
$4,235.12
|
| Rate for Payer: Humana KY Medicaid |
$1,713.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1,730.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,085.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,677.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,494.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,747.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,384.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,736.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$996.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$647.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,544.58
|
| Rate for Payer: PHCS Commercial |
$4,783.20
|
| Rate for Payer: United Healthcare All Payer |
$4,384.60
|
|
|
PLATE LP MET OPN WDG TI R 6MM
|
Facility
|
IP
|
$4,982.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$647.72 |
| Max. Negotiated Rate |
$4,783.20 |
| Rate for Payer: Aetna Commercial |
$3,836.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,886.35
|
| Rate for Payer: Cash Price |
$2,491.25
|
| Rate for Payer: Cigna Commercial |
$4,135.48
|
| Rate for Payer: First Health Commercial |
$4,733.38
|
| Rate for Payer: Humana Commercial |
$4,235.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,085.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,677.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,494.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,384.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,736.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$996.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$647.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,544.58
|
| Rate for Payer: PHCS Commercial |
$4,783.20
|
| Rate for Payer: United Healthcare All Payer |
$4,384.60
|
|
|
PLATE LP MET OPN WDG TI R 7MM
|
Facility
|
OP
|
$4,982.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$647.72 |
| Max. Negotiated Rate |
$4,783.20 |
| Rate for Payer: Aetna Commercial |
$3,836.52
|
| Rate for Payer: Anthem Medicaid |
$1,713.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,886.35
|
| Rate for Payer: Cash Price |
$2,491.25
|
| Rate for Payer: Cigna Commercial |
$4,135.48
|
| Rate for Payer: First Health Commercial |
$4,733.38
|
| Rate for Payer: Humana Commercial |
$4,235.12
|
| Rate for Payer: Humana KY Medicaid |
$1,713.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1,730.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,085.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,677.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,494.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,747.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,384.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,736.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$996.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$647.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,544.58
|
| Rate for Payer: PHCS Commercial |
$4,783.20
|
| Rate for Payer: United Healthcare All Payer |
$4,384.60
|
|
|
PLATE LP MET OPN WDG TI R 7MM
|
Facility
|
IP
|
$4,982.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$647.72 |
| Max. Negotiated Rate |
$4,783.20 |
| Rate for Payer: Aetna Commercial |
$3,836.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,886.35
|
| Rate for Payer: Cash Price |
$2,491.25
|
| Rate for Payer: Cigna Commercial |
$4,135.48
|
| Rate for Payer: First Health Commercial |
$4,733.38
|
| Rate for Payer: Humana Commercial |
$4,235.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,085.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,677.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,494.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,384.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,736.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$996.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$647.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,544.58
|
| Rate for Payer: PHCS Commercial |
$4,783.20
|
| Rate for Payer: United Healthcare All Payer |
$4,384.60
|
|
|
PLATE L PROFYLE 90D 2.3 6H LT
|
Facility
|
OP
|
$3,684.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$478.92 |
| Max. Negotiated Rate |
$3,536.64 |
| Rate for Payer: Humana Commercial |
$3,131.40
|
| Rate for Payer: Humana KY Medicaid |
$1,266.93
|
| Rate for Payer: Kentucky WC Medicaid |
$1,279.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,020.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,718.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,105.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,292.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,241.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,763.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$736.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$478.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,142.04
|
| Rate for Payer: PHCS Commercial |
$3,536.64
|
| Rate for Payer: United Healthcare All Payer |
$3,241.92
|
| Rate for Payer: Aetna Commercial |
$2,836.68
|
| Rate for Payer: Anthem Medicaid |
$1,266.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,873.52
|
| Rate for Payer: Cash Price |
$1,842.00
|
| Rate for Payer: Cigna Commercial |
$3,057.72
|
| Rate for Payer: First Health Commercial |
$3,499.80
|
|
|
PLATE L PROFYLE 90D 2.3 6H LT
|
Facility
|
IP
|
$3,684.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$478.92 |
| Max. Negotiated Rate |
$3,536.64 |
| Rate for Payer: Aetna Commercial |
$2,836.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,873.52
|
| Rate for Payer: Cash Price |
$1,842.00
|
| Rate for Payer: Cigna Commercial |
$3,057.72
|
| Rate for Payer: First Health Commercial |
$3,499.80
|
| Rate for Payer: Humana Commercial |
$3,131.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,020.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,718.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,105.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,241.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,763.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$736.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$478.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,142.04
|
| Rate for Payer: PHCS Commercial |
$3,536.64
|
| Rate for Payer: United Healthcare All Payer |
$3,241.92
|
|
|
PLATE L PROFYLE 90D 2.3 6H RT
|
Facility
|
OP
|
$3,684.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$478.92 |
| Max. Negotiated Rate |
$3,536.64 |
| Rate for Payer: Aetna Commercial |
$2,836.68
|
| Rate for Payer: Anthem Medicaid |
$1,266.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,873.52
|
| Rate for Payer: Cash Price |
$1,842.00
|
| Rate for Payer: Cigna Commercial |
$3,057.72
|
| Rate for Payer: First Health Commercial |
$3,499.80
|
| Rate for Payer: Humana Commercial |
$3,131.40
|
| Rate for Payer: Humana KY Medicaid |
$1,266.93
|
| Rate for Payer: Kentucky WC Medicaid |
$1,279.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,020.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,718.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,105.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,292.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,241.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,763.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$736.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$478.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,142.04
|
| Rate for Payer: PHCS Commercial |
$3,536.64
|
| Rate for Payer: United Healthcare All Payer |
$3,241.92
|
|
|
PLATE L PROFYLE 90D 2.3 6H RT
|
Facility
|
IP
|
$3,684.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$478.92 |
| Max. Negotiated Rate |
$3,536.64 |
| Rate for Payer: Aetna Commercial |
$2,836.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,873.52
|
| Rate for Payer: Cash Price |
$1,842.00
|
| Rate for Payer: Cigna Commercial |
$3,057.72
|
| Rate for Payer: First Health Commercial |
$3,499.80
|
| Rate for Payer: Humana Commercial |
$3,131.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,020.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,718.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,105.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,241.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,763.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$736.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$478.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,142.04
|
| Rate for Payer: PHCS Commercial |
$3,536.64
|
| Rate for Payer: United Healthcare All Payer |
$3,241.92
|
|
|
PLATE L PROFYLE COMP LE 6H L
|
Facility
|
IP
|
$3,964.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$515.32 |
| Max. Negotiated Rate |
$3,805.44 |
| Rate for Payer: Aetna Commercial |
$3,052.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,091.92
|
| Rate for Payer: Cash Price |
$1,982.00
|
| Rate for Payer: Cigna Commercial |
$3,290.12
|
| Rate for Payer: First Health Commercial |
$3,765.80
|
| Rate for Payer: Humana Commercial |
$3,369.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,250.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,925.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,189.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,488.32
|
| Rate for Payer: Ohio Health Group HMO |
$2,973.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$792.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$515.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,228.84
|
| Rate for Payer: PHCS Commercial |
$3,805.44
|
| Rate for Payer: United Healthcare All Payer |
$3,488.32
|
|
|
PLATE L PROFYLE COMP LE 6H L
|
Facility
|
OP
|
$3,964.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$515.32 |
| Max. Negotiated Rate |
$3,805.44 |
| Rate for Payer: Aetna Commercial |
$3,052.28
|
| Rate for Payer: Anthem Medicaid |
$1,363.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,091.92
|
| Rate for Payer: Cash Price |
$1,982.00
|
| Rate for Payer: Cigna Commercial |
$3,290.12
|
| Rate for Payer: First Health Commercial |
$3,765.80
|
| Rate for Payer: Humana Commercial |
$3,369.40
|
| Rate for Payer: Humana KY Medicaid |
$1,363.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1,377.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,250.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,925.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,189.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,390.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,488.32
|
| Rate for Payer: Ohio Health Group HMO |
$2,973.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$792.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$515.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,228.84
|
| Rate for Payer: PHCS Commercial |
$3,805.44
|
| Rate for Payer: United Healthcare All Payer |
$3,488.32
|
|
|
PLATE L PROFYLE LCK RI 1.7 6H
|
Facility
|
IP
|
$3,283.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$426.79 |
| Max. Negotiated Rate |
$3,151.68 |
| Rate for Payer: Aetna Commercial |
$2,527.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,560.74
|
| Rate for Payer: Cash Price |
$1,641.50
|
| Rate for Payer: Cigna Commercial |
$2,724.89
|
| Rate for Payer: First Health Commercial |
$3,118.85
|
| Rate for Payer: Humana Commercial |
$2,790.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,692.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,422.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$984.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,889.04
|
| Rate for Payer: Ohio Health Group HMO |
$2,462.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$656.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$426.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,017.73
|
| Rate for Payer: PHCS Commercial |
$3,151.68
|
| Rate for Payer: United Healthcare All Payer |
$2,889.04
|
|
|
PLATE L PROFYLE LCK RI 1.7 6H
|
Facility
|
OP
|
$3,283.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$426.79 |
| Max. Negotiated Rate |
$3,151.68 |
| Rate for Payer: Aetna Commercial |
$2,527.91
|
| Rate for Payer: Anthem Medicaid |
$1,129.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,560.74
|
| Rate for Payer: Cash Price |
$1,641.50
|
| Rate for Payer: Cigna Commercial |
$2,724.89
|
| Rate for Payer: First Health Commercial |
$3,118.85
|
| Rate for Payer: Humana Commercial |
$2,790.55
|
| Rate for Payer: Humana KY Medicaid |
$1,129.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,140.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,692.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,422.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$984.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,151.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,889.04
|
| Rate for Payer: Ohio Health Group HMO |
$2,462.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$656.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$426.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,017.73
|
| Rate for Payer: PHCS Commercial |
$3,151.68
|
| Rate for Payer: United Healthcare All Payer |
$2,889.04
|
|
|
PLATE L PROFYLE L COMP RI 6H
|
Facility
|
OP
|
$3,964.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$515.32 |
| Max. Negotiated Rate |
$3,805.44 |
| Rate for Payer: Aetna Commercial |
$3,052.28
|
| Rate for Payer: Anthem Medicaid |
$1,363.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,091.92
|
| Rate for Payer: Cash Price |
$1,982.00
|
| Rate for Payer: Cigna Commercial |
$3,290.12
|
| Rate for Payer: First Health Commercial |
$3,765.80
|
| Rate for Payer: Humana Commercial |
$3,369.40
|
| Rate for Payer: Humana KY Medicaid |
$1,363.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1,377.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,250.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,925.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,189.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,390.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,488.32
|
| Rate for Payer: Ohio Health Group HMO |
$2,973.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$792.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$515.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,228.84
|
| Rate for Payer: PHCS Commercial |
$3,805.44
|
| Rate for Payer: United Healthcare All Payer |
$3,488.32
|
|
|
PLATE L PROFYLE L COMP RI 6H
|
Facility
|
IP
|
$3,964.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$515.32 |
| Max. Negotiated Rate |
$3,805.44 |
| Rate for Payer: Aetna Commercial |
$3,052.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,091.92
|
| Rate for Payer: Cash Price |
$1,982.00
|
| Rate for Payer: Cigna Commercial |
$3,290.12
|
| Rate for Payer: First Health Commercial |
$3,765.80
|
| Rate for Payer: Humana Commercial |
$3,369.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,250.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,925.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,189.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,488.32
|
| Rate for Payer: Ohio Health Group HMO |
$2,973.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$792.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$515.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,228.84
|
| Rate for Payer: PHCS Commercial |
$3,805.44
|
| Rate for Payer: United Healthcare All Payer |
$3,488.32
|
|
|
PLATE L PROFYLE LOCK 2.3 LE 6H
|
Facility
|
IP
|
$4,230.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$549.90 |
| Max. Negotiated Rate |
$4,060.80 |
| Rate for Payer: Aetna Commercial |
$3,257.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,299.40
|
| Rate for Payer: Cash Price |
$2,115.00
|
| Rate for Payer: Cigna Commercial |
$3,510.90
|
| Rate for Payer: First Health Commercial |
$4,018.50
|
| Rate for Payer: Humana Commercial |
$3,595.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,468.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,121.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,269.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,722.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,172.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$846.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$549.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,311.30
|
| Rate for Payer: PHCS Commercial |
$4,060.80
|
| Rate for Payer: United Healthcare All Payer |
$3,722.40
|
|
|
PLATE L PROFYLE LOCK 2.3 LE 6H
|
Facility
|
OP
|
$4,230.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$549.90 |
| Max. Negotiated Rate |
$4,060.80 |
| Rate for Payer: Aetna Commercial |
$3,257.10
|
| Rate for Payer: Anthem Medicaid |
$1,454.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,299.40
|
| Rate for Payer: Cash Price |
$2,115.00
|
| Rate for Payer: Cigna Commercial |
$3,510.90
|
| Rate for Payer: First Health Commercial |
$4,018.50
|
| Rate for Payer: Humana Commercial |
$3,595.50
|
| Rate for Payer: Humana KY Medicaid |
$1,454.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1,469.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,468.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,121.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,269.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,483.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,722.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,172.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$846.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$549.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,311.30
|
| Rate for Payer: PHCS Commercial |
$4,060.80
|
| Rate for Payer: United Healthcare All Payer |
$3,722.40
|
|
|
PLATE L PROFYLE LOCK 2.3 RI 6H
|
Facility
|
OP
|
$3,901.32
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$507.17 |
| Max. Negotiated Rate |
$3,745.27 |
| Rate for Payer: Aetna Commercial |
$3,004.02
|
| Rate for Payer: Anthem Medicaid |
$1,341.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,043.03
|
| Rate for Payer: Cash Price |
$1,950.66
|
| Rate for Payer: Cigna Commercial |
$3,238.10
|
| Rate for Payer: First Health Commercial |
$3,706.25
|
| Rate for Payer: Humana Commercial |
$3,316.12
|
| Rate for Payer: Humana KY Medicaid |
$1,341.66
|
| Rate for Payer: Kentucky WC Medicaid |
$1,355.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,199.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,879.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,170.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,368.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,433.16
|
| Rate for Payer: Ohio Health Group HMO |
$2,925.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$780.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$507.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,209.41
|
| Rate for Payer: PHCS Commercial |
$3,745.27
|
| Rate for Payer: United Healthcare All Payer |
$3,433.16
|
|
|
PLATE L PROFYLE LOCK 2.3 RI 6H
|
Facility
|
IP
|
$3,901.32
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$507.17 |
| Max. Negotiated Rate |
$3,745.27 |
| Rate for Payer: Aetna Commercial |
$3,004.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,043.03
|
| Rate for Payer: Cash Price |
$1,950.66
|
| Rate for Payer: Cigna Commercial |
$3,238.10
|
| Rate for Payer: First Health Commercial |
$3,706.25
|
| Rate for Payer: Humana Commercial |
$3,316.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,199.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,879.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,170.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,433.16
|
| Rate for Payer: Ohio Health Group HMO |
$2,925.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$780.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$507.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,209.41
|
| Rate for Payer: PHCS Commercial |
$3,745.27
|
| Rate for Payer: United Healthcare All Payer |
$3,433.16
|
|
|
PLATE L PROFYLE LOCK LE 1.7 6H
|
Facility
|
OP
|
$4,230.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$549.90 |
| Max. Negotiated Rate |
$4,060.80 |
| Rate for Payer: Aetna Commercial |
$3,257.10
|
| Rate for Payer: Anthem Medicaid |
$1,454.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,299.40
|
| Rate for Payer: Cash Price |
$2,115.00
|
| Rate for Payer: Cigna Commercial |
$3,510.90
|
| Rate for Payer: First Health Commercial |
$4,018.50
|
| Rate for Payer: Humana Commercial |
$3,595.50
|
| Rate for Payer: Humana KY Medicaid |
$1,454.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1,469.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,468.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,121.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,269.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,483.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,722.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,172.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$846.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$549.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,311.30
|
| Rate for Payer: PHCS Commercial |
$4,060.80
|
| Rate for Payer: United Healthcare All Payer |
$3,722.40
|
|
|
PLATE L PROFYLE LOCK LE 1.7 6H
|
Facility
|
IP
|
$4,230.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$549.90 |
| Max. Negotiated Rate |
$4,060.80 |
| Rate for Payer: Aetna Commercial |
$3,257.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,299.40
|
| Rate for Payer: Cash Price |
$2,115.00
|
| Rate for Payer: Cigna Commercial |
$3,510.90
|
| Rate for Payer: First Health Commercial |
$4,018.50
|
| Rate for Payer: Humana Commercial |
$3,595.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,468.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,121.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,269.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,722.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,172.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$846.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$549.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,311.30
|
| Rate for Payer: PHCS Commercial |
$4,060.80
|
| Rate for Payer: United Healthcare All Payer |
$3,722.40
|
|
|
PLATE L PROFYLE M COMP LE 6H
|
Facility
|
IP
|
$3,964.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$515.32 |
| Max. Negotiated Rate |
$3,805.44 |
| Rate for Payer: Aetna Commercial |
$3,052.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,091.92
|
| Rate for Payer: Cash Price |
$1,982.00
|
| Rate for Payer: Cigna Commercial |
$3,290.12
|
| Rate for Payer: First Health Commercial |
$3,765.80
|
| Rate for Payer: Humana Commercial |
$3,369.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,250.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,925.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,189.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,488.32
|
| Rate for Payer: Ohio Health Group HMO |
$2,973.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$792.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$515.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,228.84
|
| Rate for Payer: PHCS Commercial |
$3,805.44
|
| Rate for Payer: United Healthcare All Payer |
$3,488.32
|
|
|
PLATE L PROFYLE M COMP LE 6H
|
Facility
|
OP
|
$3,964.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$515.32 |
| Max. Negotiated Rate |
$3,805.44 |
| Rate for Payer: Aetna Commercial |
$3,052.28
|
| Rate for Payer: Anthem Medicaid |
$1,363.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,091.92
|
| Rate for Payer: Cash Price |
$1,982.00
|
| Rate for Payer: Cigna Commercial |
$3,290.12
|
| Rate for Payer: First Health Commercial |
$3,765.80
|
| Rate for Payer: Humana Commercial |
$3,369.40
|
| Rate for Payer: Humana KY Medicaid |
$1,363.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1,377.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,250.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,925.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,189.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,390.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,488.32
|
| Rate for Payer: Ohio Health Group HMO |
$2,973.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$792.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$515.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,228.84
|
| Rate for Payer: PHCS Commercial |
$3,805.44
|
| Rate for Payer: United Healthcare All Payer |
$3,488.32
|
|
