|
PLATE MPT 0^ SM LEFT
|
Facility
|
OP
|
$7,362.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$957.12 |
| Max. Negotiated Rate |
$7,068.00 |
| Rate for Payer: Aetna Commercial |
$5,669.12
|
| Rate for Payer: Anthem Medicaid |
$2,531.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,742.75
|
| Rate for Payer: Cash Price |
$3,681.25
|
| Rate for Payer: Cigna Commercial |
$6,110.88
|
| Rate for Payer: First Health Commercial |
$6,994.38
|
| Rate for Payer: Humana Commercial |
$6,258.12
|
| Rate for Payer: Humana KY Medicaid |
$2,531.96
|
| Rate for Payer: Kentucky WC Medicaid |
$2,557.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,037.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,433.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,208.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,582.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,479.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,521.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,472.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,282.38
|
| Rate for Payer: PHCS Commercial |
$7,068.00
|
| Rate for Payer: United Healthcare All Payer |
$6,479.00
|
|
|
PLATE MPT 0^ SM LEFT
|
Facility
|
IP
|
$7,362.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$957.12 |
| Max. Negotiated Rate |
$7,068.00 |
| Rate for Payer: Aetna Commercial |
$5,669.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,742.75
|
| Rate for Payer: Cash Price |
$3,681.25
|
| Rate for Payer: Cigna Commercial |
$6,110.88
|
| Rate for Payer: First Health Commercial |
$6,994.38
|
| Rate for Payer: Humana Commercial |
$6,258.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,037.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,433.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,208.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,479.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,521.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,472.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,282.38
|
| Rate for Payer: PHCS Commercial |
$7,068.00
|
| Rate for Payer: United Healthcare All Payer |
$6,479.00
|
|
|
PLATE MPT 5^ SM LEFT
|
Facility
|
IP
|
$7,362.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$957.12 |
| Max. Negotiated Rate |
$7,068.00 |
| Rate for Payer: Aetna Commercial |
$5,669.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,742.75
|
| Rate for Payer: Cash Price |
$3,681.25
|
| Rate for Payer: Cigna Commercial |
$6,110.88
|
| Rate for Payer: First Health Commercial |
$6,994.38
|
| Rate for Payer: Humana Commercial |
$6,258.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,037.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,433.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,208.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,479.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,521.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,472.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,282.38
|
| Rate for Payer: PHCS Commercial |
$7,068.00
|
| Rate for Payer: United Healthcare All Payer |
$6,479.00
|
|
|
PLATE MPT 5^ SM LEFT
|
Facility
|
OP
|
$7,362.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$957.12 |
| Max. Negotiated Rate |
$7,068.00 |
| Rate for Payer: Aetna Commercial |
$5,669.12
|
| Rate for Payer: Anthem Medicaid |
$2,531.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,742.75
|
| Rate for Payer: Cash Price |
$3,681.25
|
| Rate for Payer: Cigna Commercial |
$6,110.88
|
| Rate for Payer: First Health Commercial |
$6,994.38
|
| Rate for Payer: Humana Commercial |
$6,258.12
|
| Rate for Payer: Humana KY Medicaid |
$2,531.96
|
| Rate for Payer: Kentucky WC Medicaid |
$2,557.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,037.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,433.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,208.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,582.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,479.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,521.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,472.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,282.38
|
| Rate for Payer: PHCS Commercial |
$7,068.00
|
| Rate for Payer: United Healthcare All Payer |
$6,479.00
|
|
|
PLATE MTP 0*SHORT RIGHT
|
Facility
|
OP
|
$7,362.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$957.12 |
| Max. Negotiated Rate |
$7,068.00 |
| Rate for Payer: Aetna Commercial |
$5,669.12
|
| Rate for Payer: Anthem Medicaid |
$2,531.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,742.75
|
| Rate for Payer: Cash Price |
$3,681.25
|
| Rate for Payer: Cigna Commercial |
$6,110.88
|
| Rate for Payer: First Health Commercial |
$6,994.38
|
| Rate for Payer: Humana Commercial |
$6,258.12
|
| Rate for Payer: Humana KY Medicaid |
$2,531.96
|
| Rate for Payer: Kentucky WC Medicaid |
$2,557.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,037.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,433.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,208.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,582.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,479.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,521.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,472.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,282.38
|
| Rate for Payer: PHCS Commercial |
$7,068.00
|
| Rate for Payer: United Healthcare All Payer |
$6,479.00
|
|
|
PLATE MTP 0*SHORT RIGHT
|
Facility
|
IP
|
$7,362.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$957.12 |
| Max. Negotiated Rate |
$7,068.00 |
| Rate for Payer: Aetna Commercial |
$5,669.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,742.75
|
| Rate for Payer: Cash Price |
$3,681.25
|
| Rate for Payer: Cigna Commercial |
$6,110.88
|
| Rate for Payer: First Health Commercial |
$6,994.38
|
| Rate for Payer: Humana Commercial |
$6,258.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,037.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,433.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,208.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,479.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,521.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,472.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,282.38
|
| Rate for Payer: PHCS Commercial |
$7,068.00
|
| Rate for Payer: United Healthcare All Payer |
$6,479.00
|
|
|
PLATE MTP 48 STRAIGHT LEFT
|
Facility
|
IP
|
$7,691.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$999.83 |
| Max. Negotiated Rate |
$7,383.36 |
| Rate for Payer: Aetna Commercial |
$5,922.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,998.98
|
| Rate for Payer: Cash Price |
$3,845.50
|
| Rate for Payer: Cigna Commercial |
$6,383.53
|
| Rate for Payer: First Health Commercial |
$7,306.45
|
| Rate for Payer: Humana Commercial |
$6,537.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,306.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,675.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,307.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,768.08
|
| Rate for Payer: Ohio Health Group HMO |
$5,768.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,538.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$999.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,384.21
|
| Rate for Payer: PHCS Commercial |
$7,383.36
|
| Rate for Payer: United Healthcare All Payer |
$6,768.08
|
|
|
PLATE MTP 48 STRAIGHT LEFT
|
Facility
|
OP
|
$7,691.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$999.83 |
| Max. Negotiated Rate |
$7,383.36 |
| Rate for Payer: Aetna Commercial |
$5,922.07
|
| Rate for Payer: Anthem Medicaid |
$2,644.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,998.98
|
| Rate for Payer: Cash Price |
$3,845.50
|
| Rate for Payer: Cigna Commercial |
$6,383.53
|
| Rate for Payer: First Health Commercial |
$7,306.45
|
| Rate for Payer: Humana Commercial |
$6,537.35
|
| Rate for Payer: Humana KY Medicaid |
$2,644.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,671.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,306.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,675.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,307.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,698.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,768.08
|
| Rate for Payer: Ohio Health Group HMO |
$5,768.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,538.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$999.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,384.21
|
| Rate for Payer: PHCS Commercial |
$7,383.36
|
| Rate for Payer: United Healthcare All Payer |
$6,768.08
|
|
|
PLATE MTP CP 5H R
|
Facility
|
OP
|
$12,703.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,651.42 |
| Max. Negotiated Rate |
$12,195.07 |
| Rate for Payer: Aetna Commercial |
$9,781.46
|
| Rate for Payer: Anthem Medicaid |
$4,368.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,908.50
|
| Rate for Payer: Cash Price |
$6,351.60
|
| Rate for Payer: Cigna Commercial |
$10,543.66
|
| Rate for Payer: First Health Commercial |
$12,068.04
|
| Rate for Payer: Humana Commercial |
$10,797.72
|
| Rate for Payer: Humana KY Medicaid |
$4,368.63
|
| Rate for Payer: Kentucky WC Medicaid |
$4,413.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,416.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,374.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,810.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,456.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,178.82
|
| Rate for Payer: Ohio Health Group HMO |
$9,527.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,540.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,651.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,937.99
|
| Rate for Payer: PHCS Commercial |
$12,195.07
|
| Rate for Payer: United Healthcare All Payer |
$11,178.82
|
|
|
PLATE MTP CP 5H R
|
Facility
|
IP
|
$12,703.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,651.42 |
| Max. Negotiated Rate |
$12,195.07 |
| Rate for Payer: Aetna Commercial |
$9,781.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,908.50
|
| Rate for Payer: Cash Price |
$6,351.60
|
| Rate for Payer: Cigna Commercial |
$10,543.66
|
| Rate for Payer: First Health Commercial |
$12,068.04
|
| Rate for Payer: Humana Commercial |
$10,797.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,416.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,374.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,810.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,178.82
|
| Rate for Payer: Ohio Health Group HMO |
$9,527.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,540.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,651.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,937.99
|
| Rate for Payer: PHCS Commercial |
$12,195.07
|
| Rate for Payer: United Healthcare All Payer |
$11,178.82
|
|
|
PLATE MTP FUSION EXT LEFT
|
Facility
|
OP
|
$7,344.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$954.75 |
| Max. Negotiated Rate |
$7,050.48 |
| Rate for Payer: Aetna Commercial |
$5,655.07
|
| Rate for Payer: Anthem Medicaid |
$2,525.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,728.52
|
| Rate for Payer: Cash Price |
$3,672.12
|
| Rate for Payer: Cigna Commercial |
$6,095.73
|
| Rate for Payer: First Health Commercial |
$6,977.04
|
| Rate for Payer: Humana Commercial |
$6,242.61
|
| Rate for Payer: Humana KY Medicaid |
$2,525.69
|
| Rate for Payer: Kentucky WC Medicaid |
$2,551.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,022.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,420.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,203.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,576.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,462.94
|
| Rate for Payer: Ohio Health Group HMO |
$5,508.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,468.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$954.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,276.72
|
| Rate for Payer: PHCS Commercial |
$7,050.48
|
| Rate for Payer: United Healthcare All Payer |
$6,462.94
|
|
|
PLATE MTP FUSION EXT LEFT
|
Facility
|
IP
|
$7,344.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$954.75 |
| Max. Negotiated Rate |
$7,050.48 |
| Rate for Payer: Aetna Commercial |
$5,655.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,728.52
|
| Rate for Payer: Cash Price |
$3,672.12
|
| Rate for Payer: Cigna Commercial |
$6,095.73
|
| Rate for Payer: First Health Commercial |
$6,977.04
|
| Rate for Payer: Humana Commercial |
$6,242.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,022.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,420.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,203.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,462.94
|
| Rate for Payer: Ohio Health Group HMO |
$5,508.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,468.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$954.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,276.72
|
| Rate for Payer: PHCS Commercial |
$7,050.48
|
| Rate for Payer: United Healthcare All Payer |
$6,462.94
|
|
|
PLATE MTP FUSION EXT RIGHT
|
Facility
|
OP
|
$7,344.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$954.75 |
| Max. Negotiated Rate |
$7,050.48 |
| Rate for Payer: Aetna Commercial |
$5,655.07
|
| Rate for Payer: Anthem Medicaid |
$2,525.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,728.52
|
| Rate for Payer: Cash Price |
$3,672.12
|
| Rate for Payer: Cigna Commercial |
$6,095.73
|
| Rate for Payer: First Health Commercial |
$6,977.04
|
| Rate for Payer: Humana Commercial |
$6,242.61
|
| Rate for Payer: Humana KY Medicaid |
$2,525.69
|
| Rate for Payer: Kentucky WC Medicaid |
$2,551.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,022.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,420.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,203.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,576.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,462.94
|
| Rate for Payer: Ohio Health Group HMO |
$5,508.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,468.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$954.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,276.72
|
| Rate for Payer: PHCS Commercial |
$7,050.48
|
| Rate for Payer: United Healthcare All Payer |
$6,462.94
|
|
|
PLATE MTP FUSION EXT RIGHT
|
Facility
|
IP
|
$7,344.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$954.75 |
| Max. Negotiated Rate |
$7,050.48 |
| Rate for Payer: Aetna Commercial |
$5,655.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,728.52
|
| Rate for Payer: Cash Price |
$3,672.12
|
| Rate for Payer: Cigna Commercial |
$6,095.73
|
| Rate for Payer: First Health Commercial |
$6,977.04
|
| Rate for Payer: Humana Commercial |
$6,242.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,022.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,420.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,203.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,462.94
|
| Rate for Payer: Ohio Health Group HMO |
$5,508.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,468.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$954.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,276.72
|
| Rate for Payer: PHCS Commercial |
$7,050.48
|
| Rate for Payer: United Healthcare All Payer |
$6,462.94
|
|
|
PLATE MTP FUSION SM LEFT
|
Facility
|
OP
|
$7,344.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$954.75 |
| Max. Negotiated Rate |
$7,050.48 |
| Rate for Payer: Aetna Commercial |
$5,655.07
|
| Rate for Payer: Anthem Medicaid |
$2,525.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,728.52
|
| Rate for Payer: Cash Price |
$3,672.12
|
| Rate for Payer: Cigna Commercial |
$6,095.73
|
| Rate for Payer: First Health Commercial |
$6,977.04
|
| Rate for Payer: Humana Commercial |
$6,242.61
|
| Rate for Payer: Humana KY Medicaid |
$2,525.69
|
| Rate for Payer: Kentucky WC Medicaid |
$2,551.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,022.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,420.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,203.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,576.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,462.94
|
| Rate for Payer: Ohio Health Group HMO |
$5,508.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,468.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$954.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,276.72
|
| Rate for Payer: PHCS Commercial |
$7,050.48
|
| Rate for Payer: United Healthcare All Payer |
$6,462.94
|
|
|
PLATE MTP FUSION SM LEFT
|
Facility
|
IP
|
$7,344.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$954.75 |
| Max. Negotiated Rate |
$7,050.48 |
| Rate for Payer: Aetna Commercial |
$5,655.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,728.52
|
| Rate for Payer: Cash Price |
$3,672.12
|
| Rate for Payer: Cigna Commercial |
$6,095.73
|
| Rate for Payer: First Health Commercial |
$6,977.04
|
| Rate for Payer: Humana Commercial |
$6,242.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,022.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,420.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,203.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,462.94
|
| Rate for Payer: Ohio Health Group HMO |
$5,508.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,468.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$954.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,276.72
|
| Rate for Payer: PHCS Commercial |
$7,050.48
|
| Rate for Payer: United Healthcare All Payer |
$6,462.94
|
|
|
PLATE MTP FUSION SM RIGHT
|
Facility
|
IP
|
$7,344.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$954.75 |
| Max. Negotiated Rate |
$7,050.48 |
| Rate for Payer: Aetna Commercial |
$5,655.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,728.52
|
| Rate for Payer: Cash Price |
$3,672.12
|
| Rate for Payer: Cigna Commercial |
$6,095.73
|
| Rate for Payer: First Health Commercial |
$6,977.04
|
| Rate for Payer: Humana Commercial |
$6,242.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,022.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,420.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,203.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,462.94
|
| Rate for Payer: Ohio Health Group HMO |
$5,508.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,468.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$954.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,276.72
|
| Rate for Payer: PHCS Commercial |
$7,050.48
|
| Rate for Payer: United Healthcare All Payer |
$6,462.94
|
|
|
PLATE MTP FUSION SM RIGHT
|
Facility
|
OP
|
$7,344.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$954.75 |
| Max. Negotiated Rate |
$7,050.48 |
| Rate for Payer: Aetna Commercial |
$5,655.07
|
| Rate for Payer: Anthem Medicaid |
$2,525.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,728.52
|
| Rate for Payer: Cash Price |
$3,672.12
|
| Rate for Payer: Cigna Commercial |
$6,095.73
|
| Rate for Payer: First Health Commercial |
$6,977.04
|
| Rate for Payer: Humana Commercial |
$6,242.61
|
| Rate for Payer: Humana KY Medicaid |
$2,525.69
|
| Rate for Payer: Kentucky WC Medicaid |
$2,551.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,022.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,420.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,203.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,576.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,462.94
|
| Rate for Payer: Ohio Health Group HMO |
$5,508.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,468.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$954.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,276.72
|
| Rate for Payer: PHCS Commercial |
$7,050.48
|
| Rate for Payer: United Healthcare All Payer |
$6,462.94
|
|
|
PLATE MTP FUSION STD LEFT
|
Facility
|
IP
|
$7,344.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$954.75 |
| Max. Negotiated Rate |
$7,050.48 |
| Rate for Payer: Aetna Commercial |
$5,655.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,728.52
|
| Rate for Payer: Cash Price |
$3,672.12
|
| Rate for Payer: Cigna Commercial |
$6,095.73
|
| Rate for Payer: First Health Commercial |
$6,977.04
|
| Rate for Payer: Humana Commercial |
$6,242.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,022.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,420.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,203.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,462.94
|
| Rate for Payer: Ohio Health Group HMO |
$5,508.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,468.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$954.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,276.72
|
| Rate for Payer: PHCS Commercial |
$7,050.48
|
| Rate for Payer: United Healthcare All Payer |
$6,462.94
|
|
|
PLATE MTP FUSION STD LEFT
|
Facility
|
OP
|
$7,344.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$954.75 |
| Max. Negotiated Rate |
$7,050.48 |
| Rate for Payer: Aetna Commercial |
$5,655.07
|
| Rate for Payer: Anthem Medicaid |
$2,525.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,728.52
|
| Rate for Payer: Cash Price |
$3,672.12
|
| Rate for Payer: Cigna Commercial |
$6,095.73
|
| Rate for Payer: First Health Commercial |
$6,977.04
|
| Rate for Payer: Humana Commercial |
$6,242.61
|
| Rate for Payer: Humana KY Medicaid |
$2,525.69
|
| Rate for Payer: Kentucky WC Medicaid |
$2,551.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,022.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,420.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,203.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,576.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,462.94
|
| Rate for Payer: Ohio Health Group HMO |
$5,508.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,468.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$954.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,276.72
|
| Rate for Payer: PHCS Commercial |
$7,050.48
|
| Rate for Payer: United Healthcare All Payer |
$6,462.94
|
|
|
PLATE MTP FUSION STD RIGHT
|
Facility
|
OP
|
$7,344.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$954.75 |
| Max. Negotiated Rate |
$7,050.48 |
| Rate for Payer: Aetna Commercial |
$5,655.07
|
| Rate for Payer: Anthem Medicaid |
$2,525.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,728.52
|
| Rate for Payer: Cash Price |
$3,672.12
|
| Rate for Payer: Cigna Commercial |
$6,095.73
|
| Rate for Payer: First Health Commercial |
$6,977.04
|
| Rate for Payer: Humana Commercial |
$6,242.61
|
| Rate for Payer: Humana KY Medicaid |
$2,525.69
|
| Rate for Payer: Kentucky WC Medicaid |
$2,551.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,022.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,420.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,203.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,576.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,462.94
|
| Rate for Payer: Ohio Health Group HMO |
$5,508.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,468.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$954.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,276.72
|
| Rate for Payer: PHCS Commercial |
$7,050.48
|
| Rate for Payer: United Healthcare All Payer |
$6,462.94
|
|
|
PLATE MTP FUSION STD RIGHT
|
Facility
|
IP
|
$7,344.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$954.75 |
| Max. Negotiated Rate |
$7,050.48 |
| Rate for Payer: Aetna Commercial |
$5,655.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,728.52
|
| Rate for Payer: Cash Price |
$3,672.12
|
| Rate for Payer: Cigna Commercial |
$6,095.73
|
| Rate for Payer: First Health Commercial |
$6,977.04
|
| Rate for Payer: Humana Commercial |
$6,242.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,022.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,420.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,203.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,462.94
|
| Rate for Payer: Ohio Health Group HMO |
$5,508.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,468.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$954.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,276.72
|
| Rate for Payer: PHCS Commercial |
$7,050.48
|
| Rate for Payer: United Healthcare All Payer |
$6,462.94
|
|
|
PLATE MTP STAND 5 VALGUS 5 LT
|
Facility
|
IP
|
$10,081.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,310.63 |
| Max. Negotiated Rate |
$9,678.48 |
| Rate for Payer: Aetna Commercial |
$7,762.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,863.76
|
| Rate for Payer: Cash Price |
$5,040.88
|
| Rate for Payer: Cigna Commercial |
$8,367.85
|
| Rate for Payer: First Health Commercial |
$9,577.66
|
| Rate for Payer: Humana Commercial |
$8,569.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,267.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,440.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,024.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,871.94
|
| Rate for Payer: Ohio Health Group HMO |
$7,561.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,016.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,310.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,125.34
|
| Rate for Payer: PHCS Commercial |
$9,678.48
|
| Rate for Payer: United Healthcare All Payer |
$8,871.94
|
|
|
PLATE MTP STAND 5 VALGUS 5 LT
|
Facility
|
OP
|
$10,081.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,310.63 |
| Max. Negotiated Rate |
$9,678.48 |
| Rate for Payer: Aetna Commercial |
$7,762.95
|
| Rate for Payer: Anthem Medicaid |
$3,467.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,863.76
|
| Rate for Payer: Cash Price |
$5,040.88
|
| Rate for Payer: Cigna Commercial |
$8,367.85
|
| Rate for Payer: First Health Commercial |
$9,577.66
|
| Rate for Payer: Humana Commercial |
$8,569.49
|
| Rate for Payer: Humana KY Medicaid |
$3,467.11
|
| Rate for Payer: Kentucky WC Medicaid |
$3,502.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,267.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,440.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,024.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,536.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,871.94
|
| Rate for Payer: Ohio Health Group HMO |
$7,561.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,016.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,310.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,125.34
|
| Rate for Payer: PHCS Commercial |
$9,678.48
|
| Rate for Payer: United Healthcare All Payer |
$8,871.94
|
|
|
PLATE MTP V2 5H L
|
Facility
|
IP
|
$9,415.84
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,224.06 |
| Max. Negotiated Rate |
$9,039.21 |
| Rate for Payer: Aetna Commercial |
$7,250.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,344.36
|
| Rate for Payer: Cash Price |
$4,707.92
|
| Rate for Payer: Cigna Commercial |
$7,815.15
|
| Rate for Payer: First Health Commercial |
$8,945.05
|
| Rate for Payer: Humana Commercial |
$8,003.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,720.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,948.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,824.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,285.94
|
| Rate for Payer: Ohio Health Group HMO |
$7,061.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,883.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,224.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,918.91
|
| Rate for Payer: PHCS Commercial |
$9,039.21
|
| Rate for Payer: United Healthcare All Payer |
$8,285.94
|
|
