|
PLATE DVRAW WIDE LEFT
|
Facility
|
OP
|
$6,938.35
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,081.51 |
| Max. Negotiated Rate |
$6,660.82 |
| Rate for Payer: Aetna Commercial |
$5,342.53
|
| Rate for Payer: Anthem Medicaid |
$2,386.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,411.91
|
| Rate for Payer: Cash Price |
$3,469.18
|
| Rate for Payer: Cigna Commercial |
$5,758.83
|
| Rate for Payer: First Health Commercial |
$6,591.43
|
| Rate for Payer: Humana Commercial |
$5,897.60
|
| Rate for Payer: Humana KY Medicaid |
$2,386.10
|
| Rate for Payer: Kentucky WC Medicaid |
$2,410.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,689.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,120.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,081.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,433.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,105.75
|
| Rate for Payer: Ohio Health Group HMO |
$5,203.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,550.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,036.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,787.46
|
| Rate for Payer: PHCS Commercial |
$6,660.82
|
| Rate for Payer: United Healthcare All Payer |
$6,105.75
|
|
|
PLATE DVRAW WIDE LEFT
|
Facility
|
IP
|
$6,938.35
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,081.51 |
| Max. Negotiated Rate |
$6,660.82 |
| Rate for Payer: Aetna Commercial |
$5,342.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,411.91
|
| Rate for Payer: Cash Price |
$3,469.18
|
| Rate for Payer: Cigna Commercial |
$5,758.83
|
| Rate for Payer: First Health Commercial |
$6,591.43
|
| Rate for Payer: Humana Commercial |
$5,897.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,689.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,120.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,081.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,105.75
|
| Rate for Payer: Ohio Health Group HMO |
$5,203.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,550.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,036.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,787.46
|
| Rate for Payer: PHCS Commercial |
$6,660.82
|
| Rate for Payer: United Healthcare All Payer |
$6,105.75
|
|
|
PLATE DVRAW WIDE RIGHT
|
Facility
|
IP
|
$6,858.05
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,057.41 |
| Max. Negotiated Rate |
$6,583.73 |
| Rate for Payer: Aetna Commercial |
$5,280.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,349.28
|
| Rate for Payer: Cash Price |
$3,429.02
|
| Rate for Payer: Cigna Commercial |
$5,692.18
|
| Rate for Payer: First Health Commercial |
$6,515.15
|
| Rate for Payer: Humana Commercial |
$5,829.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,623.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,061.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,057.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,035.08
|
| Rate for Payer: Ohio Health Group HMO |
$5,143.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,486.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,966.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,732.05
|
| Rate for Payer: PHCS Commercial |
$6,583.73
|
| Rate for Payer: United Healthcare All Payer |
$6,035.08
|
|
|
PLATE DVRAW WIDE RIGHT
|
Facility
|
OP
|
$6,858.05
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,057.41 |
| Max. Negotiated Rate |
$6,583.73 |
| Rate for Payer: Aetna Commercial |
$5,280.70
|
| Rate for Payer: Anthem Medicaid |
$2,358.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,349.28
|
| Rate for Payer: Cash Price |
$3,429.02
|
| Rate for Payer: Cigna Commercial |
$5,692.18
|
| Rate for Payer: First Health Commercial |
$6,515.15
|
| Rate for Payer: Humana Commercial |
$5,829.34
|
| Rate for Payer: Humana KY Medicaid |
$2,358.48
|
| Rate for Payer: Kentucky WC Medicaid |
$2,382.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,623.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,061.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,057.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,405.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,035.08
|
| Rate for Payer: Ohio Health Group HMO |
$5,143.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,486.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,966.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,732.05
|
| Rate for Payer: PHCS Commercial |
$6,583.73
|
| Rate for Payer: United Healthcare All Payer |
$6,035.08
|
|
|
PLATE DVRAX EXTENDED LEFT
|
Facility
|
OP
|
$6,938.35
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,081.51 |
| Max. Negotiated Rate |
$6,660.82 |
| Rate for Payer: Aetna Commercial |
$5,342.53
|
| Rate for Payer: Anthem Medicaid |
$2,386.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,411.91
|
| Rate for Payer: Cash Price |
$3,469.18
|
| Rate for Payer: Cigna Commercial |
$5,758.83
|
| Rate for Payer: First Health Commercial |
$6,591.43
|
| Rate for Payer: Humana Commercial |
$5,897.60
|
| Rate for Payer: Humana KY Medicaid |
$2,386.10
|
| Rate for Payer: Kentucky WC Medicaid |
$2,410.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,689.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,120.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,081.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,433.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,105.75
|
| Rate for Payer: Ohio Health Group HMO |
$5,203.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,550.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,036.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,787.46
|
| Rate for Payer: PHCS Commercial |
$6,660.82
|
| Rate for Payer: United Healthcare All Payer |
$6,105.75
|
|
|
PLATE DVRAX EXTENDED LEFT
|
Facility
|
IP
|
$6,938.35
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,081.51 |
| Max. Negotiated Rate |
$6,660.82 |
| Rate for Payer: Aetna Commercial |
$5,342.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,411.91
|
| Rate for Payer: Cash Price |
$3,469.18
|
| Rate for Payer: Cigna Commercial |
$5,758.83
|
| Rate for Payer: First Health Commercial |
$6,591.43
|
| Rate for Payer: Humana Commercial |
$5,897.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,689.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,120.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,081.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,105.75
|
| Rate for Payer: Ohio Health Group HMO |
$5,203.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,550.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,036.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,787.46
|
| Rate for Payer: PHCS Commercial |
$6,660.82
|
| Rate for Payer: United Healthcare All Payer |
$6,105.75
|
|
|
PLATE DVRAX EXTENDED RIGHT
|
Facility
|
IP
|
$5,341.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,602.38 |
| Max. Negotiated Rate |
$5,127.60 |
| Rate for Payer: Aetna Commercial |
$4,112.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,166.18
|
| Rate for Payer: Cash Price |
$2,670.62
|
| Rate for Payer: Cigna Commercial |
$4,433.24
|
| Rate for Payer: First Health Commercial |
$5,074.19
|
| Rate for Payer: Humana Commercial |
$4,540.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,379.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,941.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,602.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,700.30
|
| Rate for Payer: Ohio Health Group HMO |
$4,005.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,273.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,646.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,685.46
|
| Rate for Payer: PHCS Commercial |
$5,127.60
|
| Rate for Payer: United Healthcare All Payer |
$4,700.30
|
|
|
PLATE DVRAX EXTENDED RIGHT
|
Facility
|
OP
|
$5,341.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,602.38 |
| Max. Negotiated Rate |
$5,127.60 |
| Rate for Payer: Aetna Commercial |
$4,112.76
|
| Rate for Payer: Anthem Medicaid |
$1,836.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,166.18
|
| Rate for Payer: Cash Price |
$2,670.62
|
| Rate for Payer: Cigna Commercial |
$4,433.24
|
| Rate for Payer: First Health Commercial |
$5,074.19
|
| Rate for Payer: Humana Commercial |
$4,540.06
|
| Rate for Payer: Humana KY Medicaid |
$1,836.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,855.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,379.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,941.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,602.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,873.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,700.30
|
| Rate for Payer: Ohio Health Group HMO |
$4,005.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,273.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,646.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,685.46
|
| Rate for Payer: PHCS Commercial |
$5,127.60
|
| Rate for Payer: United Healthcare All Payer |
$4,700.30
|
|
|
PLATE DVRAXXL EX EXT LEFT
|
Facility
|
OP
|
$6,858.05
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,057.41 |
| Max. Negotiated Rate |
$6,583.73 |
| Rate for Payer: Aetna Commercial |
$5,280.70
|
| Rate for Payer: Anthem Medicaid |
$2,358.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,349.28
|
| Rate for Payer: Cash Price |
$3,429.02
|
| Rate for Payer: Cigna Commercial |
$5,692.18
|
| Rate for Payer: First Health Commercial |
$6,515.15
|
| Rate for Payer: Humana Commercial |
$5,829.34
|
| Rate for Payer: Humana KY Medicaid |
$2,358.48
|
| Rate for Payer: Kentucky WC Medicaid |
$2,382.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,623.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,061.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,057.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,405.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,035.08
|
| Rate for Payer: Ohio Health Group HMO |
$5,143.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,486.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,966.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,732.05
|
| Rate for Payer: PHCS Commercial |
$6,583.73
|
| Rate for Payer: United Healthcare All Payer |
$6,035.08
|
|
|
PLATE DVRAXXL EX EXT LEFT
|
Facility
|
IP
|
$6,858.05
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,057.41 |
| Max. Negotiated Rate |
$6,583.73 |
| Rate for Payer: Aetna Commercial |
$5,280.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,349.28
|
| Rate for Payer: Cash Price |
$3,429.02
|
| Rate for Payer: Cigna Commercial |
$5,692.18
|
| Rate for Payer: First Health Commercial |
$6,515.15
|
| Rate for Payer: Humana Commercial |
$5,829.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,623.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,061.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,057.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,035.08
|
| Rate for Payer: Ohio Health Group HMO |
$5,143.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,486.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,966.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,732.05
|
| Rate for Payer: PHCS Commercial |
$6,583.73
|
| Rate for Payer: United Healthcare All Payer |
$6,035.08
|
|
|
PLATE DVRAXXR EX EXT RIGHT
|
Facility
|
OP
|
$6,858.05
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,057.41 |
| Max. Negotiated Rate |
$6,583.73 |
| Rate for Payer: Aetna Commercial |
$5,280.70
|
| Rate for Payer: Anthem Medicaid |
$2,358.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,349.28
|
| Rate for Payer: Cash Price |
$3,429.02
|
| Rate for Payer: Cigna Commercial |
$5,692.18
|
| Rate for Payer: First Health Commercial |
$6,515.15
|
| Rate for Payer: Humana Commercial |
$5,829.34
|
| Rate for Payer: Humana KY Medicaid |
$2,358.48
|
| Rate for Payer: Kentucky WC Medicaid |
$2,382.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,623.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,061.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,057.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,405.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,035.08
|
| Rate for Payer: Ohio Health Group HMO |
$5,143.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,486.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,966.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,732.05
|
| Rate for Payer: PHCS Commercial |
$6,583.73
|
| Rate for Payer: United Healthcare All Payer |
$6,035.08
|
|
|
PLATE DVRAXXR EX EXT RIGHT
|
Facility
|
IP
|
$6,858.05
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,057.41 |
| Max. Negotiated Rate |
$6,583.73 |
| Rate for Payer: Aetna Commercial |
$5,280.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,349.28
|
| Rate for Payer: Cash Price |
$3,429.02
|
| Rate for Payer: Cigna Commercial |
$5,692.18
|
| Rate for Payer: First Health Commercial |
$6,515.15
|
| Rate for Payer: Humana Commercial |
$5,829.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,623.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,061.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,057.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,035.08
|
| Rate for Payer: Ohio Health Group HMO |
$5,143.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,486.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,966.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,732.05
|
| Rate for Payer: PHCS Commercial |
$6,583.73
|
| Rate for Payer: United Healthcare All Payer |
$6,035.08
|
|
|
PLATE DVSR STD LEFT
|
Facility
|
OP
|
$7,135.45
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,140.64 |
| Max. Negotiated Rate |
$6,850.03 |
| Rate for Payer: Aetna Commercial |
$5,494.30
|
| Rate for Payer: Anthem Medicaid |
$2,453.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,565.65
|
| Rate for Payer: Cash Price |
$3,567.72
|
| Rate for Payer: Cigna Commercial |
$5,922.42
|
| Rate for Payer: First Health Commercial |
$6,778.68
|
| Rate for Payer: Humana Commercial |
$6,065.13
|
| Rate for Payer: Humana KY Medicaid |
$2,453.88
|
| Rate for Payer: Kentucky WC Medicaid |
$2,478.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,851.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,265.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,140.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,503.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,279.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,351.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,708.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,207.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,923.46
|
| Rate for Payer: PHCS Commercial |
$6,850.03
|
| Rate for Payer: United Healthcare All Payer |
$6,279.20
|
|
|
PLATE DVSR STD LEFT
|
Facility
|
IP
|
$7,135.45
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,140.64 |
| Max. Negotiated Rate |
$6,850.03 |
| Rate for Payer: Aetna Commercial |
$5,494.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,565.65
|
| Rate for Payer: Cash Price |
$3,567.72
|
| Rate for Payer: Cigna Commercial |
$5,922.42
|
| Rate for Payer: First Health Commercial |
$6,778.68
|
| Rate for Payer: Humana Commercial |
$6,065.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,851.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,265.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,140.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,279.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,351.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,708.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,207.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,923.46
|
| Rate for Payer: PHCS Commercial |
$6,850.03
|
| Rate for Payer: United Healthcare All Payer |
$6,279.20
|
|
|
PLATE DVSR STD RIGHT
|
Facility
|
OP
|
$7,135.45
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,140.64 |
| Max. Negotiated Rate |
$6,850.03 |
| Rate for Payer: Aetna Commercial |
$5,494.30
|
| Rate for Payer: Anthem Medicaid |
$2,453.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,565.65
|
| Rate for Payer: Cash Price |
$3,567.72
|
| Rate for Payer: Cigna Commercial |
$5,922.42
|
| Rate for Payer: First Health Commercial |
$6,778.68
|
| Rate for Payer: Humana Commercial |
$6,065.13
|
| Rate for Payer: Humana KY Medicaid |
$2,453.88
|
| Rate for Payer: Kentucky WC Medicaid |
$2,478.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,851.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,265.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,140.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,503.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,279.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,351.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,708.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,207.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,923.46
|
| Rate for Payer: PHCS Commercial |
$6,850.03
|
| Rate for Payer: United Healthcare All Payer |
$6,279.20
|
|
|
PLATE DVSR STD RIGHT
|
Facility
|
IP
|
$7,135.45
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,140.64 |
| Max. Negotiated Rate |
$6,850.03 |
| Rate for Payer: Aetna Commercial |
$5,494.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,565.65
|
| Rate for Payer: Cash Price |
$3,567.72
|
| Rate for Payer: Cigna Commercial |
$5,922.42
|
| Rate for Payer: First Health Commercial |
$6,778.68
|
| Rate for Payer: Humana Commercial |
$6,065.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,851.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,265.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,140.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,279.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,351.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,708.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,207.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,923.46
|
| Rate for Payer: PHCS Commercial |
$6,850.03
|
| Rate for Payer: United Healthcare All Payer |
$6,279.20
|
|
|
PLATE ELBOW POSTERIOR
|
Facility
|
OP
|
$4,812.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,443.75 |
| Max. Negotiated Rate |
$4,620.00 |
| Rate for Payer: Aetna Commercial |
$3,705.62
|
| Rate for Payer: Anthem Medicaid |
$1,655.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,753.75
|
| Rate for Payer: Cash Price |
$2,406.25
|
| Rate for Payer: Cigna Commercial |
$3,994.38
|
| Rate for Payer: First Health Commercial |
$4,571.88
|
| Rate for Payer: Humana Commercial |
$4,090.62
|
| Rate for Payer: Humana KY Medicaid |
$1,655.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,671.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,946.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,551.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,443.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,688.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,609.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,186.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,320.62
|
| Rate for Payer: PHCS Commercial |
$4,620.00
|
| Rate for Payer: United Healthcare All Payer |
$4,235.00
|
|
|
PLATE ELBOW POSTERIOR
|
Facility
|
IP
|
$4,812.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,443.75 |
| Max. Negotiated Rate |
$4,620.00 |
| Rate for Payer: Aetna Commercial |
$3,705.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,753.75
|
| Rate for Payer: Cash Price |
$2,406.25
|
| Rate for Payer: Cigna Commercial |
$3,994.38
|
| Rate for Payer: First Health Commercial |
$4,571.88
|
| Rate for Payer: Humana Commercial |
$4,090.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,946.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,551.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,443.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,609.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,186.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,320.62
|
| Rate for Payer: PHCS Commercial |
$4,620.00
|
| Rate for Payer: United Healthcare All Payer |
$4,235.00
|
|
|
PLATE ELBW LAT EPICONDYAL XL L
|
Facility
|
IP
|
$5,408.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,622.62 |
| Max. Negotiated Rate |
$5,192.40 |
| Rate for Payer: Aetna Commercial |
$4,164.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,218.82
|
| Rate for Payer: Cash Price |
$2,704.38
|
| Rate for Payer: Cigna Commercial |
$4,489.26
|
| Rate for Payer: First Health Commercial |
$5,138.31
|
| Rate for Payer: Humana Commercial |
$4,597.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,435.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,991.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,622.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,759.70
|
| Rate for Payer: Ohio Health Group HMO |
$4,056.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,327.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,705.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,732.04
|
| Rate for Payer: PHCS Commercial |
$5,192.40
|
| Rate for Payer: United Healthcare All Payer |
$4,759.70
|
|
|
PLATE ELBW LAT EPICONDYAL XL L
|
Facility
|
OP
|
$5,408.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,622.62 |
| Max. Negotiated Rate |
$5,192.40 |
| Rate for Payer: Aetna Commercial |
$4,164.74
|
| Rate for Payer: Anthem Medicaid |
$1,860.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,218.82
|
| Rate for Payer: Cash Price |
$2,704.38
|
| Rate for Payer: Cigna Commercial |
$4,489.26
|
| Rate for Payer: First Health Commercial |
$5,138.31
|
| Rate for Payer: Humana Commercial |
$4,597.44
|
| Rate for Payer: Humana KY Medicaid |
$1,860.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,879.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,435.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,991.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,622.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,897.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,759.70
|
| Rate for Payer: Ohio Health Group HMO |
$4,056.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,327.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,705.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,732.04
|
| Rate for Payer: PHCS Commercial |
$5,192.40
|
| Rate for Payer: United Healthcare All Payer |
$4,759.70
|
|
|
PLATE ELBW LAT EPICONDYAL XL R
|
Facility
|
OP
|
$4,294.85
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,288.45 |
| Max. Negotiated Rate |
$4,123.06 |
| Rate for Payer: Aetna Commercial |
$3,307.03
|
| Rate for Payer: Anthem Medicaid |
$1,477.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,349.98
|
| Rate for Payer: Cash Price |
$2,147.43
|
| Rate for Payer: Cigna Commercial |
$3,564.73
|
| Rate for Payer: First Health Commercial |
$4,080.11
|
| Rate for Payer: Humana Commercial |
$3,650.62
|
| Rate for Payer: Humana KY Medicaid |
$1,477.00
|
| Rate for Payer: Kentucky WC Medicaid |
$1,492.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,521.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,169.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,288.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,506.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,779.47
|
| Rate for Payer: Ohio Health Group HMO |
$3,221.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,435.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,736.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,963.45
|
| Rate for Payer: PHCS Commercial |
$4,123.06
|
| Rate for Payer: United Healthcare All Payer |
$3,779.47
|
|
|
PLATE ELBW LAT EPICONDYAL XL R
|
Facility
|
IP
|
$4,294.85
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,288.45 |
| Max. Negotiated Rate |
$4,123.06 |
| Rate for Payer: Aetna Commercial |
$3,307.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,349.98
|
| Rate for Payer: Cash Price |
$2,147.43
|
| Rate for Payer: Cigna Commercial |
$3,564.73
|
| Rate for Payer: First Health Commercial |
$4,080.11
|
| Rate for Payer: Humana Commercial |
$3,650.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,521.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,169.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,288.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,779.47
|
| Rate for Payer: Ohio Health Group HMO |
$3,221.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,435.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,736.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,963.45
|
| Rate for Payer: PHCS Commercial |
$4,123.06
|
| Rate for Payer: United Healthcare All Payer |
$3,779.47
|
|
|
PLATE ELBW MEDL EPICONDYAL XL
|
Facility
|
OP
|
$4,294.85
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,288.45 |
| Max. Negotiated Rate |
$4,123.06 |
| Rate for Payer: Aetna Commercial |
$3,307.03
|
| Rate for Payer: Anthem Medicaid |
$1,477.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,349.98
|
| Rate for Payer: Cash Price |
$2,147.43
|
| Rate for Payer: Cigna Commercial |
$3,564.73
|
| Rate for Payer: First Health Commercial |
$4,080.11
|
| Rate for Payer: Humana Commercial |
$3,650.62
|
| Rate for Payer: Humana KY Medicaid |
$1,477.00
|
| Rate for Payer: Kentucky WC Medicaid |
$1,492.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,521.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,169.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,288.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,506.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,779.47
|
| Rate for Payer: Ohio Health Group HMO |
$3,221.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,435.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,736.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,963.45
|
| Rate for Payer: PHCS Commercial |
$4,123.06
|
| Rate for Payer: United Healthcare All Payer |
$3,779.47
|
|
|
PLATE ELBW MEDL EPICONDYAL XL
|
Facility
|
IP
|
$4,294.85
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,288.45 |
| Max. Negotiated Rate |
$4,123.06 |
| Rate for Payer: Aetna Commercial |
$3,307.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,349.98
|
| Rate for Payer: Cash Price |
$2,147.43
|
| Rate for Payer: Cigna Commercial |
$3,564.73
|
| Rate for Payer: First Health Commercial |
$4,080.11
|
| Rate for Payer: Humana Commercial |
$3,650.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,521.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,169.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,288.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,779.47
|
| Rate for Payer: Ohio Health Group HMO |
$3,221.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,435.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,736.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,963.45
|
| Rate for Payer: PHCS Commercial |
$4,123.06
|
| Rate for Payer: United Healthcare All Payer |
$3,779.47
|
|
|
PLATE EPICONDYAL LAT LONG LEFT
|
Facility
|
OP
|
$3,968.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,190.62 |
| Max. Negotiated Rate |
$3,810.00 |
| Rate for Payer: Aetna Commercial |
$3,055.94
|
| Rate for Payer: Anthem Medicaid |
$1,364.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,095.62
|
| Rate for Payer: Cash Price |
$1,984.38
|
| Rate for Payer: Cigna Commercial |
$3,294.06
|
| Rate for Payer: First Health Commercial |
$3,770.31
|
| Rate for Payer: Humana Commercial |
$3,373.44
|
| Rate for Payer: Humana KY Medicaid |
$1,364.85
|
| Rate for Payer: Kentucky WC Medicaid |
$1,378.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,254.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,928.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,190.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,392.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,492.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,976.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,175.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,452.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,738.44
|
| Rate for Payer: PHCS Commercial |
$3,810.00
|
| Rate for Payer: United Healthcare All Payer |
$3,492.50
|
|
