|
PLATE EVOS VOL 4H STD TI 56M R
|
Facility
|
IP
|
$6,661.68
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,998.50 |
| Max. Negotiated Rate |
$6,395.21 |
| Rate for Payer: Aetna Commercial |
$5,129.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,196.11
|
| Rate for Payer: Cash Price |
$3,330.84
|
| Rate for Payer: Cigna Commercial |
$5,529.19
|
| Rate for Payer: First Health Commercial |
$6,328.60
|
| Rate for Payer: Humana Commercial |
$5,662.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,462.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,916.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,998.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,862.28
|
| Rate for Payer: Ohio Health Group HMO |
$4,996.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,329.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,795.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,596.56
|
| Rate for Payer: PHCS Commercial |
$6,395.21
|
| Rate for Payer: United Healthcare All Payer |
$5,862.28
|
|
|
PLATE EVOS VOL 4H STD TI 56M R
|
Facility
|
OP
|
$6,661.68
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,998.50 |
| Max. Negotiated Rate |
$6,395.21 |
| Rate for Payer: Aetna Commercial |
$5,129.49
|
| Rate for Payer: Anthem Medicaid |
$2,290.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,196.11
|
| Rate for Payer: Cash Price |
$3,330.84
|
| Rate for Payer: Cigna Commercial |
$5,529.19
|
| Rate for Payer: First Health Commercial |
$6,328.60
|
| Rate for Payer: Humana Commercial |
$5,662.43
|
| Rate for Payer: Humana KY Medicaid |
$2,290.95
|
| Rate for Payer: Kentucky WC Medicaid |
$2,314.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,462.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,916.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,998.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,336.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,862.28
|
| Rate for Payer: Ohio Health Group HMO |
$4,996.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,329.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,795.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,596.56
|
| Rate for Payer: PHCS Commercial |
$6,395.21
|
| Rate for Payer: United Healthcare All Payer |
$5,862.28
|
|
|
PLATE EVOS VOL 4H WDE TI 56M L
|
Facility
|
IP
|
$6,962.80
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,088.84 |
| Max. Negotiated Rate |
$6,684.29 |
| Rate for Payer: Aetna Commercial |
$5,361.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,430.98
|
| Rate for Payer: Cash Price |
$3,481.40
|
| Rate for Payer: Cigna Commercial |
$5,779.12
|
| Rate for Payer: First Health Commercial |
$6,614.66
|
| Rate for Payer: Humana Commercial |
$5,918.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,709.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,138.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,088.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,127.26
|
| Rate for Payer: Ohio Health Group HMO |
$5,222.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,570.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,057.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,804.33
|
| Rate for Payer: PHCS Commercial |
$6,684.29
|
| Rate for Payer: United Healthcare All Payer |
$6,127.26
|
|
|
PLATE EVOS VOL 4H WDE TI 56M L
|
Facility
|
OP
|
$6,962.80
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,088.84 |
| Max. Negotiated Rate |
$6,684.29 |
| Rate for Payer: Aetna Commercial |
$5,361.36
|
| Rate for Payer: Anthem Medicaid |
$2,394.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,430.98
|
| Rate for Payer: Cash Price |
$3,481.40
|
| Rate for Payer: Cigna Commercial |
$5,779.12
|
| Rate for Payer: First Health Commercial |
$6,614.66
|
| Rate for Payer: Humana Commercial |
$5,918.38
|
| Rate for Payer: Humana KY Medicaid |
$2,394.51
|
| Rate for Payer: Kentucky WC Medicaid |
$2,418.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,709.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,138.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,088.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,442.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,127.26
|
| Rate for Payer: Ohio Health Group HMO |
$5,222.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,570.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,057.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,804.33
|
| Rate for Payer: PHCS Commercial |
$6,684.29
|
| Rate for Payer: United Healthcare All Payer |
$6,127.26
|
|
|
PLATE EVOS VOL 4H WDE TI 56M R
|
Facility
|
OP
|
$6,661.68
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,998.50 |
| Max. Negotiated Rate |
$6,395.21 |
| Rate for Payer: Aetna Commercial |
$5,129.49
|
| Rate for Payer: Anthem Medicaid |
$2,290.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,196.11
|
| Rate for Payer: Cash Price |
$3,330.84
|
| Rate for Payer: Cigna Commercial |
$5,529.19
|
| Rate for Payer: First Health Commercial |
$6,328.60
|
| Rate for Payer: Humana Commercial |
$5,662.43
|
| Rate for Payer: Humana KY Medicaid |
$2,290.95
|
| Rate for Payer: Kentucky WC Medicaid |
$2,314.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,462.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,916.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,998.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,336.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,862.28
|
| Rate for Payer: Ohio Health Group HMO |
$4,996.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,329.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,795.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,596.56
|
| Rate for Payer: PHCS Commercial |
$6,395.21
|
| Rate for Payer: United Healthcare All Payer |
$5,862.28
|
|
|
PLATE EVOS VOL 4H WDE TI 56M R
|
Facility
|
IP
|
$6,661.68
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,998.50 |
| Max. Negotiated Rate |
$6,395.21 |
| Rate for Payer: Aetna Commercial |
$5,129.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,196.11
|
| Rate for Payer: Cash Price |
$3,330.84
|
| Rate for Payer: Cigna Commercial |
$5,529.19
|
| Rate for Payer: First Health Commercial |
$6,328.60
|
| Rate for Payer: Humana Commercial |
$5,662.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,462.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,916.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,998.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,862.28
|
| Rate for Payer: Ohio Health Group HMO |
$4,996.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,329.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,795.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,596.56
|
| Rate for Payer: PHCS Commercial |
$6,395.21
|
| Rate for Payer: United Healthcare All Payer |
$5,862.28
|
|
|
PLATE EVOS VOL 5H STD TI 81M R
|
Facility
|
OP
|
$8,805.69
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,641.71 |
| Max. Negotiated Rate |
$8,453.46 |
| Rate for Payer: Aetna Commercial |
$6,780.38
|
| Rate for Payer: Anthem Medicaid |
$3,028.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,868.44
|
| Rate for Payer: Cash Price |
$4,402.84
|
| Rate for Payer: Cigna Commercial |
$7,308.72
|
| Rate for Payer: First Health Commercial |
$8,365.41
|
| Rate for Payer: Humana Commercial |
$7,484.84
|
| Rate for Payer: Humana KY Medicaid |
$3,028.28
|
| Rate for Payer: Kentucky WC Medicaid |
$3,059.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,220.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,498.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,641.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,089.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,749.01
|
| Rate for Payer: Ohio Health Group HMO |
$6,604.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,044.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,660.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,075.93
|
| Rate for Payer: PHCS Commercial |
$8,453.46
|
| Rate for Payer: United Healthcare All Payer |
$7,749.01
|
|
|
PLATE EVOS VOL 5H STD TI 81M R
|
Facility
|
IP
|
$8,805.69
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,641.71 |
| Max. Negotiated Rate |
$8,453.46 |
| Rate for Payer: Aetna Commercial |
$6,780.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,868.44
|
| Rate for Payer: Cash Price |
$4,402.84
|
| Rate for Payer: Cigna Commercial |
$7,308.72
|
| Rate for Payer: First Health Commercial |
$8,365.41
|
| Rate for Payer: Humana Commercial |
$7,484.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,220.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,498.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,641.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,749.01
|
| Rate for Payer: Ohio Health Group HMO |
$6,604.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,044.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,660.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,075.93
|
| Rate for Payer: PHCS Commercial |
$8,453.46
|
| Rate for Payer: United Healthcare All Payer |
$7,749.01
|
|
|
PLATE EVOS VOL 5H WDE TI 83M L
|
Facility
|
OP
|
$8,962.27
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,688.68 |
| Max. Negotiated Rate |
$8,603.78 |
| Rate for Payer: Aetna Commercial |
$6,900.95
|
| Rate for Payer: Anthem Medicaid |
$3,082.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,990.57
|
| Rate for Payer: Cash Price |
$4,481.14
|
| Rate for Payer: Cigna Commercial |
$7,438.68
|
| Rate for Payer: First Health Commercial |
$8,514.16
|
| Rate for Payer: Humana Commercial |
$7,617.93
|
| Rate for Payer: Humana KY Medicaid |
$3,082.12
|
| Rate for Payer: Kentucky WC Medicaid |
$3,113.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,349.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,614.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,688.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,143.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,886.80
|
| Rate for Payer: Ohio Health Group HMO |
$6,721.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,169.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,797.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,183.97
|
| Rate for Payer: PHCS Commercial |
$8,603.78
|
| Rate for Payer: United Healthcare All Payer |
$7,886.80
|
|
|
PLATE EVOS VOL 5H WDE TI 83M L
|
Facility
|
IP
|
$8,962.27
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,688.68 |
| Max. Negotiated Rate |
$8,603.78 |
| Rate for Payer: Aetna Commercial |
$6,900.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,990.57
|
| Rate for Payer: Cash Price |
$4,481.14
|
| Rate for Payer: Cigna Commercial |
$7,438.68
|
| Rate for Payer: First Health Commercial |
$8,514.16
|
| Rate for Payer: Humana Commercial |
$7,617.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,349.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,614.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,688.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,886.80
|
| Rate for Payer: Ohio Health Group HMO |
$6,721.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,169.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,797.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,183.97
|
| Rate for Payer: PHCS Commercial |
$8,603.78
|
| Rate for Payer: United Healthcare All Payer |
$7,886.80
|
|
|
PLATE EVOS VOL 5H WDE TI 83M R
|
Facility
|
OP
|
$8,781.60
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,634.48 |
| Max. Negotiated Rate |
$8,430.34 |
| Rate for Payer: Aetna Commercial |
$6,761.83
|
| Rate for Payer: Anthem Medicaid |
$3,019.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,849.65
|
| Rate for Payer: Cash Price |
$4,390.80
|
| Rate for Payer: Cigna Commercial |
$7,288.73
|
| Rate for Payer: First Health Commercial |
$8,342.52
|
| Rate for Payer: Humana Commercial |
$7,464.36
|
| Rate for Payer: Humana KY Medicaid |
$3,019.99
|
| Rate for Payer: Kentucky WC Medicaid |
$3,050.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,200.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,480.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,634.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,080.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,727.81
|
| Rate for Payer: Ohio Health Group HMO |
$6,586.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,025.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,639.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,059.30
|
| Rate for Payer: PHCS Commercial |
$8,430.34
|
| Rate for Payer: United Healthcare All Payer |
$7,727.81
|
|
|
PLATE EVOS VOL 5H WDE TI 83M R
|
Facility
|
IP
|
$8,781.60
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,634.48 |
| Max. Negotiated Rate |
$8,430.34 |
| Rate for Payer: Aetna Commercial |
$6,761.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,849.65
|
| Rate for Payer: Cash Price |
$4,390.80
|
| Rate for Payer: Cigna Commercial |
$7,288.73
|
| Rate for Payer: First Health Commercial |
$8,342.52
|
| Rate for Payer: Humana Commercial |
$7,464.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,200.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,480.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,634.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,727.81
|
| Rate for Payer: Ohio Health Group HMO |
$6,586.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,025.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,639.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,059.30
|
| Rate for Payer: PHCS Commercial |
$8,430.34
|
| Rate for Payer: United Healthcare All Payer |
$7,727.81
|
|
|
PLATE EVOS VOLAR 4H 56MM R
|
Facility
|
OP
|
$6,661.68
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,998.50 |
| Max. Negotiated Rate |
$6,395.21 |
| Rate for Payer: Aetna Commercial |
$5,129.49
|
| Rate for Payer: Anthem Medicaid |
$2,290.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,196.11
|
| Rate for Payer: Cash Price |
$3,330.84
|
| Rate for Payer: Cigna Commercial |
$5,529.19
|
| Rate for Payer: First Health Commercial |
$6,328.60
|
| Rate for Payer: Humana Commercial |
$5,662.43
|
| Rate for Payer: Humana KY Medicaid |
$2,290.95
|
| Rate for Payer: Kentucky WC Medicaid |
$2,314.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,462.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,916.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,998.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,336.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,862.28
|
| Rate for Payer: Ohio Health Group HMO |
$4,996.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,329.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,795.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,596.56
|
| Rate for Payer: PHCS Commercial |
$6,395.21
|
| Rate for Payer: United Healthcare All Payer |
$5,862.28
|
|
|
PLATE EVOS VOLAR 4H 56MM R
|
Facility
|
IP
|
$6,661.68
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,998.50 |
| Max. Negotiated Rate |
$6,395.21 |
| Rate for Payer: Aetna Commercial |
$5,129.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,196.11
|
| Rate for Payer: Cash Price |
$3,330.84
|
| Rate for Payer: Cigna Commercial |
$5,529.19
|
| Rate for Payer: First Health Commercial |
$6,328.60
|
| Rate for Payer: Humana Commercial |
$5,662.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,462.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,916.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,998.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,862.28
|
| Rate for Payer: Ohio Health Group HMO |
$4,996.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,329.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,795.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,596.56
|
| Rate for Payer: PHCS Commercial |
$6,395.21
|
| Rate for Payer: United Healthcare All Payer |
$5,862.28
|
|
|
PLATE EVS INTL 4H WDE TI 54M L
|
Facility
|
IP
|
$6,830.31
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,049.09 |
| Max. Negotiated Rate |
$6,557.10 |
| Rate for Payer: Aetna Commercial |
$5,259.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,327.64
|
| Rate for Payer: Cash Price |
$3,415.16
|
| Rate for Payer: Cigna Commercial |
$5,669.16
|
| Rate for Payer: First Health Commercial |
$6,488.79
|
| Rate for Payer: Humana Commercial |
$5,805.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,600.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,040.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,049.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,010.67
|
| Rate for Payer: Ohio Health Group HMO |
$5,122.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,464.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,942.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,712.91
|
| Rate for Payer: PHCS Commercial |
$6,557.10
|
| Rate for Payer: United Healthcare All Payer |
$6,010.67
|
|
|
PLATE EVS INTL 4H WDE TI 54M L
|
Facility
|
OP
|
$6,830.31
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,049.09 |
| Max. Negotiated Rate |
$6,557.10 |
| Rate for Payer: Aetna Commercial |
$5,259.34
|
| Rate for Payer: Anthem Medicaid |
$2,348.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,327.64
|
| Rate for Payer: Cash Price |
$3,415.16
|
| Rate for Payer: Cigna Commercial |
$5,669.16
|
| Rate for Payer: First Health Commercial |
$6,488.79
|
| Rate for Payer: Humana Commercial |
$5,805.76
|
| Rate for Payer: Humana KY Medicaid |
$2,348.94
|
| Rate for Payer: Kentucky WC Medicaid |
$2,372.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,600.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,040.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,049.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,396.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,010.67
|
| Rate for Payer: Ohio Health Group HMO |
$5,122.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,464.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,942.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,712.91
|
| Rate for Payer: PHCS Commercial |
$6,557.10
|
| Rate for Payer: United Healthcare All Payer |
$6,010.67
|
|
|
PLATE EVS INTL 4H WDE TI 57M L
|
Facility
|
OP
|
$7,468.70
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,240.61 |
| Max. Negotiated Rate |
$7,169.95 |
| Rate for Payer: Aetna Commercial |
$5,750.90
|
| Rate for Payer: Anthem Medicaid |
$2,568.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,825.59
|
| Rate for Payer: Cash Price |
$3,734.35
|
| Rate for Payer: Cigna Commercial |
$6,199.02
|
| Rate for Payer: First Health Commercial |
$7,095.27
|
| Rate for Payer: Humana Commercial |
$6,348.40
|
| Rate for Payer: Humana KY Medicaid |
$2,568.49
|
| Rate for Payer: Kentucky WC Medicaid |
$2,594.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,124.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,511.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,240.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,620.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,572.46
|
| Rate for Payer: Ohio Health Group HMO |
$5,601.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,974.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,497.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,153.40
|
| Rate for Payer: PHCS Commercial |
$7,169.95
|
| Rate for Payer: United Healthcare All Payer |
$6,572.46
|
|
|
PLATE EVS INTL 4H WDE TI 57M L
|
Facility
|
IP
|
$7,468.70
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,240.61 |
| Max. Negotiated Rate |
$7,169.95 |
| Rate for Payer: Aetna Commercial |
$5,750.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,825.59
|
| Rate for Payer: Cash Price |
$3,734.35
|
| Rate for Payer: Cigna Commercial |
$6,199.02
|
| Rate for Payer: First Health Commercial |
$7,095.27
|
| Rate for Payer: Humana Commercial |
$6,348.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,124.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,511.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,240.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,572.46
|
| Rate for Payer: Ohio Health Group HMO |
$5,601.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,974.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,497.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,153.40
|
| Rate for Payer: PHCS Commercial |
$7,169.95
|
| Rate for Payer: United Healthcare All Payer |
$6,572.46
|
|
|
PLATE EVS VL 10H STD TI 141M R
|
Facility
|
IP
|
$9,130.91
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,739.27 |
| Max. Negotiated Rate |
$8,765.67 |
| Rate for Payer: Aetna Commercial |
$7,030.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,122.11
|
| Rate for Payer: Cash Price |
$4,565.45
|
| Rate for Payer: Cigna Commercial |
$7,578.66
|
| Rate for Payer: First Health Commercial |
$8,674.36
|
| Rate for Payer: Humana Commercial |
$7,761.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,487.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,738.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,739.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,035.20
|
| Rate for Payer: Ohio Health Group HMO |
$6,848.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,304.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,943.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,300.33
|
| Rate for Payer: PHCS Commercial |
$8,765.67
|
| Rate for Payer: United Healthcare All Payer |
$8,035.20
|
|
|
PLATE EVS VL 10H STD TI 141M R
|
Facility
|
OP
|
$9,130.91
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,739.27 |
| Max. Negotiated Rate |
$8,765.67 |
| Rate for Payer: Aetna Commercial |
$7,030.80
|
| Rate for Payer: Anthem Medicaid |
$3,140.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,122.11
|
| Rate for Payer: Cash Price |
$4,565.45
|
| Rate for Payer: Cigna Commercial |
$7,578.66
|
| Rate for Payer: First Health Commercial |
$8,674.36
|
| Rate for Payer: Humana Commercial |
$7,761.27
|
| Rate for Payer: Humana KY Medicaid |
$3,140.12
|
| Rate for Payer: Kentucky WC Medicaid |
$3,172.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,487.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,738.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,739.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,203.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,035.20
|
| Rate for Payer: Ohio Health Group HMO |
$6,848.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,304.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,943.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,300.33
|
| Rate for Payer: PHCS Commercial |
$8,765.67
|
| Rate for Payer: United Healthcare All Payer |
$8,035.20
|
|
|
PLATE EXT 4H GTR 4 CABLES 23*2
|
Facility
|
IP
|
$25,662.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,698.75 |
| Max. Negotiated Rate |
$24,636.00 |
| Rate for Payer: Aetna Commercial |
$19,760.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,016.75
|
| Rate for Payer: Cash Price |
$12,831.25
|
| Rate for Payer: Cigna Commercial |
$21,299.88
|
| Rate for Payer: First Health Commercial |
$24,379.38
|
| Rate for Payer: Humana Commercial |
$21,813.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,043.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,938.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,698.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,583.00
|
| Rate for Payer: Ohio Health Group HMO |
$19,246.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,530.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,326.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,707.12
|
| Rate for Payer: PHCS Commercial |
$24,636.00
|
| Rate for Payer: United Healthcare All Payer |
$22,583.00
|
|
|
PLATE EXT 4H GTR 4 CABLES 23*2
|
Facility
|
OP
|
$25,662.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,698.75 |
| Max. Negotiated Rate |
$24,636.00 |
| Rate for Payer: Aetna Commercial |
$19,760.12
|
| Rate for Payer: Anthem Medicaid |
$8,825.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,016.75
|
| Rate for Payer: Cash Price |
$12,831.25
|
| Rate for Payer: Cigna Commercial |
$21,299.88
|
| Rate for Payer: First Health Commercial |
$24,379.38
|
| Rate for Payer: Humana Commercial |
$21,813.12
|
| Rate for Payer: Humana KY Medicaid |
$8,825.33
|
| Rate for Payer: Kentucky WC Medicaid |
$8,915.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,043.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,938.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,698.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,002.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,583.00
|
| Rate for Payer: Ohio Health Group HMO |
$19,246.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,530.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,326.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,707.12
|
| Rate for Payer: PHCS Commercial |
$24,636.00
|
| Rate for Payer: United Healthcare All Payer |
$22,583.00
|
|
|
PLATE F3 T
|
Facility
|
OP
|
$4,688.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,406.62 |
| Max. Negotiated Rate |
$4,501.20 |
| Rate for Payer: Aetna Commercial |
$3,610.34
|
| Rate for Payer: Anthem Medicaid |
$1,612.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,657.22
|
| Rate for Payer: Cash Price |
$2,344.38
|
| Rate for Payer: Cigna Commercial |
$3,891.66
|
| Rate for Payer: First Health Commercial |
$4,454.31
|
| Rate for Payer: Humana Commercial |
$3,985.44
|
| Rate for Payer: Humana KY Medicaid |
$1,612.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1,628.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,844.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,460.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,406.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,644.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,126.10
|
| Rate for Payer: Ohio Health Group HMO |
$3,516.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,751.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,079.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,235.24
|
| Rate for Payer: PHCS Commercial |
$4,501.20
|
| Rate for Payer: United Healthcare All Payer |
$4,126.10
|
|
|
PLATE F3 T
|
Facility
|
IP
|
$4,688.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,406.62 |
| Max. Negotiated Rate |
$4,501.20 |
| Rate for Payer: Aetna Commercial |
$3,610.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,657.22
|
| Rate for Payer: Cash Price |
$2,344.38
|
| Rate for Payer: Cigna Commercial |
$3,891.66
|
| Rate for Payer: First Health Commercial |
$4,454.31
|
| Rate for Payer: Humana Commercial |
$3,985.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,844.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,460.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,406.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,126.10
|
| Rate for Payer: Ohio Health Group HMO |
$3,516.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,751.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,079.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,235.24
|
| Rate for Payer: PHCS Commercial |
$4,501.20
|
| Rate for Payer: United Healthcare All Payer |
$4,126.10
|
|
|
PLATE FB LK 3.5M L-D 11H155M L
|
Facility
|
IP
|
$4,632.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,389.75 |
| Max. Negotiated Rate |
$4,447.20 |
| Rate for Payer: Aetna Commercial |
$3,567.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,613.35
|
| Rate for Payer: Cash Price |
$2,316.25
|
| Rate for Payer: Cigna Commercial |
$3,844.97
|
| Rate for Payer: First Health Commercial |
$4,400.88
|
| Rate for Payer: Humana Commercial |
$3,937.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,798.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,418.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,389.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,076.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,474.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,706.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,030.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,196.43
|
| Rate for Payer: PHCS Commercial |
$4,447.20
|
| Rate for Payer: United Healthcare All Payer |
$4,076.60
|
|
