|
PLATE GEMI VOL DIS RAD N 4H R
|
Facility
|
OP
|
$4,797.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.25 |
| Max. Negotiated Rate |
$4,605.60 |
| Rate for Payer: Aetna Commercial |
$3,694.07
|
| Rate for Payer: Anthem Medicaid |
$1,649.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,742.05
|
| Rate for Payer: Cash Price |
$2,398.75
|
| Rate for Payer: Cigna Commercial |
$3,981.93
|
| Rate for Payer: First Health Commercial |
$4,557.62
|
| Rate for Payer: Humana Commercial |
$4,077.88
|
| Rate for Payer: Humana KY Medicaid |
$1,649.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,666.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,933.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,540.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,439.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,682.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,221.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,598.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,838.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,173.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,310.28
|
| Rate for Payer: PHCS Commercial |
$4,605.60
|
| Rate for Payer: United Healthcare All Payer |
$4,221.80
|
|
|
PLATE GEMI VOL DISRAD SD 3H L
|
Facility
|
OP
|
$4,797.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.25 |
| Max. Negotiated Rate |
$4,605.60 |
| Rate for Payer: Aetna Commercial |
$3,694.07
|
| Rate for Payer: Anthem Medicaid |
$1,649.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,742.05
|
| Rate for Payer: Cash Price |
$2,398.75
|
| Rate for Payer: Cigna Commercial |
$3,981.93
|
| Rate for Payer: First Health Commercial |
$4,557.62
|
| Rate for Payer: Humana Commercial |
$4,077.88
|
| Rate for Payer: Humana KY Medicaid |
$1,649.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,666.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,933.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,540.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,439.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,682.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,221.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,598.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,838.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,173.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,310.28
|
| Rate for Payer: PHCS Commercial |
$4,605.60
|
| Rate for Payer: United Healthcare All Payer |
$4,221.80
|
|
|
PLATE GEMI VOL DISRAD SD 3H L
|
Facility
|
IP
|
$4,797.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.25 |
| Max. Negotiated Rate |
$4,605.60 |
| Rate for Payer: Aetna Commercial |
$3,694.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,742.05
|
| Rate for Payer: Cash Price |
$2,398.75
|
| Rate for Payer: Cigna Commercial |
$3,981.93
|
| Rate for Payer: First Health Commercial |
$4,557.62
|
| Rate for Payer: Humana Commercial |
$4,077.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,933.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,540.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,439.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,221.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,598.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,838.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,173.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,310.28
|
| Rate for Payer: PHCS Commercial |
$4,605.60
|
| Rate for Payer: United Healthcare All Payer |
$4,221.80
|
|
|
PLATE GEMI VOL DIS RAD SD 3H R
|
Facility
|
OP
|
$4,797.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.25 |
| Max. Negotiated Rate |
$4,605.60 |
| Rate for Payer: Aetna Commercial |
$3,694.07
|
| Rate for Payer: Anthem Medicaid |
$1,649.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,742.05
|
| Rate for Payer: Cash Price |
$2,398.75
|
| Rate for Payer: Cigna Commercial |
$3,981.93
|
| Rate for Payer: First Health Commercial |
$4,557.62
|
| Rate for Payer: Humana Commercial |
$4,077.88
|
| Rate for Payer: Humana KY Medicaid |
$1,649.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,666.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,933.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,540.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,439.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,682.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,221.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,598.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,838.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,173.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,310.28
|
| Rate for Payer: PHCS Commercial |
$4,605.60
|
| Rate for Payer: United Healthcare All Payer |
$4,221.80
|
|
|
PLATE GEMI VOL DIS RAD SD 3H R
|
Facility
|
IP
|
$4,797.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.25 |
| Max. Negotiated Rate |
$4,605.60 |
| Rate for Payer: Aetna Commercial |
$3,694.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,742.05
|
| Rate for Payer: Cash Price |
$2,398.75
|
| Rate for Payer: Cigna Commercial |
$3,981.93
|
| Rate for Payer: First Health Commercial |
$4,557.62
|
| Rate for Payer: Humana Commercial |
$4,077.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,933.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,540.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,439.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,221.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,598.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,838.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,173.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,310.28
|
| Rate for Payer: PHCS Commercial |
$4,605.60
|
| Rate for Payer: United Healthcare All Payer |
$4,221.80
|
|
|
PLATE GEMI VOL DISRAD SD 4H L
|
Facility
|
OP
|
$4,797.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.25 |
| Max. Negotiated Rate |
$4,605.60 |
| Rate for Payer: Aetna Commercial |
$3,694.07
|
| Rate for Payer: Anthem Medicaid |
$1,649.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,742.05
|
| Rate for Payer: Cash Price |
$2,398.75
|
| Rate for Payer: Cigna Commercial |
$3,981.93
|
| Rate for Payer: First Health Commercial |
$4,557.62
|
| Rate for Payer: Humana Commercial |
$4,077.88
|
| Rate for Payer: Humana KY Medicaid |
$1,649.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,666.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,933.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,540.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,439.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,682.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,221.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,598.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,838.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,173.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,310.28
|
| Rate for Payer: PHCS Commercial |
$4,605.60
|
| Rate for Payer: United Healthcare All Payer |
$4,221.80
|
|
|
PLATE GEMI VOL DISRAD SD 4H L
|
Facility
|
IP
|
$4,797.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.25 |
| Max. Negotiated Rate |
$4,605.60 |
| Rate for Payer: Aetna Commercial |
$3,694.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,742.05
|
| Rate for Payer: Cash Price |
$2,398.75
|
| Rate for Payer: Cigna Commercial |
$3,981.93
|
| Rate for Payer: First Health Commercial |
$4,557.62
|
| Rate for Payer: Humana Commercial |
$4,077.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,933.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,540.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,439.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,221.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,598.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,838.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,173.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,310.28
|
| Rate for Payer: PHCS Commercial |
$4,605.60
|
| Rate for Payer: United Healthcare All Payer |
$4,221.80
|
|
|
PLATE GEMI VOL DISRAD SD 4H R
|
Facility
|
IP
|
$4,797.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.25 |
| Max. Negotiated Rate |
$4,605.60 |
| Rate for Payer: Aetna Commercial |
$3,694.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,742.05
|
| Rate for Payer: Cash Price |
$2,398.75
|
| Rate for Payer: Cigna Commercial |
$3,981.93
|
| Rate for Payer: First Health Commercial |
$4,557.62
|
| Rate for Payer: Humana Commercial |
$4,077.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,933.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,540.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,439.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,221.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,598.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,838.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,173.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,310.28
|
| Rate for Payer: PHCS Commercial |
$4,605.60
|
| Rate for Payer: United Healthcare All Payer |
$4,221.80
|
|
|
PLATE GEMI VOL DISRAD SD 4H R
|
Facility
|
OP
|
$4,797.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.25 |
| Max. Negotiated Rate |
$4,605.60 |
| Rate for Payer: Aetna Commercial |
$3,694.07
|
| Rate for Payer: Anthem Medicaid |
$1,649.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,742.05
|
| Rate for Payer: Cash Price |
$2,398.75
|
| Rate for Payer: Cigna Commercial |
$3,981.93
|
| Rate for Payer: First Health Commercial |
$4,557.62
|
| Rate for Payer: Humana Commercial |
$4,077.88
|
| Rate for Payer: Humana KY Medicaid |
$1,649.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,666.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,933.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,540.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,439.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,682.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,221.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,598.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,838.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,173.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,310.28
|
| Rate for Payer: PHCS Commercial |
$4,605.60
|
| Rate for Payer: United Healthcare All Payer |
$4,221.80
|
|
|
PLATE GEMI VOL DISRAD SD 7H L
|
Facility
|
IP
|
$4,797.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.25 |
| Max. Negotiated Rate |
$4,605.60 |
| Rate for Payer: Aetna Commercial |
$3,694.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,742.05
|
| Rate for Payer: Cash Price |
$2,398.75
|
| Rate for Payer: Cigna Commercial |
$3,981.93
|
| Rate for Payer: First Health Commercial |
$4,557.62
|
| Rate for Payer: Humana Commercial |
$4,077.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,933.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,540.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,439.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,221.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,598.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,838.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,173.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,310.28
|
| Rate for Payer: PHCS Commercial |
$4,605.60
|
| Rate for Payer: United Healthcare All Payer |
$4,221.80
|
|
|
PLATE GEMI VOL DISRAD SD 7H L
|
Facility
|
OP
|
$4,797.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.25 |
| Max. Negotiated Rate |
$4,605.60 |
| Rate for Payer: Aetna Commercial |
$3,694.07
|
| Rate for Payer: Anthem Medicaid |
$1,649.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,742.05
|
| Rate for Payer: Cash Price |
$2,398.75
|
| Rate for Payer: Cigna Commercial |
$3,981.93
|
| Rate for Payer: First Health Commercial |
$4,557.62
|
| Rate for Payer: Humana Commercial |
$4,077.88
|
| Rate for Payer: Humana KY Medicaid |
$1,649.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,666.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,933.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,540.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,439.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,682.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,221.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,598.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,838.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,173.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,310.28
|
| Rate for Payer: PHCS Commercial |
$4,605.60
|
| Rate for Payer: United Healthcare All Payer |
$4,221.80
|
|
|
PLATE GEMI VOL DISRAD SD 7H R
|
Facility
|
IP
|
$4,797.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.25 |
| Max. Negotiated Rate |
$4,605.60 |
| Rate for Payer: Aetna Commercial |
$3,694.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,742.05
|
| Rate for Payer: Cash Price |
$2,398.75
|
| Rate for Payer: Cigna Commercial |
$3,981.93
|
| Rate for Payer: First Health Commercial |
$4,557.62
|
| Rate for Payer: Humana Commercial |
$4,077.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,933.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,540.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,439.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,221.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,598.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,838.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,173.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,310.28
|
| Rate for Payer: PHCS Commercial |
$4,605.60
|
| Rate for Payer: United Healthcare All Payer |
$4,221.80
|
|
|
PLATE GEMI VOL DISRAD SD 7H R
|
Facility
|
OP
|
$4,797.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.25 |
| Max. Negotiated Rate |
$4,605.60 |
| Rate for Payer: Aetna Commercial |
$3,694.07
|
| Rate for Payer: Anthem Medicaid |
$1,649.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,742.05
|
| Rate for Payer: Cash Price |
$2,398.75
|
| Rate for Payer: Cigna Commercial |
$3,981.93
|
| Rate for Payer: First Health Commercial |
$4,557.62
|
| Rate for Payer: Humana Commercial |
$4,077.88
|
| Rate for Payer: Humana KY Medicaid |
$1,649.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,666.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,933.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,540.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,439.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,682.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,221.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,598.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,838.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,173.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,310.28
|
| Rate for Payer: PHCS Commercial |
$4,605.60
|
| Rate for Payer: United Healthcare All Payer |
$4,221.80
|
|
|
PLATE GEMI VOL DIS RAD WD 4H L
|
Facility
|
OP
|
$4,797.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.25 |
| Max. Negotiated Rate |
$4,605.60 |
| Rate for Payer: Aetna Commercial |
$3,694.07
|
| Rate for Payer: Anthem Medicaid |
$1,649.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,742.05
|
| Rate for Payer: Cash Price |
$2,398.75
|
| Rate for Payer: Cigna Commercial |
$3,981.93
|
| Rate for Payer: First Health Commercial |
$4,557.62
|
| Rate for Payer: Humana Commercial |
$4,077.88
|
| Rate for Payer: Humana KY Medicaid |
$1,649.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,666.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,933.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,540.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,439.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,682.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,221.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,598.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,838.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,173.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,310.28
|
| Rate for Payer: PHCS Commercial |
$4,605.60
|
| Rate for Payer: United Healthcare All Payer |
$4,221.80
|
|
|
PLATE GEMI VOL DIS RAD WD 4H L
|
Facility
|
IP
|
$4,797.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.25 |
| Max. Negotiated Rate |
$4,605.60 |
| Rate for Payer: Aetna Commercial |
$3,694.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,742.05
|
| Rate for Payer: Cash Price |
$2,398.75
|
| Rate for Payer: Cigna Commercial |
$3,981.93
|
| Rate for Payer: First Health Commercial |
$4,557.62
|
| Rate for Payer: Humana Commercial |
$4,077.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,933.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,540.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,439.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,221.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,598.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,838.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,173.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,310.28
|
| Rate for Payer: PHCS Commercial |
$4,605.60
|
| Rate for Payer: United Healthcare All Payer |
$4,221.80
|
|
|
PLATE GEMI VOL DISRAD WD 4H R
|
Facility
|
IP
|
$4,797.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.25 |
| Max. Negotiated Rate |
$4,605.60 |
| Rate for Payer: Aetna Commercial |
$3,694.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,742.05
|
| Rate for Payer: Cash Price |
$2,398.75
|
| Rate for Payer: Cigna Commercial |
$3,981.93
|
| Rate for Payer: First Health Commercial |
$4,557.62
|
| Rate for Payer: Humana Commercial |
$4,077.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,933.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,540.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,439.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,221.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,598.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,838.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,173.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,310.28
|
| Rate for Payer: PHCS Commercial |
$4,605.60
|
| Rate for Payer: United Healthcare All Payer |
$4,221.80
|
|
|
PLATE GEMI VOL DISRAD WD 4H R
|
Facility
|
OP
|
$4,797.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,439.25 |
| Max. Negotiated Rate |
$4,605.60 |
| Rate for Payer: Aetna Commercial |
$3,694.07
|
| Rate for Payer: Anthem Medicaid |
$1,649.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,742.05
|
| Rate for Payer: Cash Price |
$2,398.75
|
| Rate for Payer: Cigna Commercial |
$3,981.93
|
| Rate for Payer: First Health Commercial |
$4,557.62
|
| Rate for Payer: Humana Commercial |
$4,077.88
|
| Rate for Payer: Humana KY Medicaid |
$1,649.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,666.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,933.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,540.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,439.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,682.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,221.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,598.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,838.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,173.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,310.28
|
| Rate for Payer: PHCS Commercial |
$4,605.60
|
| Rate for Payer: United Healthcare All Payer |
$4,221.80
|
|
|
PLATE H 2.0MM 4H
|
Facility
|
IP
|
$1,962.15
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$588.64 |
| Max. Negotiated Rate |
$1,883.66 |
| Rate for Payer: Aetna Commercial |
$1,510.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,530.48
|
| Rate for Payer: Cash Price |
$981.08
|
| Rate for Payer: Cigna Commercial |
$1,628.58
|
| Rate for Payer: First Health Commercial |
$1,864.04
|
| Rate for Payer: Humana Commercial |
$1,667.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,608.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,448.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$588.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,726.69
|
| Rate for Payer: Ohio Health Group HMO |
$1,471.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,569.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,707.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,353.88
|
| Rate for Payer: PHCS Commercial |
$1,883.66
|
| Rate for Payer: United Healthcare All Payer |
$1,726.69
|
|
|
PLATE H 2.0MM 4H
|
Facility
|
OP
|
$1,962.15
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$588.64 |
| Max. Negotiated Rate |
$1,883.66 |
| Rate for Payer: Aetna Commercial |
$1,510.86
|
| Rate for Payer: Anthem Medicaid |
$674.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,530.48
|
| Rate for Payer: Cash Price |
$981.08
|
| Rate for Payer: Cigna Commercial |
$1,628.58
|
| Rate for Payer: First Health Commercial |
$1,864.04
|
| Rate for Payer: Humana Commercial |
$1,667.83
|
| Rate for Payer: Humana KY Medicaid |
$674.78
|
| Rate for Payer: Kentucky WC Medicaid |
$681.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,608.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,448.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$588.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$688.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,726.69
|
| Rate for Payer: Ohio Health Group HMO |
$1,471.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,569.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,707.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,353.88
|
| Rate for Payer: PHCS Commercial |
$1,883.66
|
| Rate for Payer: United Healthcare All Payer |
$1,726.69
|
|
|
PLATE-H 28*16MM SM LT
|
Facility
|
OP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem Medicaid |
$1,461.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Humana KY Medicaid |
$1,461.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1,476.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,490.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
|
PLATE-H 28*16MM SM LT
|
Facility
|
IP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
|
PLATE-H 28*16 SM RT
|
Facility
|
OP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem Medicaid |
$1,461.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Humana KY Medicaid |
$1,461.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1,476.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,490.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
|
PLATE-H 28*16 SM RT
|
Facility
|
IP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
|
PLATE-H 32*16 16MM WEDGE RT
|
Facility
|
OP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem Medicaid |
$1,461.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Humana KY Medicaid |
$1,461.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1,476.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,490.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
|
PLATE-H 32*16 16MM WEDGE RT
|
Facility
|
IP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
