|
PLATE POSTEROMEDL DIS TIB 3H R
|
Facility
|
OP
|
$4,202.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$546.26 |
| Max. Negotiated Rate |
$4,033.92 |
| Rate for Payer: Anthem Medicaid |
$1,445.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,277.56
|
| Rate for Payer: Cash Price |
$2,101.00
|
| Rate for Payer: Cigna Commercial |
$3,487.66
|
| Rate for Payer: First Health Commercial |
$3,991.90
|
| Rate for Payer: Humana Commercial |
$3,571.70
|
| Rate for Payer: Humana KY Medicaid |
$1,445.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,459.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,445.64
|
| Rate for Payer: Aetna Commercial |
$3,235.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,101.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,260.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,474.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,697.76
|
| Rate for Payer: Ohio Health Group HMO |
$3,151.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$840.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$546.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,302.62
|
| Rate for Payer: PHCS Commercial |
$4,033.92
|
| Rate for Payer: United Healthcare All Payer |
$3,697.76
|
|
|
PLATE POSTEROMEDL DIS TIB 3H R
|
Facility
|
IP
|
$4,202.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$546.26 |
| Max. Negotiated Rate |
$4,033.92 |
| Rate for Payer: Aetna Commercial |
$3,235.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,277.56
|
| Rate for Payer: Cash Price |
$2,101.00
|
| Rate for Payer: Cigna Commercial |
$3,487.66
|
| Rate for Payer: First Health Commercial |
$3,991.90
|
| Rate for Payer: Humana Commercial |
$3,571.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,445.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,101.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,260.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,697.76
|
| Rate for Payer: Ohio Health Group HMO |
$3,151.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$840.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$546.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,302.62
|
| Rate for Payer: PHCS Commercial |
$4,033.92
|
| Rate for Payer: United Healthcare All Payer |
$3,697.76
|
|
|
PLATE POST FSN 3.5MM 80MM L
|
Facility
|
IP
|
$6,852.78
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$890.86 |
| Max. Negotiated Rate |
$6,578.67 |
| Rate for Payer: Aetna Commercial |
$5,276.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,345.17
|
| Rate for Payer: Cash Price |
$3,426.39
|
| Rate for Payer: Cigna Commercial |
$5,687.81
|
| Rate for Payer: First Health Commercial |
$6,510.14
|
| Rate for Payer: Humana Commercial |
$5,824.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,619.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,057.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,055.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,030.45
|
| Rate for Payer: Ohio Health Group HMO |
$5,139.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,370.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$890.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,124.36
|
| Rate for Payer: PHCS Commercial |
$6,578.67
|
| Rate for Payer: United Healthcare All Payer |
$6,030.45
|
|
|
PLATE POST FSN 3.5MM 80MM L
|
Facility
|
OP
|
$6,852.78
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$890.86 |
| Max. Negotiated Rate |
$6,578.67 |
| Rate for Payer: Aetna Commercial |
$5,276.64
|
| Rate for Payer: Anthem Medicaid |
$2,356.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,345.17
|
| Rate for Payer: Cash Price |
$3,426.39
|
| Rate for Payer: Cigna Commercial |
$5,687.81
|
| Rate for Payer: First Health Commercial |
$6,510.14
|
| Rate for Payer: Humana Commercial |
$5,824.86
|
| Rate for Payer: Humana KY Medicaid |
$2,356.67
|
| Rate for Payer: Kentucky WC Medicaid |
$2,380.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,619.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,057.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,055.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,403.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,030.45
|
| Rate for Payer: Ohio Health Group HMO |
$5,139.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,370.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$890.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,124.36
|
| Rate for Payer: PHCS Commercial |
$6,578.67
|
| Rate for Payer: United Healthcare All Payer |
$6,030.45
|
|
|
PLATE POST FSN 3.5MM 80MM R
|
Facility
|
IP
|
$6,968.85
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$905.95 |
| Max. Negotiated Rate |
$6,690.10 |
| Rate for Payer: Aetna Commercial |
$5,366.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,435.70
|
| Rate for Payer: Cash Price |
$3,484.42
|
| Rate for Payer: Cigna Commercial |
$5,784.15
|
| Rate for Payer: First Health Commercial |
$6,620.41
|
| Rate for Payer: Humana Commercial |
$5,923.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,714.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,143.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,090.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,132.59
|
| Rate for Payer: Ohio Health Group HMO |
$5,226.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,393.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$905.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,160.34
|
| Rate for Payer: PHCS Commercial |
$6,690.10
|
| Rate for Payer: United Healthcare All Payer |
$6,132.59
|
|
|
PLATE POST FSN 3.5MM 80MM R
|
Facility
|
OP
|
$6,968.85
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$905.95 |
| Max. Negotiated Rate |
$6,690.10 |
| Rate for Payer: Aetna Commercial |
$5,366.01
|
| Rate for Payer: Anthem Medicaid |
$2,396.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,435.70
|
| Rate for Payer: Cash Price |
$3,484.42
|
| Rate for Payer: Cigna Commercial |
$5,784.15
|
| Rate for Payer: First Health Commercial |
$6,620.41
|
| Rate for Payer: Humana Commercial |
$5,923.52
|
| Rate for Payer: Humana KY Medicaid |
$2,396.59
|
| Rate for Payer: Kentucky WC Medicaid |
$2,420.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,714.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,143.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,090.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,444.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,132.59
|
| Rate for Payer: Ohio Health Group HMO |
$5,226.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,393.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$905.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,160.34
|
| Rate for Payer: PHCS Commercial |
$6,690.10
|
| Rate for Payer: United Healthcare All Payer |
$6,132.59
|
|
|
PLATE PRFL LK 3D REPL 1.7 4X2H
|
Facility
|
OP
|
$4,941.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$642.36 |
| Max. Negotiated Rate |
$4,743.55 |
| Rate for Payer: Aetna Commercial |
$3,804.72
|
| Rate for Payer: Anthem Medicaid |
$1,699.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,854.14
|
| Rate for Payer: Cash Price |
$2,470.60
|
| Rate for Payer: Cigna Commercial |
$4,101.20
|
| Rate for Payer: First Health Commercial |
$4,694.14
|
| Rate for Payer: Humana Commercial |
$4,200.02
|
| Rate for Payer: Humana KY Medicaid |
$1,699.28
|
| Rate for Payer: Kentucky WC Medicaid |
$1,716.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,051.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,646.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,482.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,733.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,348.26
|
| Rate for Payer: Ohio Health Group HMO |
$3,705.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$988.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$642.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,531.77
|
| Rate for Payer: PHCS Commercial |
$4,743.55
|
| Rate for Payer: United Healthcare All Payer |
$4,348.26
|
|
|
PLATE PRFL LK 3D REPL 1.7 4X2H
|
Facility
|
IP
|
$4,941.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$642.36 |
| Max. Negotiated Rate |
$4,743.55 |
| Rate for Payer: Aetna Commercial |
$3,804.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,854.14
|
| Rate for Payer: Cash Price |
$2,470.60
|
| Rate for Payer: Cigna Commercial |
$4,101.20
|
| Rate for Payer: First Health Commercial |
$4,694.14
|
| Rate for Payer: Humana Commercial |
$4,200.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,051.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,646.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,482.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,348.26
|
| Rate for Payer: Ohio Health Group HMO |
$3,705.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$988.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$642.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,531.77
|
| Rate for Payer: PHCS Commercial |
$4,743.55
|
| Rate for Payer: United Healthcare All Payer |
$4,348.26
|
|
|
PLATE PRIM AK FSN 3.5M 67M 3 L
|
Facility
|
IP
|
$6,852.78
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$890.86 |
| Max. Negotiated Rate |
$6,578.67 |
| Rate for Payer: Aetna Commercial |
$5,276.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,345.17
|
| Rate for Payer: Cash Price |
$3,426.39
|
| Rate for Payer: Cigna Commercial |
$5,687.81
|
| Rate for Payer: First Health Commercial |
$6,510.14
|
| Rate for Payer: Humana Commercial |
$5,824.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,619.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,057.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,055.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,030.45
|
| Rate for Payer: Ohio Health Group HMO |
$5,139.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,370.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$890.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,124.36
|
| Rate for Payer: PHCS Commercial |
$6,578.67
|
| Rate for Payer: United Healthcare All Payer |
$6,030.45
|
|
|
PLATE PRIM AK FSN 3.5M 67M 3 L
|
Facility
|
OP
|
$6,852.78
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$890.86 |
| Max. Negotiated Rate |
$6,578.67 |
| Rate for Payer: Aetna Commercial |
$5,276.64
|
| Rate for Payer: Anthem Medicaid |
$2,356.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,345.17
|
| Rate for Payer: Cash Price |
$3,426.39
|
| Rate for Payer: Cigna Commercial |
$5,687.81
|
| Rate for Payer: First Health Commercial |
$6,510.14
|
| Rate for Payer: Humana Commercial |
$5,824.86
|
| Rate for Payer: Humana KY Medicaid |
$2,356.67
|
| Rate for Payer: Kentucky WC Medicaid |
$2,380.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,619.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,057.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,055.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,403.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,030.45
|
| Rate for Payer: Ohio Health Group HMO |
$5,139.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,370.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$890.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,124.36
|
| Rate for Payer: PHCS Commercial |
$6,578.67
|
| Rate for Payer: United Healthcare All Payer |
$6,030.45
|
|
|
PLATE PRIM AK FSN 3.5M 67M 3 R
|
Facility
|
OP
|
$6,852.78
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$890.86 |
| Max. Negotiated Rate |
$6,578.67 |
| Rate for Payer: Anthem Medicaid |
$2,356.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,345.17
|
| Rate for Payer: Cash Price |
$3,426.39
|
| Rate for Payer: Cigna Commercial |
$5,687.81
|
| Rate for Payer: First Health Commercial |
$6,510.14
|
| Rate for Payer: Humana Commercial |
$5,824.86
|
| Rate for Payer: Humana KY Medicaid |
$2,356.67
|
| Rate for Payer: Kentucky WC Medicaid |
$2,380.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,619.28
|
| Rate for Payer: Aetna Commercial |
$5,276.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,057.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,055.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,403.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,030.45
|
| Rate for Payer: Ohio Health Group HMO |
$5,139.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,370.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$890.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,124.36
|
| Rate for Payer: PHCS Commercial |
$6,578.67
|
| Rate for Payer: United Healthcare All Payer |
$6,030.45
|
|
|
PLATE PRIM AK FSN 3.5M 67M 3 R
|
Facility
|
IP
|
$6,852.78
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$890.86 |
| Max. Negotiated Rate |
$6,578.67 |
| Rate for Payer: Aetna Commercial |
$5,276.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,345.17
|
| Rate for Payer: Cash Price |
$3,426.39
|
| Rate for Payer: Cigna Commercial |
$5,687.81
|
| Rate for Payer: First Health Commercial |
$6,510.14
|
| Rate for Payer: Humana Commercial |
$5,824.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,619.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,057.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,055.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,030.45
|
| Rate for Payer: Ohio Health Group HMO |
$5,139.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,370.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$890.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,124.36
|
| Rate for Payer: PHCS Commercial |
$6,578.67
|
| Rate for Payer: United Healthcare All Payer |
$6,030.45
|
|
|
PLATE PRIM AK FSN 3.5M 92M 5 R
|
Facility
|
OP
|
$6,968.85
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$905.95 |
| Max. Negotiated Rate |
$6,690.10 |
| Rate for Payer: Aetna Commercial |
$5,366.01
|
| Rate for Payer: Anthem Medicaid |
$2,396.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,435.70
|
| Rate for Payer: Cash Price |
$3,484.42
|
| Rate for Payer: Cigna Commercial |
$5,784.15
|
| Rate for Payer: First Health Commercial |
$6,620.41
|
| Rate for Payer: Humana Commercial |
$5,923.52
|
| Rate for Payer: Humana KY Medicaid |
$2,396.59
|
| Rate for Payer: Kentucky WC Medicaid |
$2,420.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,714.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,143.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,090.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,444.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,132.59
|
| Rate for Payer: Ohio Health Group HMO |
$5,226.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,393.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$905.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,160.34
|
| Rate for Payer: PHCS Commercial |
$6,690.10
|
| Rate for Payer: United Healthcare All Payer |
$6,132.59
|
|
|
PLATE PRIM AK FSN 3.5M 92M 5 R
|
Facility
|
IP
|
$6,968.85
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$905.95 |
| Max. Negotiated Rate |
$6,690.10 |
| Rate for Payer: Aetna Commercial |
$5,366.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,435.70
|
| Rate for Payer: Cash Price |
$3,484.42
|
| Rate for Payer: Cigna Commercial |
$5,784.15
|
| Rate for Payer: First Health Commercial |
$6,620.41
|
| Rate for Payer: Humana Commercial |
$5,923.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,714.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,143.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,090.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,132.59
|
| Rate for Payer: Ohio Health Group HMO |
$5,226.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,393.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$905.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,160.34
|
| Rate for Payer: PHCS Commercial |
$6,690.10
|
| Rate for Payer: United Healthcare All Payer |
$6,132.59
|
|
|
PLATE PRIMARY RECON 11H
|
Facility
|
IP
|
$4,120.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$535.63 |
| Max. Negotiated Rate |
$3,955.39 |
| Rate for Payer: Aetna Commercial |
$3,172.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,213.76
|
| Rate for Payer: Cash Price |
$2,060.10
|
| Rate for Payer: Cigna Commercial |
$3,419.77
|
| Rate for Payer: First Health Commercial |
$3,914.19
|
| Rate for Payer: Humana Commercial |
$3,502.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,378.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,040.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,236.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,625.78
|
| Rate for Payer: Ohio Health Group HMO |
$3,090.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$824.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$535.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,277.26
|
| Rate for Payer: PHCS Commercial |
$3,955.39
|
| Rate for Payer: United Healthcare All Payer |
$3,625.78
|
|
|
PLATE PRIMARY RECON 11H
|
Facility
|
OP
|
$4,120.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$535.63 |
| Max. Negotiated Rate |
$3,955.39 |
| Rate for Payer: Aetna Commercial |
$3,172.55
|
| Rate for Payer: Anthem Medicaid |
$1,416.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,213.76
|
| Rate for Payer: Cash Price |
$2,060.10
|
| Rate for Payer: Cigna Commercial |
$3,419.77
|
| Rate for Payer: First Health Commercial |
$3,914.19
|
| Rate for Payer: Humana Commercial |
$3,502.17
|
| Rate for Payer: Humana KY Medicaid |
$1,416.94
|
| Rate for Payer: Kentucky WC Medicaid |
$1,431.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,378.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,040.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,236.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,445.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,625.78
|
| Rate for Payer: Ohio Health Group HMO |
$3,090.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$824.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$535.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,277.26
|
| Rate for Payer: PHCS Commercial |
$3,955.39
|
| Rate for Payer: United Healthcare All Payer |
$3,625.78
|
|
|
PLATE PRIMARY RECON 17H
|
Facility
|
OP
|
$4,468.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$580.84 |
| Max. Negotiated Rate |
$4,289.28 |
| Rate for Payer: Aetna Commercial |
$3,440.36
|
| Rate for Payer: Anthem Medicaid |
$1,536.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,485.04
|
| Rate for Payer: Cash Price |
$2,234.00
|
| Rate for Payer: Cigna Commercial |
$3,708.44
|
| Rate for Payer: First Health Commercial |
$4,244.60
|
| Rate for Payer: Humana Commercial |
$3,797.80
|
| Rate for Payer: Humana KY Medicaid |
$1,536.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1,552.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,663.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,297.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,340.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,567.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,931.84
|
| Rate for Payer: Ohio Health Group HMO |
$3,351.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$893.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$580.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,385.08
|
| Rate for Payer: PHCS Commercial |
$4,289.28
|
| Rate for Payer: United Healthcare All Payer |
$3,931.84
|
|
|
PLATE PRIMARY RECON 17H
|
Facility
|
IP
|
$4,468.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$580.84 |
| Max. Negotiated Rate |
$4,289.28 |
| Rate for Payer: Aetna Commercial |
$3,440.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,485.04
|
| Rate for Payer: Cash Price |
$2,234.00
|
| Rate for Payer: Cigna Commercial |
$3,708.44
|
| Rate for Payer: First Health Commercial |
$4,244.60
|
| Rate for Payer: Humana Commercial |
$3,797.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,663.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,297.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,340.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,931.84
|
| Rate for Payer: Ohio Health Group HMO |
$3,351.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$893.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$580.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,385.08
|
| Rate for Payer: PHCS Commercial |
$4,289.28
|
| Rate for Payer: United Healthcare All Payer |
$3,931.84
|
|
|
PLATE PRIM MTP 2.7MM LT
|
Facility
|
OP
|
$5,103.08
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$663.40 |
| Max. Negotiated Rate |
$4,898.96 |
| Rate for Payer: Aetna Commercial |
$3,929.37
|
| Rate for Payer: Anthem Medicaid |
$1,754.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,980.40
|
| Rate for Payer: Cash Price |
$2,551.54
|
| Rate for Payer: Cigna Commercial |
$4,235.56
|
| Rate for Payer: First Health Commercial |
$4,847.93
|
| Rate for Payer: Humana Commercial |
$4,337.62
|
| Rate for Payer: Humana KY Medicaid |
$1,754.95
|
| Rate for Payer: Kentucky WC Medicaid |
$1,772.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,184.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,766.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,530.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,790.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,490.71
|
| Rate for Payer: Ohio Health Group HMO |
$3,827.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,020.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$663.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,581.95
|
| Rate for Payer: PHCS Commercial |
$4,898.96
|
| Rate for Payer: United Healthcare All Payer |
$4,490.71
|
|
|
PLATE PRIM MTP 2.7MM LT
|
Facility
|
IP
|
$5,103.08
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$663.40 |
| Max. Negotiated Rate |
$4,898.96 |
| Rate for Payer: Aetna Commercial |
$3,929.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,980.40
|
| Rate for Payer: Cash Price |
$2,551.54
|
| Rate for Payer: Cigna Commercial |
$4,235.56
|
| Rate for Payer: First Health Commercial |
$4,847.93
|
| Rate for Payer: Humana Commercial |
$4,337.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,184.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,766.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,530.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,490.71
|
| Rate for Payer: Ohio Health Group HMO |
$3,827.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,020.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$663.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,581.95
|
| Rate for Payer: PHCS Commercial |
$4,898.96
|
| Rate for Payer: United Healthcare All Payer |
$4,490.71
|
|
|
PLATE PRIM MTP 2.7MM RT
|
Facility
|
OP
|
$5,103.08
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$663.40 |
| Max. Negotiated Rate |
$4,898.96 |
| Rate for Payer: Anthem Medicaid |
$1,754.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,980.40
|
| Rate for Payer: Cash Price |
$2,551.54
|
| Rate for Payer: Cigna Commercial |
$4,235.56
|
| Rate for Payer: First Health Commercial |
$4,847.93
|
| Rate for Payer: Humana Commercial |
$4,337.62
|
| Rate for Payer: Humana KY Medicaid |
$1,754.95
|
| Rate for Payer: Kentucky WC Medicaid |
$1,772.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,184.53
|
| Rate for Payer: Aetna Commercial |
$3,929.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,766.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,530.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,790.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,490.71
|
| Rate for Payer: Ohio Health Group HMO |
$3,827.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,020.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$663.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,581.95
|
| Rate for Payer: PHCS Commercial |
$4,898.96
|
| Rate for Payer: United Healthcare All Payer |
$4,490.71
|
|
|
PLATE PRIM MTP 2.7MM RT
|
Facility
|
IP
|
$5,103.08
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$663.40 |
| Max. Negotiated Rate |
$4,898.96 |
| Rate for Payer: Aetna Commercial |
$3,929.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,980.40
|
| Rate for Payer: Cash Price |
$2,551.54
|
| Rate for Payer: Cigna Commercial |
$4,235.56
|
| Rate for Payer: First Health Commercial |
$4,847.93
|
| Rate for Payer: Humana Commercial |
$4,337.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,184.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,766.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,530.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,490.71
|
| Rate for Payer: Ohio Health Group HMO |
$3,827.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,020.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$663.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,581.95
|
| Rate for Payer: PHCS Commercial |
$4,898.96
|
| Rate for Payer: United Healthcare All Payer |
$4,490.71
|
|
|
PLATE PROFL LCK 2.3 3D 2X2+2H
|
Facility
|
OP
|
$4,941.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$642.36 |
| Max. Negotiated Rate |
$4,743.55 |
| Rate for Payer: Aetna Commercial |
$3,804.72
|
| Rate for Payer: Anthem Medicaid |
$1,699.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,854.14
|
| Rate for Payer: Cash Price |
$2,470.60
|
| Rate for Payer: Cigna Commercial |
$4,101.20
|
| Rate for Payer: First Health Commercial |
$4,694.14
|
| Rate for Payer: Humana Commercial |
$4,200.02
|
| Rate for Payer: Humana KY Medicaid |
$1,699.28
|
| Rate for Payer: Kentucky WC Medicaid |
$1,716.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,051.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,646.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,482.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,733.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,348.26
|
| Rate for Payer: Ohio Health Group HMO |
$3,705.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$988.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$642.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,531.77
|
| Rate for Payer: PHCS Commercial |
$4,743.55
|
| Rate for Payer: United Healthcare All Payer |
$4,348.26
|
|
|
PLATE PROFL LCK 2.3 3D 2X2+2H
|
Facility
|
IP
|
$4,941.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$642.36 |
| Max. Negotiated Rate |
$4,743.55 |
| Rate for Payer: Aetna Commercial |
$3,804.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,854.14
|
| Rate for Payer: Cash Price |
$2,470.60
|
| Rate for Payer: Cigna Commercial |
$4,101.20
|
| Rate for Payer: First Health Commercial |
$4,694.14
|
| Rate for Payer: Humana Commercial |
$4,200.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,051.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,646.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,482.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,348.26
|
| Rate for Payer: Ohio Health Group HMO |
$3,705.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$988.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$642.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,531.77
|
| Rate for Payer: PHCS Commercial |
$4,743.55
|
| Rate for Payer: United Healthcare All Payer |
$4,348.26
|
|
|
PLATE PROFL LCK 2.3 STR BAR 4H
|
Facility
|
OP
|
$3,746.34
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$487.02 |
| Max. Negotiated Rate |
$3,596.49 |
| Rate for Payer: Aetna Commercial |
$2,884.68
|
| Rate for Payer: Anthem Medicaid |
$1,288.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,922.15
|
| Rate for Payer: Cash Price |
$1,873.17
|
| Rate for Payer: Cigna Commercial |
$3,109.46
|
| Rate for Payer: First Health Commercial |
$3,559.02
|
| Rate for Payer: Humana Commercial |
$3,184.39
|
| Rate for Payer: Humana KY Medicaid |
$1,288.37
|
| Rate for Payer: Kentucky WC Medicaid |
$1,301.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,072.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,764.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,123.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,314.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,296.78
|
| Rate for Payer: Ohio Health Group HMO |
$2,809.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$749.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$487.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,161.37
|
| Rate for Payer: PHCS Commercial |
$3,596.49
|
| Rate for Payer: United Healthcare All Payer |
$3,296.78
|
|
