|
PLATE L PROFYLE L COMP RI 6H
|
Facility
|
OP
|
$3,890.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,167.00 |
| Max. Negotiated Rate |
$3,734.40 |
| Rate for Payer: Aetna Commercial |
$2,995.30
|
| Rate for Payer: Anthem Medicaid |
$1,337.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,034.20
|
| Rate for Payer: Cash Price |
$1,945.00
|
| Rate for Payer: Cigna Commercial |
$3,228.70
|
| Rate for Payer: First Health Commercial |
$3,695.50
|
| Rate for Payer: Humana Commercial |
$3,306.50
|
| Rate for Payer: Humana KY Medicaid |
$1,337.77
|
| Rate for Payer: Kentucky WC Medicaid |
$1,351.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,189.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,870.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,167.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,364.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,423.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,917.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,112.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,384.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,684.10
|
| Rate for Payer: PHCS Commercial |
$3,734.40
|
| Rate for Payer: United Healthcare All Payer |
$3,423.20
|
|
|
PLATE L PROFYLE L COMP RI 6H
|
Facility
|
IP
|
$3,890.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,167.00 |
| Max. Negotiated Rate |
$3,734.40 |
| Rate for Payer: Aetna Commercial |
$2,995.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,034.20
|
| Rate for Payer: Cash Price |
$1,945.00
|
| Rate for Payer: Cigna Commercial |
$3,228.70
|
| Rate for Payer: First Health Commercial |
$3,695.50
|
| Rate for Payer: Humana Commercial |
$3,306.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,189.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,870.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,167.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,423.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,917.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,112.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,384.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,684.10
|
| Rate for Payer: PHCS Commercial |
$3,734.40
|
| Rate for Payer: United Healthcare All Payer |
$3,423.20
|
|
|
PLATE L PROFYLE LOCK 2.3 LE 6H
|
Facility
|
IP
|
$3,125.56
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.67 |
| Max. Negotiated Rate |
$3,000.54 |
| Rate for Payer: Aetna Commercial |
$2,406.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,437.94
|
| Rate for Payer: Cash Price |
$1,562.78
|
| Rate for Payer: Cigna Commercial |
$2,594.21
|
| Rate for Payer: First Health Commercial |
$2,969.28
|
| Rate for Payer: Humana Commercial |
$2,656.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,562.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,306.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$937.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,750.49
|
| Rate for Payer: Ohio Health Group HMO |
$2,344.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,500.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,719.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,156.64
|
| Rate for Payer: PHCS Commercial |
$3,000.54
|
| Rate for Payer: United Healthcare All Payer |
$2,750.49
|
|
|
PLATE L PROFYLE LOCK 2.3 LE 6H
|
Facility
|
OP
|
$3,125.56
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.67 |
| Max. Negotiated Rate |
$3,000.54 |
| Rate for Payer: Aetna Commercial |
$2,406.68
|
| Rate for Payer: Anthem Medicaid |
$1,074.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,437.94
|
| Rate for Payer: Cash Price |
$1,562.78
|
| Rate for Payer: Cigna Commercial |
$2,594.21
|
| Rate for Payer: First Health Commercial |
$2,969.28
|
| Rate for Payer: Humana Commercial |
$2,656.73
|
| Rate for Payer: Humana KY Medicaid |
$1,074.88
|
| Rate for Payer: Kentucky WC Medicaid |
$1,085.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,562.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,306.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$937.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,096.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,750.49
|
| Rate for Payer: Ohio Health Group HMO |
$2,344.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,500.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,719.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,156.64
|
| Rate for Payer: PHCS Commercial |
$3,000.54
|
| Rate for Payer: United Healthcare All Payer |
$2,750.49
|
|
|
PLATE L PROFYLE LOCK 2.3 RI 6H
|
Facility
|
IP
|
$3,822.84
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,146.85 |
| Max. Negotiated Rate |
$3,669.93 |
| Rate for Payer: Aetna Commercial |
$2,943.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,981.82
|
| Rate for Payer: Cash Price |
$1,911.42
|
| Rate for Payer: Cigna Commercial |
$3,172.96
|
| Rate for Payer: First Health Commercial |
$3,631.70
|
| Rate for Payer: Humana Commercial |
$3,249.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,134.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,821.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,146.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,364.10
|
| Rate for Payer: Ohio Health Group HMO |
$2,867.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,058.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,325.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,637.76
|
| Rate for Payer: PHCS Commercial |
$3,669.93
|
| Rate for Payer: United Healthcare All Payer |
$3,364.10
|
|
|
PLATE L PROFYLE LOCK 2.3 RI 6H
|
Facility
|
OP
|
$3,822.84
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,146.85 |
| Max. Negotiated Rate |
$3,669.93 |
| Rate for Payer: Aetna Commercial |
$2,943.59
|
| Rate for Payer: Anthem Medicaid |
$1,314.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,981.82
|
| Rate for Payer: Cash Price |
$1,911.42
|
| Rate for Payer: Cigna Commercial |
$3,172.96
|
| Rate for Payer: First Health Commercial |
$3,631.70
|
| Rate for Payer: Humana Commercial |
$3,249.41
|
| Rate for Payer: Humana KY Medicaid |
$1,314.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1,328.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,134.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,821.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,146.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,341.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,364.10
|
| Rate for Payer: Ohio Health Group HMO |
$2,867.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,058.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,325.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,637.76
|
| Rate for Payer: PHCS Commercial |
$3,669.93
|
| Rate for Payer: United Healthcare All Payer |
$3,364.10
|
|
|
PLATE L PROFYLE LOCK LE 1.7 6H
|
Facility
|
IP
|
$4,175.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,252.50 |
| Max. Negotiated Rate |
$4,008.00 |
| Rate for Payer: Aetna Commercial |
$3,214.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,256.50
|
| Rate for Payer: Cash Price |
$2,087.50
|
| Rate for Payer: Cigna Commercial |
$3,465.25
|
| Rate for Payer: First Health Commercial |
$3,966.25
|
| Rate for Payer: Humana Commercial |
$3,548.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,423.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,081.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,252.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,674.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,131.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,340.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,632.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,880.75
|
| Rate for Payer: PHCS Commercial |
$4,008.00
|
| Rate for Payer: United Healthcare All Payer |
$3,674.00
|
|
|
PLATE L PROFYLE LOCK LE 1.7 6H
|
Facility
|
OP
|
$4,175.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,252.50 |
| Max. Negotiated Rate |
$4,008.00 |
| Rate for Payer: Aetna Commercial |
$3,214.75
|
| Rate for Payer: Anthem Medicaid |
$1,435.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,256.50
|
| Rate for Payer: Cash Price |
$2,087.50
|
| Rate for Payer: Cigna Commercial |
$3,465.25
|
| Rate for Payer: First Health Commercial |
$3,966.25
|
| Rate for Payer: Humana Commercial |
$3,548.75
|
| Rate for Payer: Humana KY Medicaid |
$1,435.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1,450.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,423.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,081.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,252.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,464.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,674.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,131.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,340.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,632.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,880.75
|
| Rate for Payer: PHCS Commercial |
$4,008.00
|
| Rate for Payer: United Healthcare All Payer |
$3,674.00
|
|
|
PLATE L PROFYLE M COMP LE 6H
|
Facility
|
IP
|
$3,890.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,167.00 |
| Max. Negotiated Rate |
$3,734.40 |
| Rate for Payer: Aetna Commercial |
$2,995.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,034.20
|
| Rate for Payer: Cash Price |
$1,945.00
|
| Rate for Payer: Cigna Commercial |
$3,228.70
|
| Rate for Payer: First Health Commercial |
$3,695.50
|
| Rate for Payer: Humana Commercial |
$3,306.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,189.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,870.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,167.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,423.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,917.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,112.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,384.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,684.10
|
| Rate for Payer: PHCS Commercial |
$3,734.40
|
| Rate for Payer: United Healthcare All Payer |
$3,423.20
|
|
|
PLATE L PROFYLE M COMP LE 6H
|
Facility
|
OP
|
$3,890.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,167.00 |
| Max. Negotiated Rate |
$3,734.40 |
| Rate for Payer: Aetna Commercial |
$2,995.30
|
| Rate for Payer: Anthem Medicaid |
$1,337.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,034.20
|
| Rate for Payer: Cash Price |
$1,945.00
|
| Rate for Payer: Cigna Commercial |
$3,228.70
|
| Rate for Payer: First Health Commercial |
$3,695.50
|
| Rate for Payer: Humana Commercial |
$3,306.50
|
| Rate for Payer: Humana KY Medicaid |
$1,337.77
|
| Rate for Payer: Kentucky WC Medicaid |
$1,351.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,189.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,870.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,167.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,364.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,423.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,917.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,112.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,384.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,684.10
|
| Rate for Payer: PHCS Commercial |
$3,734.40
|
| Rate for Payer: United Healthcare All Payer |
$3,423.20
|
|
|
PLATE L PROFYLE M COMP RI 6H
|
Facility
|
IP
|
$3,890.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,167.00 |
| Max. Negotiated Rate |
$3,734.40 |
| Rate for Payer: Aetna Commercial |
$2,995.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,034.20
|
| Rate for Payer: Cash Price |
$1,945.00
|
| Rate for Payer: Cigna Commercial |
$3,228.70
|
| Rate for Payer: First Health Commercial |
$3,695.50
|
| Rate for Payer: Humana Commercial |
$3,306.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,189.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,870.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,167.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,423.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,917.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,112.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,384.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,684.10
|
| Rate for Payer: PHCS Commercial |
$3,734.40
|
| Rate for Payer: United Healthcare All Payer |
$3,423.20
|
|
|
PLATE L PROFYLE M COMP RI 6H
|
Facility
|
OP
|
$3,890.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,167.00 |
| Max. Negotiated Rate |
$3,734.40 |
| Rate for Payer: Aetna Commercial |
$2,995.30
|
| Rate for Payer: Anthem Medicaid |
$1,337.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,034.20
|
| Rate for Payer: Cash Price |
$1,945.00
|
| Rate for Payer: Cigna Commercial |
$3,228.70
|
| Rate for Payer: First Health Commercial |
$3,695.50
|
| Rate for Payer: Humana Commercial |
$3,306.50
|
| Rate for Payer: Humana KY Medicaid |
$1,337.77
|
| Rate for Payer: Kentucky WC Medicaid |
$1,351.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,189.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,870.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,167.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,364.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,423.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,917.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,112.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,384.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,684.10
|
| Rate for Payer: PHCS Commercial |
$3,734.40
|
| Rate for Payer: United Healthcare All Payer |
$3,423.20
|
|
|
PLATE LP TB LK 3.5M 10H 149M L
|
Facility
|
IP
|
$8,847.67
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,654.30 |
| Max. Negotiated Rate |
$8,493.76 |
| Rate for Payer: Aetna Commercial |
$6,812.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,901.18
|
| Rate for Payer: Cash Price |
$4,423.83
|
| Rate for Payer: Cigna Commercial |
$7,343.57
|
| Rate for Payer: First Health Commercial |
$8,405.29
|
| Rate for Payer: Humana Commercial |
$7,520.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,255.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,529.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,654.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,785.95
|
| Rate for Payer: Ohio Health Group HMO |
$6,635.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,078.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,697.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,104.89
|
| Rate for Payer: PHCS Commercial |
$8,493.76
|
| Rate for Payer: United Healthcare All Payer |
$7,785.95
|
|
|
PLATE LP TB LK 3.5M 10H 149M L
|
Facility
|
OP
|
$8,847.67
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,654.30 |
| Max. Negotiated Rate |
$8,493.76 |
| Rate for Payer: Aetna Commercial |
$6,812.71
|
| Rate for Payer: Anthem Medicaid |
$3,042.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,901.18
|
| Rate for Payer: Cash Price |
$4,423.83
|
| Rate for Payer: Cigna Commercial |
$7,343.57
|
| Rate for Payer: First Health Commercial |
$8,405.29
|
| Rate for Payer: Humana Commercial |
$7,520.52
|
| Rate for Payer: Humana KY Medicaid |
$3,042.71
|
| Rate for Payer: Kentucky WC Medicaid |
$3,073.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,255.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,529.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,654.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,103.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,785.95
|
| Rate for Payer: Ohio Health Group HMO |
$6,635.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,078.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,697.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,104.89
|
| Rate for Payer: PHCS Commercial |
$8,493.76
|
| Rate for Payer: United Healthcare All Payer |
$7,785.95
|
|
|
PLATE LP TB LK 3.5M 10H 149M R
|
Facility
|
OP
|
$8,786.89
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,636.07 |
| Max. Negotiated Rate |
$8,435.41 |
| Rate for Payer: Aetna Commercial |
$6,765.91
|
| Rate for Payer: Anthem Medicaid |
$3,021.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,853.77
|
| Rate for Payer: Cash Price |
$4,393.45
|
| Rate for Payer: Cigna Commercial |
$7,293.12
|
| Rate for Payer: First Health Commercial |
$8,347.55
|
| Rate for Payer: Humana Commercial |
$7,468.86
|
| Rate for Payer: Humana KY Medicaid |
$3,021.81
|
| Rate for Payer: Kentucky WC Medicaid |
$3,052.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,205.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,484.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,636.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,082.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,732.46
|
| Rate for Payer: Ohio Health Group HMO |
$6,590.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,029.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,644.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,062.95
|
| Rate for Payer: PHCS Commercial |
$8,435.41
|
| Rate for Payer: United Healthcare All Payer |
$7,732.46
|
|
|
PLATE LP TB LK 3.5M 10H 149M R
|
Facility
|
IP
|
$8,786.89
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,636.07 |
| Max. Negotiated Rate |
$8,435.41 |
| Rate for Payer: Aetna Commercial |
$6,765.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,853.77
|
| Rate for Payer: Cash Price |
$4,393.45
|
| Rate for Payer: Cigna Commercial |
$7,293.12
|
| Rate for Payer: First Health Commercial |
$8,347.55
|
| Rate for Payer: Humana Commercial |
$7,468.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,205.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,484.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,636.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,732.46
|
| Rate for Payer: Ohio Health Group HMO |
$6,590.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,029.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,644.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,062.95
|
| Rate for Payer: PHCS Commercial |
$8,435.41
|
| Rate for Payer: United Healthcare All Payer |
$7,732.46
|
|
|
PLATE LP TB LK 3.5M 13H 187M R
|
Facility
|
IP
|
$8,942.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,682.66 |
| Max. Negotiated Rate |
$8,584.51 |
| Rate for Payer: Aetna Commercial |
$6,885.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,974.92
|
| Rate for Payer: Cash Price |
$4,471.10
|
| Rate for Payer: Cigna Commercial |
$7,422.03
|
| Rate for Payer: First Health Commercial |
$8,495.09
|
| Rate for Payer: Humana Commercial |
$7,600.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,332.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,599.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,682.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,869.14
|
| Rate for Payer: Ohio Health Group HMO |
$6,706.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,153.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,779.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,170.12
|
| Rate for Payer: PHCS Commercial |
$8,584.51
|
| Rate for Payer: United Healthcare All Payer |
$7,869.14
|
|
|
PLATE LP TB LK 3.5M 13H 187M R
|
Facility
|
OP
|
$8,942.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,682.66 |
| Max. Negotiated Rate |
$8,584.51 |
| Rate for Payer: Aetna Commercial |
$6,885.49
|
| Rate for Payer: Anthem Medicaid |
$3,075.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,974.92
|
| Rate for Payer: Cash Price |
$4,471.10
|
| Rate for Payer: Cigna Commercial |
$7,422.03
|
| Rate for Payer: First Health Commercial |
$8,495.09
|
| Rate for Payer: Humana Commercial |
$7,600.87
|
| Rate for Payer: Humana KY Medicaid |
$3,075.22
|
| Rate for Payer: Kentucky WC Medicaid |
$3,106.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,332.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,599.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,682.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,136.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,869.14
|
| Rate for Payer: Ohio Health Group HMO |
$6,706.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,153.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,779.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,170.12
|
| Rate for Payer: PHCS Commercial |
$8,584.51
|
| Rate for Payer: United Healthcare All Payer |
$7,869.14
|
|
|
PLATE LP TB LK 3.5M 8H 123M L
|
Facility
|
OP
|
$8,786.89
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,636.07 |
| Max. Negotiated Rate |
$8,435.41 |
| Rate for Payer: Aetna Commercial |
$6,765.91
|
| Rate for Payer: Anthem Medicaid |
$3,021.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,853.77
|
| Rate for Payer: Cash Price |
$4,393.45
|
| Rate for Payer: Cigna Commercial |
$7,293.12
|
| Rate for Payer: First Health Commercial |
$8,347.55
|
| Rate for Payer: Humana Commercial |
$7,468.86
|
| Rate for Payer: Humana KY Medicaid |
$3,021.81
|
| Rate for Payer: Kentucky WC Medicaid |
$3,052.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,205.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,484.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,636.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,082.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,732.46
|
| Rate for Payer: Ohio Health Group HMO |
$6,590.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,029.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,644.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,062.95
|
| Rate for Payer: PHCS Commercial |
$8,435.41
|
| Rate for Payer: United Healthcare All Payer |
$7,732.46
|
|
|
PLATE LP TB LK 3.5M 8H 123M L
|
Facility
|
IP
|
$8,786.89
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,636.07 |
| Max. Negotiated Rate |
$8,435.41 |
| Rate for Payer: Aetna Commercial |
$6,765.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,853.77
|
| Rate for Payer: Cash Price |
$4,393.45
|
| Rate for Payer: Cigna Commercial |
$7,293.12
|
| Rate for Payer: First Health Commercial |
$8,347.55
|
| Rate for Payer: Humana Commercial |
$7,468.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,205.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,484.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,636.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,732.46
|
| Rate for Payer: Ohio Health Group HMO |
$6,590.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,029.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,644.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,062.95
|
| Rate for Payer: PHCS Commercial |
$8,435.41
|
| Rate for Payer: United Healthcare All Payer |
$7,732.46
|
|
|
PLATE LP TB LK 4.5M 10H 201M L
|
Facility
|
IP
|
$7,983.34
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,395.00 |
| Max. Negotiated Rate |
$7,664.01 |
| Rate for Payer: Aetna Commercial |
$6,147.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,227.01
|
| Rate for Payer: Cash Price |
$3,991.67
|
| Rate for Payer: Cigna Commercial |
$6,626.17
|
| Rate for Payer: First Health Commercial |
$7,584.17
|
| Rate for Payer: Humana Commercial |
$6,785.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,395.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.34
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,386.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,945.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,508.50
|
| Rate for Payer: PHCS Commercial |
$7,664.01
|
| Rate for Payer: United Healthcare All Payer |
$7,025.34
|
|
|
PLATE LP TB LK 4.5M 10H 201M L
|
Facility
|
OP
|
$7,983.34
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,395.00 |
| Max. Negotiated Rate |
$7,664.01 |
| Rate for Payer: Aetna Commercial |
$6,147.17
|
| Rate for Payer: Anthem Medicaid |
$2,745.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,227.01
|
| Rate for Payer: Cash Price |
$3,991.67
|
| Rate for Payer: Cigna Commercial |
$6,626.17
|
| Rate for Payer: First Health Commercial |
$7,584.17
|
| Rate for Payer: Humana Commercial |
$6,785.84
|
| Rate for Payer: Humana KY Medicaid |
$2,745.47
|
| Rate for Payer: Kentucky WC Medicaid |
$2,773.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,395.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,800.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.34
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,386.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,945.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,508.50
|
| Rate for Payer: PHCS Commercial |
$7,664.01
|
| Rate for Payer: United Healthcare All Payer |
$7,025.34
|
|
|
PLATE LP TB LK 4.5M 13H 255M L
|
Facility
|
IP
|
$8,931.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,679.38 |
| Max. Negotiated Rate |
$8,574.00 |
| Rate for Payer: Aetna Commercial |
$6,877.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,966.38
|
| Rate for Payer: Cash Price |
$4,465.62
|
| Rate for Payer: Cigna Commercial |
$7,412.94
|
| Rate for Payer: First Health Commercial |
$8,484.69
|
| Rate for Payer: Humana Commercial |
$7,591.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,323.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,591.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,679.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,859.50
|
| Rate for Payer: Ohio Health Group HMO |
$6,698.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,145.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,770.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,162.56
|
| Rate for Payer: PHCS Commercial |
$8,574.00
|
| Rate for Payer: United Healthcare All Payer |
$7,859.50
|
|
|
PLATE LP TB LK 4.5M 13H 255M L
|
Facility
|
OP
|
$8,931.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,679.38 |
| Max. Negotiated Rate |
$8,574.00 |
| Rate for Payer: Aetna Commercial |
$6,877.06
|
| Rate for Payer: Anthem Medicaid |
$3,071.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,966.38
|
| Rate for Payer: Cash Price |
$4,465.62
|
| Rate for Payer: Cigna Commercial |
$7,412.94
|
| Rate for Payer: First Health Commercial |
$8,484.69
|
| Rate for Payer: Humana Commercial |
$7,591.56
|
| Rate for Payer: Humana KY Medicaid |
$3,071.46
|
| Rate for Payer: Kentucky WC Medicaid |
$3,102.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,323.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,591.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,679.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,133.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,859.50
|
| Rate for Payer: Ohio Health Group HMO |
$6,698.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,145.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,770.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,162.56
|
| Rate for Payer: PHCS Commercial |
$8,574.00
|
| Rate for Payer: United Healthcare All Payer |
$7,859.50
|
|
|
PLATE LP TB LK 4.5M 16H 309M L
|
Facility
|
OP
|
$9,009.73
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,702.92 |
| Max. Negotiated Rate |
$8,649.34 |
| Rate for Payer: Aetna Commercial |
$6,937.49
|
| Rate for Payer: Anthem Medicaid |
$3,098.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,027.59
|
| Rate for Payer: Cash Price |
$4,504.86
|
| Rate for Payer: Cigna Commercial |
$7,478.08
|
| Rate for Payer: First Health Commercial |
$8,559.24
|
| Rate for Payer: Humana Commercial |
$7,658.27
|
| Rate for Payer: Humana KY Medicaid |
$3,098.45
|
| Rate for Payer: Kentucky WC Medicaid |
$3,129.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,387.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,649.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,702.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,160.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,928.56
|
| Rate for Payer: Ohio Health Group HMO |
$6,757.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,207.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,838.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,216.71
|
| Rate for Payer: PHCS Commercial |
$8,649.34
|
| Rate for Payer: United Healthcare All Payer |
$7,928.56
|
|
