|
PLATE PROFYL COMP T 2.3 6H 90^
|
Facility
|
OP
|
$1,791.23
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$537.37 |
| Max. Negotiated Rate |
$1,719.58 |
| Rate for Payer: Aetna Commercial |
$1,379.25
|
| Rate for Payer: Anthem Medicaid |
$616.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,397.16
|
| Rate for Payer: Cash Price |
$895.61
|
| Rate for Payer: Cigna Commercial |
$1,486.72
|
| Rate for Payer: First Health Commercial |
$1,701.67
|
| Rate for Payer: Humana Commercial |
$1,522.55
|
| Rate for Payer: Humana KY Medicaid |
$616.00
|
| Rate for Payer: Kentucky WC Medicaid |
$622.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,468.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,321.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$537.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$628.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,576.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,343.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,432.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,558.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,235.95
|
| Rate for Payer: PHCS Commercial |
$1,719.58
|
| Rate for Payer: United Healthcare All Payer |
$1,576.28
|
|
|
PLATE PROFYL COMP T 2.3 6H 90^
|
Facility
|
IP
|
$1,791.23
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$537.37 |
| Max. Negotiated Rate |
$1,719.58 |
| Rate for Payer: Aetna Commercial |
$1,379.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,397.16
|
| Rate for Payer: Cash Price |
$895.61
|
| Rate for Payer: Cigna Commercial |
$1,486.72
|
| Rate for Payer: First Health Commercial |
$1,701.67
|
| Rate for Payer: Humana Commercial |
$1,522.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,468.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,321.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$537.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,576.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,343.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,432.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,558.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,235.95
|
| Rate for Payer: PHCS Commercial |
$1,719.58
|
| Rate for Payer: United Healthcare All Payer |
$1,576.28
|
|
|
PLATE PROFYL COMP T 2.3 7H 90^
|
Facility
|
IP
|
$1,791.23
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$537.37 |
| Max. Negotiated Rate |
$1,719.58 |
| Rate for Payer: Aetna Commercial |
$1,379.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,397.16
|
| Rate for Payer: Cash Price |
$895.61
|
| Rate for Payer: Cigna Commercial |
$1,486.72
|
| Rate for Payer: First Health Commercial |
$1,701.67
|
| Rate for Payer: Humana Commercial |
$1,522.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,468.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,321.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$537.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,576.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,343.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,432.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,558.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,235.95
|
| Rate for Payer: PHCS Commercial |
$1,719.58
|
| Rate for Payer: United Healthcare All Payer |
$1,576.28
|
|
|
PLATE PROFYL COMP T 2.3 7H 90^
|
Facility
|
OP
|
$1,791.23
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$537.37 |
| Max. Negotiated Rate |
$1,719.58 |
| Rate for Payer: Aetna Commercial |
$1,379.25
|
| Rate for Payer: Anthem Medicaid |
$616.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,397.16
|
| Rate for Payer: Cash Price |
$895.61
|
| Rate for Payer: Cigna Commercial |
$1,486.72
|
| Rate for Payer: First Health Commercial |
$1,701.67
|
| Rate for Payer: Humana Commercial |
$1,522.55
|
| Rate for Payer: Humana KY Medicaid |
$616.00
|
| Rate for Payer: Kentucky WC Medicaid |
$622.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,468.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,321.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$537.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$628.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,576.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,343.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,432.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,558.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,235.95
|
| Rate for Payer: PHCS Commercial |
$1,719.58
|
| Rate for Payer: United Healthcare All Payer |
$1,576.28
|
|
|
PLATE PROFYLE 1.2 3D 2*2+2H
|
Facility
|
IP
|
$3,590.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,077.00 |
| Max. Negotiated Rate |
$3,446.40 |
| Rate for Payer: Aetna Commercial |
$2,764.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,800.20
|
| Rate for Payer: Cash Price |
$1,795.00
|
| Rate for Payer: Cigna Commercial |
$2,979.70
|
| Rate for Payer: First Health Commercial |
$3,410.50
|
| Rate for Payer: Humana Commercial |
$3,051.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,943.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,649.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,077.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,159.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,692.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,872.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,123.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,477.10
|
| Rate for Payer: PHCS Commercial |
$3,446.40
|
| Rate for Payer: United Healthcare All Payer |
$3,159.20
|
|
|
PLATE PROFYLE 1.2 3D 2*2+2H
|
Facility
|
OP
|
$3,590.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,077.00 |
| Max. Negotiated Rate |
$3,446.40 |
| Rate for Payer: Aetna Commercial |
$2,764.30
|
| Rate for Payer: Anthem Medicaid |
$1,234.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,800.20
|
| Rate for Payer: Cash Price |
$1,795.00
|
| Rate for Payer: Cigna Commercial |
$2,979.70
|
| Rate for Payer: First Health Commercial |
$3,410.50
|
| Rate for Payer: Humana Commercial |
$3,051.50
|
| Rate for Payer: Humana KY Medicaid |
$1,234.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1,247.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,943.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,649.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,077.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,259.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,159.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,692.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,872.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,123.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,477.10
|
| Rate for Payer: PHCS Commercial |
$3,446.40
|
| Rate for Payer: United Healthcare All Payer |
$3,159.20
|
|
|
PLATE PROFYLE 1.2 3D 2*2H
|
Facility
|
IP
|
$3,590.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,077.00 |
| Max. Negotiated Rate |
$3,446.40 |
| Rate for Payer: Aetna Commercial |
$2,764.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,800.20
|
| Rate for Payer: Cash Price |
$1,795.00
|
| Rate for Payer: Cigna Commercial |
$2,979.70
|
| Rate for Payer: First Health Commercial |
$3,410.50
|
| Rate for Payer: Humana Commercial |
$3,051.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,943.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,649.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,077.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,159.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,692.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,872.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,123.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,477.10
|
| Rate for Payer: PHCS Commercial |
$3,446.40
|
| Rate for Payer: United Healthcare All Payer |
$3,159.20
|
|
|
PLATE PROFYLE 1.2 3D 2*2H
|
Facility
|
OP
|
$3,590.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,077.00 |
| Max. Negotiated Rate |
$3,446.40 |
| Rate for Payer: Aetna Commercial |
$2,764.30
|
| Rate for Payer: Anthem Medicaid |
$1,234.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,800.20
|
| Rate for Payer: Cash Price |
$1,795.00
|
| Rate for Payer: Cigna Commercial |
$2,979.70
|
| Rate for Payer: First Health Commercial |
$3,410.50
|
| Rate for Payer: Humana Commercial |
$3,051.50
|
| Rate for Payer: Humana KY Medicaid |
$1,234.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1,247.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,943.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,649.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,077.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,259.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,159.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,692.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,872.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,123.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,477.10
|
| Rate for Payer: PHCS Commercial |
$3,446.40
|
| Rate for Payer: United Healthcare All Payer |
$3,159.20
|
|
|
PLATE PROFYLE 1.2 3D 3*2H
|
Facility
|
IP
|
$3,590.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,077.00 |
| Max. Negotiated Rate |
$3,446.40 |
| Rate for Payer: Aetna Commercial |
$2,764.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,800.20
|
| Rate for Payer: Cash Price |
$1,795.00
|
| Rate for Payer: Cigna Commercial |
$2,979.70
|
| Rate for Payer: First Health Commercial |
$3,410.50
|
| Rate for Payer: Humana Commercial |
$3,051.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,943.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,649.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,077.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,159.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,692.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,872.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,123.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,477.10
|
| Rate for Payer: PHCS Commercial |
$3,446.40
|
| Rate for Payer: United Healthcare All Payer |
$3,159.20
|
|
|
PLATE PROFYLE 1.2 3D 3*2H
|
Facility
|
OP
|
$3,590.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,077.00 |
| Max. Negotiated Rate |
$3,446.40 |
| Rate for Payer: Aetna Commercial |
$2,764.30
|
| Rate for Payer: Anthem Medicaid |
$1,234.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,800.20
|
| Rate for Payer: Cash Price |
$1,795.00
|
| Rate for Payer: Cigna Commercial |
$2,979.70
|
| Rate for Payer: First Health Commercial |
$3,410.50
|
| Rate for Payer: Humana Commercial |
$3,051.50
|
| Rate for Payer: Humana KY Medicaid |
$1,234.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1,247.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,943.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,649.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,077.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,259.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,159.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,692.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,872.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,123.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,477.10
|
| Rate for Payer: PHCS Commercial |
$3,446.40
|
| Rate for Payer: United Healthcare All Payer |
$3,159.20
|
|
|
PLATE PROFYLE 1.2 3D 4*2H
|
Facility
|
IP
|
$3,590.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,077.00 |
| Max. Negotiated Rate |
$3,446.40 |
| Rate for Payer: Aetna Commercial |
$2,764.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,800.20
|
| Rate for Payer: Cash Price |
$1,795.00
|
| Rate for Payer: Cigna Commercial |
$2,979.70
|
| Rate for Payer: First Health Commercial |
$3,410.50
|
| Rate for Payer: Humana Commercial |
$3,051.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,943.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,649.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,077.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,159.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,692.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,872.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,123.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,477.10
|
| Rate for Payer: PHCS Commercial |
$3,446.40
|
| Rate for Payer: United Healthcare All Payer |
$3,159.20
|
|
|
PLATE PROFYLE 1.2 3D 4*2H
|
Facility
|
OP
|
$3,590.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,077.00 |
| Max. Negotiated Rate |
$3,446.40 |
| Rate for Payer: Aetna Commercial |
$2,764.30
|
| Rate for Payer: Anthem Medicaid |
$1,234.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,800.20
|
| Rate for Payer: Cash Price |
$1,795.00
|
| Rate for Payer: Cigna Commercial |
$2,979.70
|
| Rate for Payer: First Health Commercial |
$3,410.50
|
| Rate for Payer: Humana Commercial |
$3,051.50
|
| Rate for Payer: Humana KY Medicaid |
$1,234.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1,247.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,943.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,649.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,077.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,259.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,159.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,692.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,872.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,123.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,477.10
|
| Rate for Payer: PHCS Commercial |
$3,446.40
|
| Rate for Payer: United Healthcare All Payer |
$3,159.20
|
|
|
PLATE PROFYLE 1.7 12H LT
|
Facility
|
OP
|
$2,003.27
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$600.98 |
| Max. Negotiated Rate |
$1,923.14 |
| Rate for Payer: Aetna Commercial |
$1,542.52
|
| Rate for Payer: Anthem Medicaid |
$688.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,562.55
|
| Rate for Payer: Cash Price |
$1,001.63
|
| Rate for Payer: Cigna Commercial |
$1,662.71
|
| Rate for Payer: First Health Commercial |
$1,903.11
|
| Rate for Payer: Humana Commercial |
$1,702.78
|
| Rate for Payer: Humana KY Medicaid |
$688.92
|
| Rate for Payer: Kentucky WC Medicaid |
$695.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,642.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,478.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$600.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$702.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,762.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,502.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,602.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,742.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,382.26
|
| Rate for Payer: PHCS Commercial |
$1,923.14
|
| Rate for Payer: United Healthcare All Payer |
$1,762.88
|
|
|
PLATE PROFYLE 1.7 12H LT
|
Facility
|
IP
|
$2,003.27
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$600.98 |
| Max. Negotiated Rate |
$1,923.14 |
| Rate for Payer: Aetna Commercial |
$1,542.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,562.55
|
| Rate for Payer: Cash Price |
$1,001.63
|
| Rate for Payer: Cigna Commercial |
$1,662.71
|
| Rate for Payer: First Health Commercial |
$1,903.11
|
| Rate for Payer: Humana Commercial |
$1,702.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,642.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,478.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$600.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,762.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,502.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,602.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,742.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,382.26
|
| Rate for Payer: PHCS Commercial |
$1,923.14
|
| Rate for Payer: United Healthcare All Payer |
$1,762.88
|
|
|
PLATE PROFYLE 1.7 12H RT
|
Facility
|
OP
|
$2,003.27
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$600.98 |
| Max. Negotiated Rate |
$1,923.14 |
| Rate for Payer: Aetna Commercial |
$1,542.52
|
| Rate for Payer: Anthem Medicaid |
$688.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,562.55
|
| Rate for Payer: Cash Price |
$1,001.63
|
| Rate for Payer: Cigna Commercial |
$1,662.71
|
| Rate for Payer: First Health Commercial |
$1,903.11
|
| Rate for Payer: Humana Commercial |
$1,702.78
|
| Rate for Payer: Humana KY Medicaid |
$688.92
|
| Rate for Payer: Kentucky WC Medicaid |
$695.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,642.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,478.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$600.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$702.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,762.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,502.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,602.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,742.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,382.26
|
| Rate for Payer: PHCS Commercial |
$1,923.14
|
| Rate for Payer: United Healthcare All Payer |
$1,762.88
|
|
|
PLATE PROFYLE 1.7 12H RT
|
Facility
|
IP
|
$2,003.27
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$600.98 |
| Max. Negotiated Rate |
$1,923.14 |
| Rate for Payer: Aetna Commercial |
$1,542.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,562.55
|
| Rate for Payer: Cash Price |
$1,001.63
|
| Rate for Payer: Cigna Commercial |
$1,662.71
|
| Rate for Payer: First Health Commercial |
$1,903.11
|
| Rate for Payer: Humana Commercial |
$1,702.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,642.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,478.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$600.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,762.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,502.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,602.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,742.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,382.26
|
| Rate for Payer: PHCS Commercial |
$1,923.14
|
| Rate for Payer: United Healthcare All Payer |
$1,762.88
|
|
|
PLATE PROFYLE 3D 1.7 2*2+2H
|
Facility
|
OP
|
$3,329.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$998.70 |
| Max. Negotiated Rate |
$3,195.84 |
| Rate for Payer: Aetna Commercial |
$2,563.33
|
| Rate for Payer: Anthem Medicaid |
$1,144.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,596.62
|
| Rate for Payer: Cash Price |
$1,664.50
|
| Rate for Payer: Cigna Commercial |
$2,763.07
|
| Rate for Payer: First Health Commercial |
$3,162.55
|
| Rate for Payer: Humana Commercial |
$2,829.65
|
| Rate for Payer: Humana KY Medicaid |
$1,144.84
|
| Rate for Payer: Kentucky WC Medicaid |
$1,156.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,729.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,456.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$998.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,167.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,929.52
|
| Rate for Payer: Ohio Health Group HMO |
$2,496.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,663.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,896.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,297.01
|
| Rate for Payer: PHCS Commercial |
$3,195.84
|
| Rate for Payer: United Healthcare All Payer |
$2,929.52
|
|
|
PLATE PROFYLE 3D 1.7 2*2+2H
|
Facility
|
IP
|
$3,329.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$998.70 |
| Max. Negotiated Rate |
$3,195.84 |
| Rate for Payer: Aetna Commercial |
$2,563.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,596.62
|
| Rate for Payer: Cash Price |
$1,664.50
|
| Rate for Payer: Cigna Commercial |
$2,763.07
|
| Rate for Payer: First Health Commercial |
$3,162.55
|
| Rate for Payer: Humana Commercial |
$2,829.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,729.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,456.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$998.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,929.52
|
| Rate for Payer: Ohio Health Group HMO |
$2,496.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,663.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,896.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,297.01
|
| Rate for Payer: PHCS Commercial |
$3,195.84
|
| Rate for Payer: United Healthcare All Payer |
$2,929.52
|
|
|
PLATE PROFYLE 3D 1.7 2*2H
|
Facility
|
IP
|
$2,975.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$892.50 |
| Max. Negotiated Rate |
$2,856.00 |
| Rate for Payer: Aetna Commercial |
$2,290.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,320.50
|
| Rate for Payer: Cash Price |
$1,487.50
|
| Rate for Payer: Cigna Commercial |
$2,469.25
|
| Rate for Payer: First Health Commercial |
$2,826.25
|
| Rate for Payer: Humana Commercial |
$2,528.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,439.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,195.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$892.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,618.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,231.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,380.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,588.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,052.75
|
| Rate for Payer: PHCS Commercial |
$2,856.00
|
| Rate for Payer: United Healthcare All Payer |
$2,618.00
|
|
|
PLATE PROFYLE 3D 1.7 2*2H
|
Facility
|
OP
|
$2,975.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$892.50 |
| Max. Negotiated Rate |
$2,856.00 |
| Rate for Payer: Aetna Commercial |
$2,290.75
|
| Rate for Payer: Anthem Medicaid |
$1,023.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,320.50
|
| Rate for Payer: Cash Price |
$1,487.50
|
| Rate for Payer: Cigna Commercial |
$2,469.25
|
| Rate for Payer: First Health Commercial |
$2,826.25
|
| Rate for Payer: Humana Commercial |
$2,528.75
|
| Rate for Payer: Humana KY Medicaid |
$1,023.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,033.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,439.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,195.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$892.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,043.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,618.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,231.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,380.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,588.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,052.75
|
| Rate for Payer: PHCS Commercial |
$2,856.00
|
| Rate for Payer: United Healthcare All Payer |
$2,618.00
|
|
|
PLATE PROFYLE 3D 1.7 3*2H
|
Facility
|
IP
|
$4,223.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,266.90 |
| Max. Negotiated Rate |
$4,054.08 |
| Rate for Payer: Aetna Commercial |
$3,251.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,293.94
|
| Rate for Payer: Cash Price |
$2,111.50
|
| Rate for Payer: Cigna Commercial |
$3,505.09
|
| Rate for Payer: First Health Commercial |
$4,011.85
|
| Rate for Payer: Humana Commercial |
$3,589.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,462.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,116.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,266.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,716.24
|
| Rate for Payer: Ohio Health Group HMO |
$3,167.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,378.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,674.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,913.87
|
| Rate for Payer: PHCS Commercial |
$4,054.08
|
| Rate for Payer: United Healthcare All Payer |
$3,716.24
|
|
|
PLATE PROFYLE 3D 1.7 3*2H
|
Facility
|
OP
|
$4,223.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,266.90 |
| Max. Negotiated Rate |
$4,054.08 |
| Rate for Payer: Aetna Commercial |
$3,251.71
|
| Rate for Payer: Anthem Medicaid |
$1,452.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,293.94
|
| Rate for Payer: Cash Price |
$2,111.50
|
| Rate for Payer: Cigna Commercial |
$3,505.09
|
| Rate for Payer: First Health Commercial |
$4,011.85
|
| Rate for Payer: Humana Commercial |
$3,589.55
|
| Rate for Payer: Humana KY Medicaid |
$1,452.29
|
| Rate for Payer: Kentucky WC Medicaid |
$1,467.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,462.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,116.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,266.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,481.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,716.24
|
| Rate for Payer: Ohio Health Group HMO |
$3,167.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,378.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,674.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,913.87
|
| Rate for Payer: PHCS Commercial |
$4,054.08
|
| Rate for Payer: United Healthcare All Payer |
$3,716.24
|
|
|
PLATE PROFYLE 3D 1.7 4*2H
|
Facility
|
OP
|
$3,500.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$3,360.00 |
| Rate for Payer: Aetna Commercial |
$2,695.00
|
| Rate for Payer: Anthem Medicaid |
$1,203.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,730.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$2,905.00
|
| Rate for Payer: First Health Commercial |
$3,325.00
|
| Rate for Payer: Humana Commercial |
$2,975.00
|
| Rate for Payer: Humana KY Medicaid |
$1,203.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1,215.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,870.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,583.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,050.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,227.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,080.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,045.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,415.00
|
| Rate for Payer: PHCS Commercial |
$3,360.00
|
| Rate for Payer: United Healthcare All Payer |
$3,080.00
|
|
|
PLATE PROFYLE 3D 1.7 4*2H
|
Facility
|
IP
|
$3,500.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$3,360.00 |
| Rate for Payer: Aetna Commercial |
$2,695.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,730.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$2,905.00
|
| Rate for Payer: First Health Commercial |
$3,325.00
|
| Rate for Payer: Humana Commercial |
$2,975.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,870.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,583.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,050.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,080.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,045.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,415.00
|
| Rate for Payer: PHCS Commercial |
$3,360.00
|
| Rate for Payer: United Healthcare All Payer |
$3,080.00
|
|
|
PLATE PROFYLE 3D 2.3
|
Facility
|
OP
|
$2,974.74
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$892.42 |
| Max. Negotiated Rate |
$2,855.75 |
| Rate for Payer: Aetna Commercial |
$2,290.55
|
| Rate for Payer: Anthem Medicaid |
$1,023.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,320.30
|
| Rate for Payer: Cash Price |
$1,487.37
|
| Rate for Payer: Cigna Commercial |
$2,469.03
|
| Rate for Payer: First Health Commercial |
$2,826.00
|
| Rate for Payer: Humana Commercial |
$2,528.53
|
| Rate for Payer: Humana KY Medicaid |
$1,023.01
|
| Rate for Payer: Kentucky WC Medicaid |
$1,033.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,439.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,195.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$892.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,043.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,617.77
|
| Rate for Payer: Ohio Health Group HMO |
$2,231.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,379.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,588.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,052.57
|
| Rate for Payer: PHCS Commercial |
$2,855.75
|
| Rate for Payer: United Healthcare All Payer |
$2,617.77
|
|
