|
PLATE PROFYLE M COND 2.3 6H L
|
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 PROFYLE M COND 2.3 6H L
|
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 M COND 2.3 6H R
|
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 M COND 2.3 6H R
|
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 PROFYLE OBL 90D 2.3 6H L
|
Facility
|
IP
|
$2,948.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.40 |
| Max. Negotiated Rate |
$2,830.08 |
| Rate for Payer: Aetna Commercial |
$2,269.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,299.44
|
| Rate for Payer: Cash Price |
$1,474.00
|
| Rate for Payer: Cigna Commercial |
$2,446.84
|
| Rate for Payer: First Health Commercial |
$2,800.60
|
| Rate for Payer: Humana Commercial |
$2,505.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,417.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,175.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$884.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,594.24
|
| Rate for Payer: Ohio Health Group HMO |
$2,211.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,358.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,564.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,034.12
|
| Rate for Payer: PHCS Commercial |
$2,830.08
|
| Rate for Payer: United Healthcare All Payer |
$2,594.24
|
|
|
PLATE PROFYLE OBL 90D 2.3 6H L
|
Facility
|
OP
|
$2,948.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.40 |
| Max. Negotiated Rate |
$2,830.08 |
| Rate for Payer: Aetna Commercial |
$2,269.96
|
| Rate for Payer: Anthem Medicaid |
$1,013.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,299.44
|
| Rate for Payer: Cash Price |
$1,474.00
|
| Rate for Payer: Cigna Commercial |
$2,446.84
|
| Rate for Payer: First Health Commercial |
$2,800.60
|
| Rate for Payer: Humana Commercial |
$2,505.80
|
| Rate for Payer: Humana KY Medicaid |
$1,013.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,024.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,417.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,175.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$884.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,034.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,594.24
|
| Rate for Payer: Ohio Health Group HMO |
$2,211.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,358.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,564.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,034.12
|
| Rate for Payer: PHCS Commercial |
$2,830.08
|
| Rate for Payer: United Healthcare All Payer |
$2,594.24
|
|
|
PLATE PROFYLE OBL 90D 2.3 6H R
|
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 OBL 90D 2.3 6H R
|
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 OBLI L 1.7 6H LT
|
Facility
|
IP
|
$2,948.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.40 |
| Max. Negotiated Rate |
$2,830.08 |
| Rate for Payer: Aetna Commercial |
$2,269.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,299.44
|
| Rate for Payer: Cash Price |
$1,474.00
|
| Rate for Payer: Cigna Commercial |
$2,446.84
|
| Rate for Payer: First Health Commercial |
$2,800.60
|
| Rate for Payer: Humana Commercial |
$2,505.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,417.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,175.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$884.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,594.24
|
| Rate for Payer: Ohio Health Group HMO |
$2,211.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,358.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,564.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,034.12
|
| Rate for Payer: PHCS Commercial |
$2,830.08
|
| Rate for Payer: United Healthcare All Payer |
$2,594.24
|
|
|
PLATE PROFYLE OBLI L 1.7 6H LT
|
Facility
|
OP
|
$2,948.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.40 |
| Max. Negotiated Rate |
$2,830.08 |
| Rate for Payer: Aetna Commercial |
$2,269.96
|
| Rate for Payer: Anthem Medicaid |
$1,013.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,299.44
|
| Rate for Payer: Cash Price |
$1,474.00
|
| Rate for Payer: Cigna Commercial |
$2,446.84
|
| Rate for Payer: First Health Commercial |
$2,800.60
|
| Rate for Payer: Humana Commercial |
$2,505.80
|
| Rate for Payer: Humana KY Medicaid |
$1,013.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,024.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,417.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,175.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$884.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,034.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,594.24
|
| Rate for Payer: Ohio Health Group HMO |
$2,211.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,358.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,564.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,034.12
|
| Rate for Payer: PHCS Commercial |
$2,830.08
|
| Rate for Payer: United Healthcare All Payer |
$2,594.24
|
|
|
PLATE PROFYLE OBLI L 1.7 6H RT
|
Facility
|
OP
|
$2,060.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$618.00 |
| Max. Negotiated Rate |
$1,977.60 |
| Rate for Payer: Aetna Commercial |
$1,586.20
|
| Rate for Payer: Anthem Medicaid |
$708.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,606.80
|
| Rate for Payer: Cash Price |
$1,030.00
|
| Rate for Payer: Cigna Commercial |
$1,709.80
|
| Rate for Payer: First Health Commercial |
$1,957.00
|
| Rate for Payer: Humana Commercial |
$1,751.00
|
| Rate for Payer: Humana KY Medicaid |
$708.43
|
| Rate for Payer: Kentucky WC Medicaid |
$715.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,689.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,520.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$618.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$722.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,812.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,545.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,792.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,421.40
|
| Rate for Payer: PHCS Commercial |
$1,977.60
|
| Rate for Payer: United Healthcare All Payer |
$1,812.80
|
|
|
PLATE PROFYLE OBLI L 1.7 6H RT
|
Facility
|
IP
|
$2,060.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$618.00 |
| Max. Negotiated Rate |
$1,977.60 |
| Rate for Payer: Aetna Commercial |
$1,586.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,606.80
|
| Rate for Payer: Cash Price |
$1,030.00
|
| Rate for Payer: Cigna Commercial |
$1,709.80
|
| Rate for Payer: First Health Commercial |
$1,957.00
|
| Rate for Payer: Humana Commercial |
$1,751.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,689.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,520.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$618.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,812.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,545.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,792.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,421.40
|
| Rate for Payer: PHCS Commercial |
$1,977.60
|
| Rate for Payer: United Healthcare All Payer |
$1,812.80
|
|
|
PLATE PROFYLE OBL T CMP 6H L
|
Facility
|
OP
|
$2,948.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.40 |
| Max. Negotiated Rate |
$2,830.08 |
| Rate for Payer: Aetna Commercial |
$2,269.96
|
| Rate for Payer: Anthem Medicaid |
$1,013.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,299.44
|
| Rate for Payer: Cash Price |
$1,474.00
|
| Rate for Payer: Cigna Commercial |
$2,446.84
|
| Rate for Payer: First Health Commercial |
$2,800.60
|
| Rate for Payer: Humana Commercial |
$2,505.80
|
| Rate for Payer: Humana KY Medicaid |
$1,013.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,024.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,417.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,175.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$884.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,034.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,594.24
|
| Rate for Payer: Ohio Health Group HMO |
$2,211.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,358.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,564.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,034.12
|
| Rate for Payer: PHCS Commercial |
$2,830.08
|
| Rate for Payer: United Healthcare All Payer |
$2,594.24
|
|
|
PLATE PROFYLE OBL T CMP 6H L
|
Facility
|
IP
|
$2,948.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.40 |
| Max. Negotiated Rate |
$2,830.08 |
| Rate for Payer: Aetna Commercial |
$2,269.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,299.44
|
| Rate for Payer: Cash Price |
$1,474.00
|
| Rate for Payer: Cigna Commercial |
$2,446.84
|
| Rate for Payer: First Health Commercial |
$2,800.60
|
| Rate for Payer: Humana Commercial |
$2,505.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,417.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,175.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$884.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,594.24
|
| Rate for Payer: Ohio Health Group HMO |
$2,211.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,358.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,564.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,034.12
|
| Rate for Payer: PHCS Commercial |
$2,830.08
|
| Rate for Payer: United Healthcare All Payer |
$2,594.24
|
|
|
PLATE PROFYLE OBL T CMP 6H R
|
Facility
|
IP
|
$1,844.24
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$553.27 |
| Max. Negotiated Rate |
$1,770.47 |
| Rate for Payer: Aetna Commercial |
$1,420.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,438.51
|
| Rate for Payer: Cash Price |
$922.12
|
| Rate for Payer: Cigna Commercial |
$1,530.72
|
| Rate for Payer: First Health Commercial |
$1,752.03
|
| Rate for Payer: Humana Commercial |
$1,567.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,512.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,361.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$553.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,622.93
|
| Rate for Payer: Ohio Health Group HMO |
$1,383.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,475.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,604.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,272.53
|
| Rate for Payer: PHCS Commercial |
$1,770.47
|
| Rate for Payer: United Healthcare All Payer |
$1,622.93
|
|
|
PLATE PROFYLE OBL T CMP 6H R
|
Facility
|
OP
|
$1,844.24
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$553.27 |
| Max. Negotiated Rate |
$1,770.47 |
| Rate for Payer: Aetna Commercial |
$1,420.06
|
| Rate for Payer: Anthem Medicaid |
$634.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,438.51
|
| Rate for Payer: Cash Price |
$922.12
|
| Rate for Payer: Cigna Commercial |
$1,530.72
|
| Rate for Payer: First Health Commercial |
$1,752.03
|
| Rate for Payer: Humana Commercial |
$1,567.60
|
| Rate for Payer: Humana KY Medicaid |
$634.23
|
| Rate for Payer: Kentucky WC Medicaid |
$640.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,512.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,361.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$553.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$646.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,622.93
|
| Rate for Payer: Ohio Health Group HMO |
$1,383.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,475.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,604.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,272.53
|
| Rate for Payer: PHCS Commercial |
$1,770.47
|
| Rate for Payer: United Healthcare All Payer |
$1,622.93
|
|
|
PLATE PROFYLE REPLANT 1.7 4*2H
|
Facility
|
IP
|
$4,185.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,255.65 |
| Max. Negotiated Rate |
$4,018.08 |
| Rate for Payer: Aetna Commercial |
$3,222.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,264.69
|
| Rate for Payer: Cash Price |
$2,092.75
|
| Rate for Payer: Cigna Commercial |
$3,473.97
|
| Rate for Payer: First Health Commercial |
$3,976.22
|
| Rate for Payer: Humana Commercial |
$3,557.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,432.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,088.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,255.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,683.24
|
| Rate for Payer: Ohio Health Group HMO |
$3,139.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,348.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,641.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,887.99
|
| Rate for Payer: PHCS Commercial |
$4,018.08
|
| Rate for Payer: United Healthcare All Payer |
$3,683.24
|
|
|
PLATE PROFYLE REPLANT 1.7 4*2H
|
Facility
|
OP
|
$4,185.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,255.65 |
| Max. Negotiated Rate |
$4,018.08 |
| Rate for Payer: Aetna Commercial |
$3,222.84
|
| Rate for Payer: Anthem Medicaid |
$1,439.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,264.69
|
| Rate for Payer: Cash Price |
$2,092.75
|
| Rate for Payer: Cigna Commercial |
$3,473.97
|
| Rate for Payer: First Health Commercial |
$3,976.22
|
| Rate for Payer: Humana Commercial |
$3,557.68
|
| Rate for Payer: Humana KY Medicaid |
$1,439.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,454.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,432.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,088.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,255.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,468.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,683.24
|
| Rate for Payer: Ohio Health Group HMO |
$3,139.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,348.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,641.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,887.99
|
| Rate for Payer: PHCS Commercial |
$4,018.08
|
| Rate for Payer: United Healthcare All Payer |
$3,683.24
|
|
|
PLATE PROFYLE REPLANT 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 REPLANT 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 ROT 2.3 5H
|
Facility
|
IP
|
$4,832.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,449.60 |
| Max. Negotiated Rate |
$4,638.72 |
| Rate for Payer: Aetna Commercial |
$3,720.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,768.96
|
| Rate for Payer: Cash Price |
$2,416.00
|
| Rate for Payer: Cigna Commercial |
$4,010.56
|
| Rate for Payer: First Health Commercial |
$4,590.40
|
| Rate for Payer: Humana Commercial |
$4,107.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,962.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,566.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,449.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,252.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,624.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,865.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,203.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,334.08
|
| Rate for Payer: PHCS Commercial |
$4,638.72
|
| Rate for Payer: United Healthcare All Payer |
$4,252.16
|
|
|
PLATE PROFYLE ROT 2.3 5H
|
Facility
|
OP
|
$4,832.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,449.60 |
| Max. Negotiated Rate |
$4,638.72 |
| Rate for Payer: Aetna Commercial |
$3,720.64
|
| Rate for Payer: Anthem Medicaid |
$1,661.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,768.96
|
| Rate for Payer: Cash Price |
$2,416.00
|
| Rate for Payer: Cigna Commercial |
$4,010.56
|
| Rate for Payer: First Health Commercial |
$4,590.40
|
| Rate for Payer: Humana Commercial |
$4,107.20
|
| Rate for Payer: Humana KY Medicaid |
$1,661.72
|
| Rate for Payer: Kentucky WC Medicaid |
$1,678.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,962.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,566.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,449.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,695.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,252.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,624.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,865.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,203.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,334.08
|
| Rate for Payer: PHCS Commercial |
$4,638.72
|
| Rate for Payer: United Healthcare All Payer |
$4,252.16
|
|
|
PLATE PROFYLE STRAIGHT 1.7 16H
|
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 STRAIGHT 1.7 16H
|
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 STRAIGHT 1.7 4H
|
Facility
|
OP
|
$1,535.73
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$460.72 |
| Max. Negotiated Rate |
$1,474.30 |
| Rate for Payer: Aetna Commercial |
$1,182.51
|
| Rate for Payer: Anthem Medicaid |
$528.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,197.87
|
| Rate for Payer: Cash Price |
$767.86
|
| Rate for Payer: Cigna Commercial |
$1,274.66
|
| Rate for Payer: First Health Commercial |
$1,458.94
|
| Rate for Payer: Humana Commercial |
$1,305.37
|
| Rate for Payer: Humana KY Medicaid |
$528.14
|
| Rate for Payer: Kentucky WC Medicaid |
$533.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,259.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,133.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$460.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$538.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,351.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,151.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,228.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,336.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,059.65
|
| Rate for Payer: PHCS Commercial |
$1,474.30
|
| Rate for Payer: United Healthcare All Payer |
$1,351.44
|
|
