|
PLATE PROFYLE T CMP 2.3 6H 90^
|
Facility
|
IP
|
$3,902.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,170.60 |
| Max. Negotiated Rate |
$3,745.92 |
| Rate for Payer: Aetna Commercial |
$3,004.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,043.56
|
| Rate for Payer: Cash Price |
$1,951.00
|
| Rate for Payer: Cigna Commercial |
$3,238.66
|
| Rate for Payer: First Health Commercial |
$3,706.90
|
| Rate for Payer: Humana Commercial |
$3,316.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,199.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,879.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,170.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,433.76
|
| Rate for Payer: Ohio Health Group HMO |
$2,926.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,121.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,394.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,692.38
|
| Rate for Payer: PHCS Commercial |
$3,745.92
|
| Rate for Payer: United Healthcare All Payer |
$3,433.76
|
|
|
PLATE PROFYLE T CMP 2.3 6H 90^
|
Facility
|
OP
|
$3,902.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,170.60 |
| Max. Negotiated Rate |
$3,745.92 |
| Rate for Payer: Aetna Commercial |
$3,004.54
|
| Rate for Payer: Anthem Medicaid |
$1,341.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,043.56
|
| Rate for Payer: Cash Price |
$1,951.00
|
| Rate for Payer: Cigna Commercial |
$3,238.66
|
| Rate for Payer: First Health Commercial |
$3,706.90
|
| Rate for Payer: Humana Commercial |
$3,316.70
|
| Rate for Payer: Humana KY Medicaid |
$1,341.90
|
| Rate for Payer: Kentucky WC Medicaid |
$1,355.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,199.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,879.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,170.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,368.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,433.76
|
| Rate for Payer: Ohio Health Group HMO |
$2,926.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,121.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,394.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,692.38
|
| Rate for Payer: PHCS Commercial |
$3,745.92
|
| Rate for Payer: United Healthcare All Payer |
$3,433.76
|
|
|
PLATE PROFYLE T L CMP 10H 90^
|
Facility
|
IP
|
$2,942.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$882.60 |
| Max. Negotiated Rate |
$2,824.32 |
| Rate for Payer: Aetna Commercial |
$2,265.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,294.76
|
| Rate for Payer: Cash Price |
$1,471.00
|
| Rate for Payer: Cigna Commercial |
$2,441.86
|
| Rate for Payer: First Health Commercial |
$2,794.90
|
| Rate for Payer: Humana Commercial |
$2,500.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,412.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,171.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$882.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,588.96
|
| Rate for Payer: Ohio Health Group HMO |
$2,206.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,353.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,559.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,029.98
|
| Rate for Payer: PHCS Commercial |
$2,824.32
|
| Rate for Payer: United Healthcare All Payer |
$2,588.96
|
|
|
PLATE PROFYLE T L CMP 10H 90^
|
Facility
|
OP
|
$2,942.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$882.60 |
| Max. Negotiated Rate |
$2,824.32 |
| Rate for Payer: Aetna Commercial |
$2,265.34
|
| Rate for Payer: Anthem Medicaid |
$1,011.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,294.76
|
| Rate for Payer: Cash Price |
$1,471.00
|
| Rate for Payer: Cigna Commercial |
$2,441.86
|
| Rate for Payer: First Health Commercial |
$2,794.90
|
| Rate for Payer: Humana Commercial |
$2,500.70
|
| Rate for Payer: Humana KY Medicaid |
$1,011.75
|
| Rate for Payer: Kentucky WC Medicaid |
$1,022.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,412.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,171.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$882.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,032.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,588.96
|
| Rate for Payer: Ohio Health Group HMO |
$2,206.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,353.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,559.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,029.98
|
| Rate for Payer: PHCS Commercial |
$2,824.32
|
| Rate for Payer: United Healthcare All Payer |
$2,588.96
|
|
|
PLATE PROFYLE T OBLIQUE 6H LT
|
Facility
|
OP
|
$2,026.56
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$607.97 |
| Max. Negotiated Rate |
$1,945.50 |
| Rate for Payer: Aetna Commercial |
$1,560.45
|
| Rate for Payer: Anthem Medicaid |
$696.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,580.72
|
| Rate for Payer: Cash Price |
$1,013.28
|
| Rate for Payer: Cigna Commercial |
$1,682.04
|
| Rate for Payer: First Health Commercial |
$1,925.23
|
| Rate for Payer: Humana Commercial |
$1,722.58
|
| Rate for Payer: Humana KY Medicaid |
$696.93
|
| Rate for Payer: Kentucky WC Medicaid |
$704.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,661.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,495.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$607.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$710.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,783.37
|
| Rate for Payer: Ohio Health Group HMO |
$1,519.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,621.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,763.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,398.33
|
| Rate for Payer: PHCS Commercial |
$1,945.50
|
| Rate for Payer: United Healthcare All Payer |
$1,783.37
|
|
|
PLATE PROFYLE T OBLIQUE 6H LT
|
Facility
|
IP
|
$2,026.56
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$607.97 |
| Max. Negotiated Rate |
$1,945.50 |
| Rate for Payer: Aetna Commercial |
$1,560.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,580.72
|
| Rate for Payer: Cash Price |
$1,013.28
|
| Rate for Payer: Cigna Commercial |
$1,682.04
|
| Rate for Payer: First Health Commercial |
$1,925.23
|
| Rate for Payer: Humana Commercial |
$1,722.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,661.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,495.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$607.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,783.37
|
| Rate for Payer: Ohio Health Group HMO |
$1,519.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,621.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,763.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,398.33
|
| Rate for Payer: PHCS Commercial |
$1,945.50
|
| Rate for Payer: United Healthcare All Payer |
$1,783.37
|
|
|
PLATE PROFYLE T OBLIQUE 6H RT
|
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 T OBLIQUE 6H RT
|
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 Y C0MP 2.3 7H NA
|
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 Y C0MP 2.3 7H NA
|
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 Y NARROW 1.7 7H
|
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 Y NARROW 1.7 7H
|
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 Z 1.7 9H
|
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 Z 1.7 9H
|
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 PROFYL L CMP 2.3 4H W/BR
|
Facility
|
OP
|
$1,715.26
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$514.58 |
| Max. Negotiated Rate |
$1,646.65 |
| Rate for Payer: Aetna Commercial |
$1,320.75
|
| Rate for Payer: Anthem Medicaid |
$589.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,337.90
|
| Rate for Payer: Cash Price |
$857.63
|
| Rate for Payer: Cigna Commercial |
$1,423.67
|
| Rate for Payer: First Health Commercial |
$1,629.50
|
| Rate for Payer: Humana Commercial |
$1,457.97
|
| Rate for Payer: Humana KY Medicaid |
$589.88
|
| Rate for Payer: Kentucky WC Medicaid |
$595.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,406.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,265.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$514.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$601.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,509.43
|
| Rate for Payer: Ohio Health Group HMO |
$1,286.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,372.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,492.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,183.53
|
| Rate for Payer: PHCS Commercial |
$1,646.65
|
| Rate for Payer: United Healthcare All Payer |
$1,509.43
|
|
|
PLATE PROFYL L CMP 2.3 4H W/BR
|
Facility
|
IP
|
$1,715.26
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$514.58 |
| Max. Negotiated Rate |
$1,646.65 |
| Rate for Payer: Aetna Commercial |
$1,320.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,337.90
|
| Rate for Payer: Cash Price |
$857.63
|
| Rate for Payer: Cigna Commercial |
$1,423.67
|
| Rate for Payer: First Health Commercial |
$1,629.50
|
| Rate for Payer: Humana Commercial |
$1,457.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,406.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,265.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$514.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,509.43
|
| Rate for Payer: Ohio Health Group HMO |
$1,286.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,372.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,492.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,183.53
|
| Rate for Payer: PHCS Commercial |
$1,646.65
|
| Rate for Payer: United Healthcare All Payer |
$1,509.43
|
|
|
PLATE PROFYL L CMP 2.3 5H W/BR
|
Facility
|
IP
|
$3,902.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,170.60 |
| Max. Negotiated Rate |
$3,745.92 |
| Rate for Payer: Aetna Commercial |
$3,004.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,043.56
|
| Rate for Payer: Cash Price |
$1,951.00
|
| Rate for Payer: Cigna Commercial |
$3,238.66
|
| Rate for Payer: First Health Commercial |
$3,706.90
|
| Rate for Payer: Humana Commercial |
$3,316.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,199.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,879.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,170.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,433.76
|
| Rate for Payer: Ohio Health Group HMO |
$2,926.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,121.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,394.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,692.38
|
| Rate for Payer: PHCS Commercial |
$3,745.92
|
| Rate for Payer: United Healthcare All Payer |
$3,433.76
|
|
|
PLATE PROFYL L CMP 2.3 5H W/BR
|
Facility
|
OP
|
$3,902.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,170.60 |
| Max. Negotiated Rate |
$3,745.92 |
| Rate for Payer: Aetna Commercial |
$3,004.54
|
| Rate for Payer: Anthem Medicaid |
$1,341.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,043.56
|
| Rate for Payer: Cash Price |
$1,951.00
|
| Rate for Payer: Cigna Commercial |
$3,238.66
|
| Rate for Payer: First Health Commercial |
$3,706.90
|
| Rate for Payer: Humana Commercial |
$3,316.70
|
| Rate for Payer: Humana KY Medicaid |
$1,341.90
|
| Rate for Payer: Kentucky WC Medicaid |
$1,355.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,199.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,879.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,170.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,368.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,433.76
|
| Rate for Payer: Ohio Health Group HMO |
$2,926.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,121.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,394.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,692.38
|
| Rate for Payer: PHCS Commercial |
$3,745.92
|
| Rate for Payer: United Healthcare All Payer |
$3,433.76
|
|
|
PLATE PROFYL L CMP 2.3 6H W/BR
|
Facility
|
IP
|
$2,096.48
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$628.94 |
| Max. Negotiated Rate |
$2,012.62 |
| Rate for Payer: Aetna Commercial |
$1,614.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,635.25
|
| Rate for Payer: Cash Price |
$1,048.24
|
| Rate for Payer: Cigna Commercial |
$1,740.08
|
| Rate for Payer: First Health Commercial |
$1,991.66
|
| Rate for Payer: Humana Commercial |
$1,782.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,719.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,547.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$628.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,844.90
|
| Rate for Payer: Ohio Health Group HMO |
$1,572.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,677.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,823.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,446.57
|
| Rate for Payer: PHCS Commercial |
$2,012.62
|
| Rate for Payer: United Healthcare All Payer |
$1,844.90
|
|
|
PLATE PROFYL L CMP 2.3 6H W/BR
|
Facility
|
OP
|
$2,096.48
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$628.94 |
| Max. Negotiated Rate |
$2,012.62 |
| Rate for Payer: Aetna Commercial |
$1,614.29
|
| Rate for Payer: Anthem Medicaid |
$720.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,635.25
|
| Rate for Payer: Cash Price |
$1,048.24
|
| Rate for Payer: Cigna Commercial |
$1,740.08
|
| Rate for Payer: First Health Commercial |
$1,991.66
|
| Rate for Payer: Humana Commercial |
$1,782.01
|
| Rate for Payer: Humana KY Medicaid |
$720.98
|
| Rate for Payer: Kentucky WC Medicaid |
$728.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,719.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,547.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$628.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$735.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,844.90
|
| Rate for Payer: Ohio Health Group HMO |
$1,572.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,677.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,823.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,446.57
|
| Rate for Payer: PHCS Commercial |
$2,012.62
|
| Rate for Payer: United Healthcare All Payer |
$1,844.90
|
|
|
PLATE PROFYL M CMP 2.3 10H 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 M CMP 2.3 10H 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 M COMP STR BAR 4H
|
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 PROFYL M COMP STR BAR 4H
|
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 PROFYL M CON 2.3 6H LP L
|
Facility
|
IP
|
$1,867.23
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$560.17 |
| Max. Negotiated Rate |
$1,792.54 |
| Rate for Payer: Aetna Commercial |
$1,437.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,456.44
|
| Rate for Payer: Cash Price |
$933.61
|
| Rate for Payer: Cigna Commercial |
$1,549.80
|
| Rate for Payer: First Health Commercial |
$1,773.87
|
| Rate for Payer: Humana Commercial |
$1,587.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,531.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,378.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$560.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,643.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,400.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,493.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,624.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,288.39
|
| Rate for Payer: PHCS Commercial |
$1,792.54
|
| Rate for Payer: United Healthcare All Payer |
$1,643.16
|
|
