Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

PLATE VOLAR SMARTLOCK WIDE LNG

Facility

$6,809.16

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$885.19
Max. Negotiated Rate	$6,536.79
Rate for Payer: Aetna Commercial	$5,243.05
Rate for Payer: Anthem POS/PPO/Traditional	$5,311.14
Rate for Payer: Cash Price	$3,404.58
Rate for Payer: Cigna Commercial	$5,651.60
Rate for Payer: First Health Commercial	$6,468.70
Rate for Payer: Humana Commercial	$5,787.79
Rate for Payer: Medical Mutual Of Ohio HMO	$5,583.51
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,025.16
Rate for Payer: Molina Healthcare Benefit Exchange	$2,042.75
Rate for Payer: Ohio Health Choice Commercial	$5,992.06
Rate for Payer: Ohio Health Group HMO	$5,106.87
Rate for Payer: Ohio Health Group PPO Differential	$1,361.83
Rate for Payer: Ohio Health Group PPO No Differential	$885.19
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,110.84
Rate for Payer: PHCS Commercial	$6,536.79
Rate for Payer: United Healthcare All Payer	$5,992.06

PLATE VOLAR SMARTLOCK WIDE LNG

Facility

$6,809.16

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$885.19
Max. Negotiated Rate	$6,536.79
Rate for Payer: Aetna Commercial	$5,243.05
Rate for Payer: Anthem Medicaid	$2,341.67
Rate for Payer: Anthem POS/PPO/Traditional	$5,311.14
Rate for Payer: Cash Price	$3,404.58
Rate for Payer: Cigna Commercial	$5,651.60
Rate for Payer: First Health Commercial	$6,468.70
Rate for Payer: Humana Commercial	$5,787.79
Rate for Payer: Humana KY Medicaid	$2,341.67
Rate for Payer: Kentucky WC Medicaid	$2,365.50
Rate for Payer: Medical Mutual Of Ohio HMO	$5,583.51
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,025.16
Rate for Payer: Molina Healthcare Benefit Exchange	$2,042.75
Rate for Payer: Molina Healthcare Medicaid	$2,388.65
Rate for Payer: Ohio Health Choice Commercial	$5,992.06
Rate for Payer: Ohio Health Group HMO	$5,106.87
Rate for Payer: Ohio Health Group PPO Differential	$1,361.83
Rate for Payer: Ohio Health Group PPO No Differential	$885.19
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,110.84
Rate for Payer: PHCS Commercial	$6,536.79
Rate for Payer: United Healthcare All Payer	$5,992.06

PLATE VOLAR SMARTLOCK WIDE SHT

Facility

$6,809.16

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$885.19
Max. Negotiated Rate	$6,536.79
Rate for Payer: Aetna Commercial	$5,243.05
Rate for Payer: Anthem Medicaid	$2,341.67
Rate for Payer: Anthem POS/PPO/Traditional	$5,311.14
Rate for Payer: Cash Price	$3,404.58
Rate for Payer: Cigna Commercial	$5,651.60
Rate for Payer: First Health Commercial	$6,468.70
Rate for Payer: Humana Commercial	$5,787.79
Rate for Payer: Humana KY Medicaid	$2,341.67
Rate for Payer: Kentucky WC Medicaid	$2,365.50
Rate for Payer: Medical Mutual Of Ohio HMO	$5,583.51
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,025.16
Rate for Payer: Molina Healthcare Benefit Exchange	$2,042.75
Rate for Payer: Molina Healthcare Medicaid	$2,388.65
Rate for Payer: Ohio Health Choice Commercial	$5,992.06
Rate for Payer: Ohio Health Group HMO	$5,106.87
Rate for Payer: Ohio Health Group PPO Differential	$1,361.83
Rate for Payer: Ohio Health Group PPO No Differential	$885.19
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,110.84
Rate for Payer: PHCS Commercial	$6,536.79
Rate for Payer: United Healthcare All Payer	$5,992.06

PLATE VOLAR SMARTLOCK WIDE SHT

Facility

$6,809.16

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$885.19
Max. Negotiated Rate	$6,536.79
Rate for Payer: Aetna Commercial	$5,243.05
Rate for Payer: Anthem POS/PPO/Traditional	$5,311.14
Rate for Payer: Cash Price	$3,404.58
Rate for Payer: Cigna Commercial	$5,651.60
Rate for Payer: First Health Commercial	$6,468.70
Rate for Payer: Humana Commercial	$5,787.79
Rate for Payer: Medical Mutual Of Ohio HMO	$5,583.51
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,025.16
Rate for Payer: Molina Healthcare Benefit Exchange	$2,042.75
Rate for Payer: Ohio Health Choice Commercial	$5,992.06
Rate for Payer: Ohio Health Group HMO	$5,106.87
Rate for Payer: Ohio Health Group PPO Differential	$1,361.83
Rate for Payer: Ohio Health Group PPO No Differential	$885.19
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,110.84
Rate for Payer: PHCS Commercial	$6,536.79
Rate for Payer: United Healthcare All Payer	$5,992.06

PLATE VOLAR W/LIP LEFT 4H

Facility

$4,902.00

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$637.26
Max. Negotiated Rate	$4,705.92
Rate for Payer: Aetna Commercial	$3,774.54
Rate for Payer: Anthem POS/PPO/Traditional	$3,823.56
Rate for Payer: Cash Price	$2,451.00
Rate for Payer: Cigna Commercial	$4,068.66
Rate for Payer: First Health Commercial	$4,656.90
Rate for Payer: Humana Commercial	$4,166.70
Rate for Payer: Medical Mutual Of Ohio HMO	$4,019.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,617.68
Rate for Payer: Molina Healthcare Benefit Exchange	$1,470.60
Rate for Payer: Ohio Health Choice Commercial	$4,313.76
Rate for Payer: Ohio Health Group HMO	$3,676.50
Rate for Payer: Ohio Health Group PPO Differential	$980.40
Rate for Payer: Ohio Health Group PPO No Differential	$637.26
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,519.62
Rate for Payer: PHCS Commercial	$4,705.92
Rate for Payer: United Healthcare All Payer	$4,313.76

PLATE VOLAR W/LIP LEFT 4H

Facility

$4,902.00

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$637.26
Max. Negotiated Rate	$4,705.92
Rate for Payer: Aetna Commercial	$3,774.54
Rate for Payer: Anthem Medicaid	$1,685.80
Rate for Payer: Anthem POS/PPO/Traditional	$3,823.56
Rate for Payer: Cash Price	$2,451.00
Rate for Payer: Cigna Commercial	$4,068.66
Rate for Payer: First Health Commercial	$4,656.90
Rate for Payer: Humana Commercial	$4,166.70
Rate for Payer: Humana KY Medicaid	$1,685.80
Rate for Payer: Kentucky WC Medicaid	$1,702.95
Rate for Payer: Medical Mutual Of Ohio HMO	$4,019.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,617.68
Rate for Payer: Molina Healthcare Benefit Exchange	$1,470.60
Rate for Payer: Molina Healthcare Medicaid	$1,719.62
Rate for Payer: Ohio Health Choice Commercial	$4,313.76
Rate for Payer: Ohio Health Group HMO	$3,676.50
Rate for Payer: Ohio Health Group PPO Differential	$980.40
Rate for Payer: Ohio Health Group PPO No Differential	$637.26
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,519.62
Rate for Payer: PHCS Commercial	$4,705.92
Rate for Payer: United Healthcare All Payer	$4,313.76

PLATE VOLAR W/LIP LEFT 5H

Facility

$4,902.00

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$637.26
Max. Negotiated Rate	$4,705.92
Rate for Payer: Aetna Commercial	$3,774.54
Rate for Payer: Anthem Medicaid	$1,685.80
Rate for Payer: Anthem POS/PPO/Traditional	$3,823.56
Rate for Payer: Cash Price	$2,451.00
Rate for Payer: Cigna Commercial	$4,068.66
Rate for Payer: First Health Commercial	$4,656.90
Rate for Payer: Humana Commercial	$4,166.70
Rate for Payer: Humana KY Medicaid	$1,685.80
Rate for Payer: Kentucky WC Medicaid	$1,702.95
Rate for Payer: Medical Mutual Of Ohio HMO	$4,019.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,617.68
Rate for Payer: Molina Healthcare Benefit Exchange	$1,470.60
Rate for Payer: Molina Healthcare Medicaid	$1,719.62
Rate for Payer: Ohio Health Choice Commercial	$4,313.76
Rate for Payer: Ohio Health Group HMO	$3,676.50
Rate for Payer: Ohio Health Group PPO Differential	$980.40
Rate for Payer: Ohio Health Group PPO No Differential	$637.26
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,519.62
Rate for Payer: PHCS Commercial	$4,705.92
Rate for Payer: United Healthcare All Payer	$4,313.76

PLATE VOLAR W/LIP LEFT 5H

Facility

$4,902.00

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$637.26
Max. Negotiated Rate	$4,705.92
Rate for Payer: Aetna Commercial	$3,774.54
Rate for Payer: Anthem POS/PPO/Traditional	$3,823.56
Rate for Payer: Cash Price	$2,451.00
Rate for Payer: Cigna Commercial	$4,068.66
Rate for Payer: First Health Commercial	$4,656.90
Rate for Payer: Humana Commercial	$4,166.70
Rate for Payer: Medical Mutual Of Ohio HMO	$4,019.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,617.68
Rate for Payer: Molina Healthcare Benefit Exchange	$1,470.60
Rate for Payer: Ohio Health Choice Commercial	$4,313.76
Rate for Payer: Ohio Health Group HMO	$3,676.50
Rate for Payer: Ohio Health Group PPO Differential	$980.40
Rate for Payer: Ohio Health Group PPO No Differential	$637.26
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,519.62
Rate for Payer: PHCS Commercial	$4,705.92
Rate for Payer: United Healthcare All Payer	$4,313.76

PLATE VOLAR W/LIP LEFT 6H

Facility

$4,902.00

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$637.26
Max. Negotiated Rate	$4,705.92
Rate for Payer: Aetna Commercial	$3,774.54
Rate for Payer: Anthem Medicaid	$1,685.80
Rate for Payer: Anthem POS/PPO/Traditional	$3,823.56
Rate for Payer: Cash Price	$2,451.00
Rate for Payer: Cigna Commercial	$4,068.66
Rate for Payer: First Health Commercial	$4,656.90
Rate for Payer: Humana Commercial	$4,166.70
Rate for Payer: Humana KY Medicaid	$1,685.80
Rate for Payer: Kentucky WC Medicaid	$1,702.95
Rate for Payer: Medical Mutual Of Ohio HMO	$4,019.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,617.68
Rate for Payer: Molina Healthcare Benefit Exchange	$1,470.60
Rate for Payer: Molina Healthcare Medicaid	$1,719.62
Rate for Payer: Ohio Health Choice Commercial	$4,313.76
Rate for Payer: Ohio Health Group HMO	$3,676.50
Rate for Payer: Ohio Health Group PPO Differential	$980.40
Rate for Payer: Ohio Health Group PPO No Differential	$637.26
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,519.62
Rate for Payer: PHCS Commercial	$4,705.92
Rate for Payer: United Healthcare All Payer	$4,313.76

PLATE VOLAR W/LIP LEFT 6H

Facility

$4,902.00

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$637.26
Max. Negotiated Rate	$4,705.92
Rate for Payer: Aetna Commercial	$3,774.54
Rate for Payer: Anthem POS/PPO/Traditional	$3,823.56
Rate for Payer: Cash Price	$2,451.00
Rate for Payer: Cigna Commercial	$4,068.66
Rate for Payer: First Health Commercial	$4,656.90
Rate for Payer: Humana Commercial	$4,166.70
Rate for Payer: Medical Mutual Of Ohio HMO	$4,019.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,617.68
Rate for Payer: Molina Healthcare Benefit Exchange	$1,470.60
Rate for Payer: Ohio Health Choice Commercial	$4,313.76
Rate for Payer: Ohio Health Group HMO	$3,676.50
Rate for Payer: Ohio Health Group PPO Differential	$980.40
Rate for Payer: Ohio Health Group PPO No Differential	$637.26
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,519.62
Rate for Payer: PHCS Commercial	$4,705.92
Rate for Payer: United Healthcare All Payer	$4,313.76

PLATE VOLAR W/LIP LEFT 7H

Facility

$4,902.00

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$637.26
Max. Negotiated Rate	$4,705.92
Rate for Payer: Humana Commercial	$4,166.70
Rate for Payer: Medical Mutual Of Ohio HMO	$4,019.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,617.68
Rate for Payer: Molina Healthcare Benefit Exchange	$1,470.60
Rate for Payer: Ohio Health Choice Commercial	$4,313.76
Rate for Payer: Ohio Health Group HMO	$3,676.50
Rate for Payer: Ohio Health Group PPO Differential	$980.40
Rate for Payer: Ohio Health Group PPO No Differential	$637.26
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,519.62
Rate for Payer: PHCS Commercial	$4,705.92
Rate for Payer: United Healthcare All Payer	$4,313.76
Rate for Payer: Aetna Commercial	$3,774.54
Rate for Payer: Anthem POS/PPO/Traditional	$3,823.56
Rate for Payer: Cash Price	$2,451.00
Rate for Payer: Cigna Commercial	$4,068.66
Rate for Payer: First Health Commercial	$4,656.90

PLATE VOLAR W/LIP LEFT 7H

Facility

$4,902.00

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$637.26
Max. Negotiated Rate	$4,705.92
Rate for Payer: Aetna Commercial	$3,774.54
Rate for Payer: Anthem Medicaid	$1,685.80
Rate for Payer: Anthem POS/PPO/Traditional	$3,823.56
Rate for Payer: Cash Price	$2,451.00
Rate for Payer: Cigna Commercial	$4,068.66
Rate for Payer: First Health Commercial	$4,656.90
Rate for Payer: Humana Commercial	$4,166.70
Rate for Payer: Humana KY Medicaid	$1,685.80
Rate for Payer: Kentucky WC Medicaid	$1,702.95
Rate for Payer: Medical Mutual Of Ohio HMO	$4,019.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,617.68
Rate for Payer: Molina Healthcare Benefit Exchange	$1,470.60
Rate for Payer: Molina Healthcare Medicaid	$1,719.62
Rate for Payer: Ohio Health Choice Commercial	$4,313.76
Rate for Payer: Ohio Health Group HMO	$3,676.50
Rate for Payer: Ohio Health Group PPO Differential	$980.40
Rate for Payer: Ohio Health Group PPO No Differential	$637.26
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,519.62
Rate for Payer: PHCS Commercial	$4,705.92
Rate for Payer: United Healthcare All Payer	$4,313.76

PLATE VOLAR W/LIP RIGHT 4H

Facility

$4,902.00

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$637.26
Max. Negotiated Rate	$4,705.92
Rate for Payer: Aetna Commercial	$3,774.54
Rate for Payer: Anthem POS/PPO/Traditional	$3,823.56
Rate for Payer: Cash Price	$2,451.00
Rate for Payer: Cigna Commercial	$4,068.66
Rate for Payer: First Health Commercial	$4,656.90
Rate for Payer: Humana Commercial	$4,166.70
Rate for Payer: Medical Mutual Of Ohio HMO	$4,019.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,617.68
Rate for Payer: Molina Healthcare Benefit Exchange	$1,470.60
Rate for Payer: Ohio Health Choice Commercial	$4,313.76
Rate for Payer: Ohio Health Group HMO	$3,676.50
Rate for Payer: Ohio Health Group PPO Differential	$980.40
Rate for Payer: Ohio Health Group PPO No Differential	$637.26
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,519.62
Rate for Payer: PHCS Commercial	$4,705.92
Rate for Payer: United Healthcare All Payer	$4,313.76

PLATE VOLAR W/LIP RIGHT 4H

Facility

$4,902.00

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$637.26
Max. Negotiated Rate	$4,705.92
Rate for Payer: Aetna Commercial	$3,774.54
Rate for Payer: Anthem Medicaid	$1,685.80
Rate for Payer: Anthem POS/PPO/Traditional	$3,823.56
Rate for Payer: Cash Price	$2,451.00
Rate for Payer: Cigna Commercial	$4,068.66
Rate for Payer: First Health Commercial	$4,656.90
Rate for Payer: Humana Commercial	$4,166.70
Rate for Payer: Humana KY Medicaid	$1,685.80
Rate for Payer: Kentucky WC Medicaid	$1,702.95
Rate for Payer: Medical Mutual Of Ohio HMO	$4,019.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,617.68
Rate for Payer: Molina Healthcare Benefit Exchange	$1,470.60
Rate for Payer: Molina Healthcare Medicaid	$1,719.62
Rate for Payer: Ohio Health Choice Commercial	$4,313.76
Rate for Payer: Ohio Health Group HMO	$3,676.50
Rate for Payer: Ohio Health Group PPO Differential	$980.40
Rate for Payer: Ohio Health Group PPO No Differential	$637.26
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,519.62
Rate for Payer: PHCS Commercial	$4,705.92
Rate for Payer: United Healthcare All Payer	$4,313.76

PLATE VOLAR W/LIP RIGHT 5H

Facility

$4,902.00

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$637.26
Max. Negotiated Rate	$4,705.92
Rate for Payer: Aetna Commercial	$3,774.54
Rate for Payer: Anthem Medicaid	$1,685.80
Rate for Payer: Anthem POS/PPO/Traditional	$3,823.56
Rate for Payer: Cash Price	$2,451.00
Rate for Payer: Cigna Commercial	$4,068.66
Rate for Payer: First Health Commercial	$4,656.90
Rate for Payer: Humana Commercial	$4,166.70
Rate for Payer: Humana KY Medicaid	$1,685.80
Rate for Payer: Kentucky WC Medicaid	$1,702.95
Rate for Payer: Medical Mutual Of Ohio HMO	$4,019.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,617.68
Rate for Payer: Molina Healthcare Benefit Exchange	$1,470.60
Rate for Payer: Molina Healthcare Medicaid	$1,719.62
Rate for Payer: Ohio Health Choice Commercial	$4,313.76
Rate for Payer: Ohio Health Group HMO	$3,676.50
Rate for Payer: Ohio Health Group PPO Differential	$980.40
Rate for Payer: Ohio Health Group PPO No Differential	$637.26
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,519.62
Rate for Payer: PHCS Commercial	$4,705.92
Rate for Payer: United Healthcare All Payer	$4,313.76

PLATE VOLAR W/LIP RIGHT 5H

Facility

$4,902.00

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$637.26
Max. Negotiated Rate	$4,705.92
Rate for Payer: Aetna Commercial	$3,774.54
Rate for Payer: Anthem POS/PPO/Traditional	$3,823.56
Rate for Payer: Cash Price	$2,451.00
Rate for Payer: Cigna Commercial	$4,068.66
Rate for Payer: First Health Commercial	$4,656.90
Rate for Payer: Humana Commercial	$4,166.70
Rate for Payer: Medical Mutual Of Ohio HMO	$4,019.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,617.68
Rate for Payer: Molina Healthcare Benefit Exchange	$1,470.60
Rate for Payer: Ohio Health Choice Commercial	$4,313.76
Rate for Payer: Ohio Health Group HMO	$3,676.50
Rate for Payer: Ohio Health Group PPO Differential	$980.40
Rate for Payer: Ohio Health Group PPO No Differential	$637.26
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,519.62
Rate for Payer: PHCS Commercial	$4,705.92
Rate for Payer: United Healthcare All Payer	$4,313.76

PLATE VOLAR W/LIP RIGHT 6H

Facility

$4,902.00

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$637.26
Max. Negotiated Rate	$4,705.92
Rate for Payer: Aetna Commercial	$3,774.54
Rate for Payer: Anthem Medicaid	$1,685.80
Rate for Payer: Anthem POS/PPO/Traditional	$3,823.56
Rate for Payer: Cash Price	$2,451.00
Rate for Payer: Cigna Commercial	$4,068.66
Rate for Payer: First Health Commercial	$4,656.90
Rate for Payer: Humana Commercial	$4,166.70
Rate for Payer: Humana KY Medicaid	$1,685.80
Rate for Payer: Kentucky WC Medicaid	$1,702.95
Rate for Payer: Medical Mutual Of Ohio HMO	$4,019.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,617.68
Rate for Payer: Molina Healthcare Benefit Exchange	$1,470.60
Rate for Payer: Molina Healthcare Medicaid	$1,719.62
Rate for Payer: Ohio Health Choice Commercial	$4,313.76
Rate for Payer: Ohio Health Group HMO	$3,676.50
Rate for Payer: Ohio Health Group PPO Differential	$980.40
Rate for Payer: Ohio Health Group PPO No Differential	$637.26
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,519.62
Rate for Payer: PHCS Commercial	$4,705.92
Rate for Payer: United Healthcare All Payer	$4,313.76

PLATE VOLAR W/LIP RIGHT 6H

Facility

$4,902.00

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$637.26
Max. Negotiated Rate	$4,705.92
Rate for Payer: Aetna Commercial	$3,774.54
Rate for Payer: Anthem POS/PPO/Traditional	$3,823.56
Rate for Payer: Cash Price	$2,451.00
Rate for Payer: Cigna Commercial	$4,068.66
Rate for Payer: First Health Commercial	$4,656.90
Rate for Payer: Humana Commercial	$4,166.70
Rate for Payer: Medical Mutual Of Ohio HMO	$4,019.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,617.68
Rate for Payer: Molina Healthcare Benefit Exchange	$1,470.60
Rate for Payer: Ohio Health Choice Commercial	$4,313.76
Rate for Payer: Ohio Health Group HMO	$3,676.50
Rate for Payer: Ohio Health Group PPO Differential	$980.40
Rate for Payer: Ohio Health Group PPO No Differential	$637.26
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,519.62
Rate for Payer: PHCS Commercial	$4,705.92
Rate for Payer: United Healthcare All Payer	$4,313.76

PLATE VOLAR W/LIP RIGHT 7H

Facility

$4,902.00

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$637.26
Max. Negotiated Rate	$4,705.92
Rate for Payer: Humana Commercial	$4,166.70
Rate for Payer: Humana KY Medicaid	$1,685.80
Rate for Payer: Kentucky WC Medicaid	$1,702.95
Rate for Payer: Medical Mutual Of Ohio HMO	$4,019.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,617.68
Rate for Payer: Molina Healthcare Benefit Exchange	$1,470.60
Rate for Payer: Molina Healthcare Medicaid	$1,719.62
Rate for Payer: Ohio Health Choice Commercial	$4,313.76
Rate for Payer: Ohio Health Group HMO	$3,676.50
Rate for Payer: Ohio Health Group PPO Differential	$980.40
Rate for Payer: Ohio Health Group PPO No Differential	$637.26
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,519.62
Rate for Payer: PHCS Commercial	$4,705.92
Rate for Payer: United Healthcare All Payer	$4,313.76
Rate for Payer: Aetna Commercial	$3,774.54
Rate for Payer: Anthem Medicaid	$1,685.80
Rate for Payer: Anthem POS/PPO/Traditional	$3,823.56
Rate for Payer: Cash Price	$2,451.00
Rate for Payer: Cigna Commercial	$4,068.66
Rate for Payer: First Health Commercial	$4,656.90

PLATE VOLAR W/LIP RIGHT 7H

Facility

$4,902.00

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$637.26
Max. Negotiated Rate	$4,705.92
Rate for Payer: Aetna Commercial	$3,774.54
Rate for Payer: Anthem POS/PPO/Traditional	$3,823.56
Rate for Payer: Cash Price	$2,451.00
Rate for Payer: Cigna Commercial	$4,068.66
Rate for Payer: First Health Commercial	$4,656.90
Rate for Payer: Humana Commercial	$4,166.70
Rate for Payer: Medical Mutual Of Ohio HMO	$4,019.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,617.68
Rate for Payer: Molina Healthcare Benefit Exchange	$1,470.60
Rate for Payer: Ohio Health Choice Commercial	$4,313.76
Rate for Payer: Ohio Health Group HMO	$3,676.50
Rate for Payer: Ohio Health Group PPO Differential	$980.40
Rate for Payer: Ohio Health Group PPO No Differential	$637.26
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,519.62
Rate for Payer: PHCS Commercial	$4,705.92
Rate for Payer: United Healthcare All Payer	$4,313.76

PLATE VOLAR W/O LIP LEFT 4H

Facility

$4,902.00

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$637.26
Max. Negotiated Rate	$4,705.92
Rate for Payer: Aetna Commercial	$3,774.54
Rate for Payer: Anthem Medicaid	$1,685.80
Rate for Payer: Anthem POS/PPO/Traditional	$3,823.56
Rate for Payer: Cash Price	$2,451.00
Rate for Payer: Cigna Commercial	$4,068.66
Rate for Payer: First Health Commercial	$4,656.90
Rate for Payer: Humana Commercial	$4,166.70
Rate for Payer: Humana KY Medicaid	$1,685.80
Rate for Payer: Kentucky WC Medicaid	$1,702.95
Rate for Payer: Medical Mutual Of Ohio HMO	$4,019.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,617.68
Rate for Payer: Molina Healthcare Benefit Exchange	$1,470.60
Rate for Payer: Molina Healthcare Medicaid	$1,719.62
Rate for Payer: Ohio Health Choice Commercial	$4,313.76
Rate for Payer: Ohio Health Group HMO	$3,676.50
Rate for Payer: Ohio Health Group PPO Differential	$980.40
Rate for Payer: Ohio Health Group PPO No Differential	$637.26
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,519.62
Rate for Payer: PHCS Commercial	$4,705.92
Rate for Payer: United Healthcare All Payer	$4,313.76

PLATE VOLAR W/O LIP LEFT 4H

Facility

$4,902.00

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$637.26
Max. Negotiated Rate	$4,705.92
Rate for Payer: Aetna Commercial	$3,774.54
Rate for Payer: Anthem POS/PPO/Traditional	$3,823.56
Rate for Payer: Cash Price	$2,451.00
Rate for Payer: Cigna Commercial	$4,068.66
Rate for Payer: First Health Commercial	$4,656.90
Rate for Payer: Humana Commercial	$4,166.70
Rate for Payer: Medical Mutual Of Ohio HMO	$4,019.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,617.68
Rate for Payer: Molina Healthcare Benefit Exchange	$1,470.60
Rate for Payer: Ohio Health Choice Commercial	$4,313.76
Rate for Payer: Ohio Health Group HMO	$3,676.50
Rate for Payer: Ohio Health Group PPO Differential	$980.40
Rate for Payer: Ohio Health Group PPO No Differential	$637.26
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,519.62
Rate for Payer: PHCS Commercial	$4,705.92
Rate for Payer: United Healthcare All Payer	$4,313.76

PLATE VOLAR W/O LIP LEFT 5H

Facility

$4,902.00

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$637.26
Max. Negotiated Rate	$4,705.92
Rate for Payer: Aetna Commercial	$3,774.54
Rate for Payer: Anthem Medicaid	$1,685.80
Rate for Payer: Anthem POS/PPO/Traditional	$3,823.56
Rate for Payer: Cash Price	$2,451.00
Rate for Payer: Cigna Commercial	$4,068.66
Rate for Payer: First Health Commercial	$4,656.90
Rate for Payer: Humana Commercial	$4,166.70
Rate for Payer: Humana KY Medicaid	$1,685.80
Rate for Payer: Kentucky WC Medicaid	$1,702.95
Rate for Payer: Medical Mutual Of Ohio HMO	$4,019.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,617.68
Rate for Payer: Molina Healthcare Benefit Exchange	$1,470.60
Rate for Payer: Molina Healthcare Medicaid	$1,719.62
Rate for Payer: Ohio Health Choice Commercial	$4,313.76
Rate for Payer: Ohio Health Group HMO	$3,676.50
Rate for Payer: Ohio Health Group PPO Differential	$980.40
Rate for Payer: Ohio Health Group PPO No Differential	$637.26
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,519.62
Rate for Payer: PHCS Commercial	$4,705.92
Rate for Payer: United Healthcare All Payer	$4,313.76

PLATE VOLAR W/O LIP LEFT 5H

Facility

$4,902.00

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$637.26
Max. Negotiated Rate	$4,705.92
Rate for Payer: Aetna Commercial	$3,774.54
Rate for Payer: Anthem POS/PPO/Traditional	$3,823.56
Rate for Payer: Cash Price	$2,451.00
Rate for Payer: Cigna Commercial	$4,068.66
Rate for Payer: First Health Commercial	$4,656.90
Rate for Payer: Humana Commercial	$4,166.70
Rate for Payer: Medical Mutual Of Ohio HMO	$4,019.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,617.68
Rate for Payer: Molina Healthcare Benefit Exchange	$1,470.60
Rate for Payer: Ohio Health Choice Commercial	$4,313.76
Rate for Payer: Ohio Health Group HMO	$3,676.50
Rate for Payer: Ohio Health Group PPO Differential	$980.40
Rate for Payer: Ohio Health Group PPO No Differential	$637.26
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,519.62
Rate for Payer: PHCS Commercial	$4,705.92
Rate for Payer: United Healthcare All Payer	$4,313.76

PLATE VOLAR W/O LIP LEFT 6H

Facility

$4,902.00

Service Code	HCPCS C1713
Hospital Charge Code	27000005
Hospital Revenue Code	278
Min. Negotiated Rate	$637.26
Max. Negotiated Rate	$4,705.92
Rate for Payer: Aetna Commercial	$3,774.54
Rate for Payer: Anthem POS/PPO/Traditional	$3,823.56
Rate for Payer: Cash Price	$2,451.00
Rate for Payer: Cigna Commercial	$4,068.66
Rate for Payer: First Health Commercial	$4,656.90
Rate for Payer: Humana Commercial	$4,166.70
Rate for Payer: Medical Mutual Of Ohio HMO	$4,019.64
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,617.68
Rate for Payer: Molina Healthcare Benefit Exchange	$1,470.60
Rate for Payer: Ohio Health Choice Commercial	$4,313.76
Rate for Payer: Ohio Health Group HMO	$3,676.50
Rate for Payer: Ohio Health Group PPO Differential	$980.40
Rate for Payer: Ohio Health Group PPO No Differential	$637.26
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,519.62
Rate for Payer: PHCS Commercial	$4,705.92
Rate for Payer: United Healthcare All Payer	$4,313.76

Know your out-of-pocket cost for care.

All Charges