|
PLATE VOL DOR DS RD 2.4*41 +90
|
Facility
|
OP
|
$4,526.03
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$588.38 |
| Max. Negotiated Rate |
$4,344.99 |
| Rate for Payer: Aetna Commercial |
$3,485.04
|
| Rate for Payer: Anthem Medicaid |
$1,556.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,530.30
|
| Rate for Payer: Cash Price |
$2,263.01
|
| Rate for Payer: Cigna Commercial |
$3,756.60
|
| Rate for Payer: First Health Commercial |
$4,299.73
|
| Rate for Payer: Humana Commercial |
$3,847.13
|
| Rate for Payer: Humana KY Medicaid |
$1,556.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,572.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,711.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,340.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,357.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,587.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,982.91
|
| Rate for Payer: Ohio Health Group HMO |
$3,394.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$905.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$588.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,403.07
|
| Rate for Payer: PHCS Commercial |
$4,344.99
|
| Rate for Payer: United Healthcare All Payer |
$3,982.91
|
|
|
PLATE VOL DOR DS RD 2.4*41 +90
|
Facility
|
IP
|
$4,526.03
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$588.38 |
| Max. Negotiated Rate |
$4,344.99 |
| Rate for Payer: Aetna Commercial |
$3,485.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,530.30
|
| Rate for Payer: Cash Price |
$2,263.01
|
| Rate for Payer: Cigna Commercial |
$3,756.60
|
| Rate for Payer: First Health Commercial |
$4,299.73
|
| Rate for Payer: Humana Commercial |
$3,847.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,711.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,340.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,357.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,982.91
|
| Rate for Payer: Ohio Health Group HMO |
$3,394.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$905.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$588.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,403.07
|
| Rate for Payer: PHCS Commercial |
$4,344.99
|
| Rate for Payer: United Healthcare All Payer |
$3,982.91
|
|
|
PLATE VOL DOR DS RD 2.4*41 -90
|
Facility
|
IP
|
$4,526.03
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$588.38 |
| Max. Negotiated Rate |
$4,344.99 |
| Rate for Payer: Aetna Commercial |
$3,485.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,530.30
|
| Rate for Payer: Cash Price |
$2,263.01
|
| Rate for Payer: Cigna Commercial |
$3,756.60
|
| Rate for Payer: First Health Commercial |
$4,299.73
|
| Rate for Payer: Humana Commercial |
$3,847.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,711.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,340.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,357.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,982.91
|
| Rate for Payer: Ohio Health Group HMO |
$3,394.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$905.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$588.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,403.07
|
| Rate for Payer: PHCS Commercial |
$4,344.99
|
| Rate for Payer: United Healthcare All Payer |
$3,982.91
|
|
|
PLATE VOL DOR DS RD 2.4*41 -90
|
Facility
|
OP
|
$4,526.03
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$588.38 |
| Max. Negotiated Rate |
$4,344.99 |
| Rate for Payer: Aetna Commercial |
$3,485.04
|
| Rate for Payer: Anthem Medicaid |
$1,556.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,530.30
|
| Rate for Payer: Cash Price |
$2,263.01
|
| Rate for Payer: Cigna Commercial |
$3,756.60
|
| Rate for Payer: First Health Commercial |
$4,299.73
|
| Rate for Payer: Humana Commercial |
$3,847.13
|
| Rate for Payer: Humana KY Medicaid |
$1,556.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,572.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,711.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,340.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,357.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,587.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,982.91
|
| Rate for Payer: Ohio Health Group HMO |
$3,394.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$905.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$588.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,403.07
|
| Rate for Payer: PHCS Commercial |
$4,344.99
|
| Rate for Payer: United Healthcare All Payer |
$3,982.91
|
|
|
PLATE VOL DOR DS RD 2.4*49 +90
|
Facility
|
OP
|
$4,221.35
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$548.78 |
| Max. Negotiated Rate |
$4,052.50 |
| Rate for Payer: Anthem Medicaid |
$1,451.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,292.65
|
| Rate for Payer: Cash Price |
$2,110.68
|
| Rate for Payer: Cigna Commercial |
$3,503.72
|
| Rate for Payer: First Health Commercial |
$4,010.28
|
| Rate for Payer: Humana Commercial |
$3,588.15
|
| Rate for Payer: Humana KY Medicaid |
$1,451.72
|
| Rate for Payer: Kentucky WC Medicaid |
$1,466.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,461.51
|
| Rate for Payer: Aetna Commercial |
$3,250.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,115.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,266.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,480.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,714.79
|
| Rate for Payer: Ohio Health Group HMO |
$3,166.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$844.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$548.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,308.62
|
| Rate for Payer: PHCS Commercial |
$4,052.50
|
| Rate for Payer: United Healthcare All Payer |
$3,714.79
|
|
|
PLATE VOL DOR DS RD 2.4*49 +90
|
Facility
|
IP
|
$4,221.35
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$548.78 |
| Max. Negotiated Rate |
$4,052.50 |
| Rate for Payer: Aetna Commercial |
$3,250.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,292.65
|
| Rate for Payer: Cash Price |
$2,110.68
|
| Rate for Payer: Cigna Commercial |
$3,503.72
|
| Rate for Payer: First Health Commercial |
$4,010.28
|
| Rate for Payer: Humana Commercial |
$3,588.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,461.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,115.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,266.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,714.79
|
| Rate for Payer: Ohio Health Group HMO |
$3,166.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$844.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$548.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,308.62
|
| Rate for Payer: PHCS Commercial |
$4,052.50
|
| Rate for Payer: United Healthcare All Payer |
$3,714.79
|
|
|
PLATE VOL DOR DS RD 2.4*49 -90
|
Facility
|
OP
|
$4,610.52
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$599.37 |
| Max. Negotiated Rate |
$4,426.10 |
| Rate for Payer: Aetna Commercial |
$3,550.10
|
| Rate for Payer: Anthem Medicaid |
$1,585.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,596.21
|
| Rate for Payer: Cash Price |
$2,305.26
|
| Rate for Payer: Cigna Commercial |
$3,826.73
|
| Rate for Payer: First Health Commercial |
$4,379.99
|
| Rate for Payer: Humana Commercial |
$3,918.94
|
| Rate for Payer: Humana KY Medicaid |
$1,585.56
|
| Rate for Payer: Kentucky WC Medicaid |
$1,601.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,780.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,402.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,383.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,617.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,057.26
|
| Rate for Payer: Ohio Health Group HMO |
$3,457.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$922.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$599.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,429.26
|
| Rate for Payer: PHCS Commercial |
$4,426.10
|
| Rate for Payer: United Healthcare All Payer |
$4,057.26
|
|
|
PLATE VOL DOR DS RD 2.4*49 -90
|
Facility
|
IP
|
$4,610.52
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$599.37 |
| Max. Negotiated Rate |
$4,426.10 |
| Rate for Payer: Aetna Commercial |
$3,550.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,596.21
|
| Rate for Payer: Cash Price |
$2,305.26
|
| Rate for Payer: Cigna Commercial |
$3,826.73
|
| Rate for Payer: First Health Commercial |
$4,379.99
|
| Rate for Payer: Humana Commercial |
$3,918.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,780.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,402.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,383.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,057.26
|
| Rate for Payer: Ohio Health Group HMO |
$3,457.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$922.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$599.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,429.26
|
| Rate for Payer: PHCS Commercial |
$4,426.10
|
| Rate for Payer: United Healthcare All Payer |
$4,057.26
|
|
|
PLATE VOL DST RD 5H 2.4*66 R
|
Facility
|
OP
|
$6,784.01
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.92 |
| Max. Negotiated Rate |
$6,512.65 |
| Rate for Payer: Aetna Commercial |
$5,223.69
|
| Rate for Payer: Anthem Medicaid |
$2,333.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,291.53
|
| Rate for Payer: Cash Price |
$3,392.01
|
| Rate for Payer: Cigna Commercial |
$5,630.73
|
| Rate for Payer: First Health Commercial |
$6,444.81
|
| Rate for Payer: Humana Commercial |
$5,766.41
|
| Rate for Payer: Humana KY Medicaid |
$2,333.02
|
| Rate for Payer: Kentucky WC Medicaid |
$2,356.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,562.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,006.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,035.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,379.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,969.93
|
| Rate for Payer: Ohio Health Group HMO |
$5,088.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$881.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,103.04
|
| Rate for Payer: PHCS Commercial |
$6,512.65
|
| Rate for Payer: United Healthcare All Payer |
$5,969.93
|
|
|
PLATE VOL DST RD 5H 2.4*66 R
|
Facility
|
IP
|
$6,784.01
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.92 |
| Max. Negotiated Rate |
$6,512.65 |
| Rate for Payer: Aetna Commercial |
$5,223.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,291.53
|
| Rate for Payer: Cash Price |
$3,392.01
|
| Rate for Payer: Cigna Commercial |
$5,630.73
|
| Rate for Payer: First Health Commercial |
$6,444.81
|
| Rate for Payer: Humana Commercial |
$5,766.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,562.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,006.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,035.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,969.93
|
| Rate for Payer: Ohio Health Group HMO |
$5,088.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$881.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,103.04
|
| Rate for Payer: PHCS Commercial |
$6,512.65
|
| Rate for Payer: United Healthcare All Payer |
$5,969.93
|
|
|
PLATE V PROFL LCK 2.3 LE MC 5H
|
Facility
|
IP
|
$4,941.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$642.36 |
| Max. Negotiated Rate |
$4,743.55 |
| Rate for Payer: Aetna Commercial |
$3,804.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,854.14
|
| Rate for Payer: Cash Price |
$2,470.60
|
| Rate for Payer: Cigna Commercial |
$4,101.20
|
| Rate for Payer: First Health Commercial |
$4,694.14
|
| Rate for Payer: Humana Commercial |
$4,200.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,051.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,646.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,482.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,348.26
|
| Rate for Payer: Ohio Health Group HMO |
$3,705.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$988.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$642.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,531.77
|
| Rate for Payer: PHCS Commercial |
$4,743.55
|
| Rate for Payer: United Healthcare All Payer |
$4,348.26
|
|
|
PLATE V PROFL LCK 2.3 LE MC 5H
|
Facility
|
OP
|
$4,941.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$642.36 |
| Max. Negotiated Rate |
$4,743.55 |
| Rate for Payer: Aetna Commercial |
$3,804.72
|
| Rate for Payer: Anthem Medicaid |
$1,699.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,854.14
|
| Rate for Payer: Cash Price |
$2,470.60
|
| Rate for Payer: Cigna Commercial |
$4,101.20
|
| Rate for Payer: First Health Commercial |
$4,694.14
|
| Rate for Payer: Humana Commercial |
$4,200.02
|
| Rate for Payer: Humana KY Medicaid |
$1,699.28
|
| Rate for Payer: Kentucky WC Medicaid |
$1,716.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,051.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,646.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,482.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,733.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,348.26
|
| Rate for Payer: Ohio Health Group HMO |
$3,705.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$988.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$642.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,531.77
|
| Rate for Payer: PHCS Commercial |
$4,743.55
|
| Rate for Payer: United Healthcare All Payer |
$4,348.26
|
|
|
PLATE V PROFL LCK 2.3 RI MC 5H
|
Facility
|
IP
|
$4,941.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$642.36 |
| Max. Negotiated Rate |
$4,743.55 |
| Rate for Payer: Aetna Commercial |
$3,804.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,854.14
|
| Rate for Payer: Cash Price |
$2,470.60
|
| Rate for Payer: Cigna Commercial |
$4,101.20
|
| Rate for Payer: First Health Commercial |
$4,694.14
|
| Rate for Payer: Humana Commercial |
$4,200.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,051.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,646.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,482.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,348.26
|
| Rate for Payer: Ohio Health Group HMO |
$3,705.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$988.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$642.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,531.77
|
| Rate for Payer: PHCS Commercial |
$4,743.55
|
| Rate for Payer: United Healthcare All Payer |
$4,348.26
|
|
|
PLATE V PROFL LCK 2.3 RI MC 5H
|
Facility
|
OP
|
$4,941.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$642.36 |
| Max. Negotiated Rate |
$4,743.55 |
| Rate for Payer: Aetna Commercial |
$3,804.72
|
| Rate for Payer: Anthem Medicaid |
$1,699.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,854.14
|
| Rate for Payer: Cash Price |
$2,470.60
|
| Rate for Payer: Cigna Commercial |
$4,101.20
|
| Rate for Payer: First Health Commercial |
$4,694.14
|
| Rate for Payer: Humana Commercial |
$4,200.02
|
| Rate for Payer: Humana KY Medicaid |
$1,699.28
|
| Rate for Payer: Kentucky WC Medicaid |
$1,716.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,051.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,646.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,482.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,733.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,348.26
|
| Rate for Payer: Ohio Health Group HMO |
$3,705.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$988.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$642.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,531.77
|
| Rate for Payer: PHCS Commercial |
$4,743.55
|
| Rate for Payer: United Healthcare All Payer |
$4,348.26
|
|
|
PLATE WDE HD V-D-R LK 3 62MM R
|
Facility
|
OP
|
$5,016.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$652.16 |
| Max. Negotiated Rate |
$4,815.96 |
| Rate for Payer: Aetna Commercial |
$3,862.80
|
| Rate for Payer: Anthem Medicaid |
$1,725.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,912.96
|
| Rate for Payer: Cash Price |
$2,508.31
|
| Rate for Payer: Cigna Commercial |
$4,163.79
|
| Rate for Payer: First Health Commercial |
$4,765.79
|
| Rate for Payer: Humana Commercial |
$4,264.13
|
| Rate for Payer: Humana KY Medicaid |
$1,725.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1,742.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,113.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,702.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,504.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,759.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,414.63
|
| Rate for Payer: Ohio Health Group HMO |
$3,762.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,003.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$652.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,555.15
|
| Rate for Payer: PHCS Commercial |
$4,815.96
|
| Rate for Payer: United Healthcare All Payer |
$4,414.63
|
|
|
PLATE WDE HD V-D-R LK 3 62MM R
|
Facility
|
IP
|
$5,016.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$652.16 |
| Max. Negotiated Rate |
$4,815.96 |
| Rate for Payer: Aetna Commercial |
$3,862.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,912.96
|
| Rate for Payer: Cash Price |
$2,508.31
|
| Rate for Payer: Cigna Commercial |
$4,163.79
|
| Rate for Payer: First Health Commercial |
$4,765.79
|
| Rate for Payer: Humana Commercial |
$4,264.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,113.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,702.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,504.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,414.63
|
| Rate for Payer: Ohio Health Group HMO |
$3,762.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,003.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$652.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,555.15
|
| Rate for Payer: PHCS Commercial |
$4,815.96
|
| Rate for Payer: United Healthcare All Payer |
$4,414.63
|
|
|
PLATE WDE HD V-D-R LK 5 86MM R
|
Facility
|
IP
|
$5,184.98
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$674.05 |
| Max. Negotiated Rate |
$4,977.58 |
| Rate for Payer: Aetna Commercial |
$3,992.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,044.28
|
| Rate for Payer: Cash Price |
$2,592.49
|
| Rate for Payer: Cigna Commercial |
$4,303.53
|
| Rate for Payer: First Health Commercial |
$4,925.73
|
| Rate for Payer: Humana Commercial |
$4,407.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,251.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,826.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,555.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,562.78
|
| Rate for Payer: Ohio Health Group HMO |
$3,888.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,037.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$674.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,607.34
|
| Rate for Payer: PHCS Commercial |
$4,977.58
|
| Rate for Payer: United Healthcare All Payer |
$4,562.78
|
|
|
PLATE WDE HD V-D-R LK 5 86MM R
|
Facility
|
OP
|
$5,184.98
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$674.05 |
| Max. Negotiated Rate |
$4,977.58 |
| Rate for Payer: Anthem Medicaid |
$1,783.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,044.28
|
| Rate for Payer: Cash Price |
$2,592.49
|
| Rate for Payer: Cigna Commercial |
$4,303.53
|
| Rate for Payer: First Health Commercial |
$4,925.73
|
| Rate for Payer: Humana Commercial |
$4,407.23
|
| Rate for Payer: Humana KY Medicaid |
$1,783.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,801.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,251.68
|
| Rate for Payer: Aetna Commercial |
$3,992.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,826.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,555.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,818.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,562.78
|
| Rate for Payer: Ohio Health Group HMO |
$3,888.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,037.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$674.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,607.34
|
| Rate for Payer: PHCS Commercial |
$4,977.58
|
| Rate for Payer: United Healthcare All Payer |
$4,562.78
|
|
|
PLATE WDE LCK HD VDR 3H 62MM L
|
Facility
|
OP
|
$5,016.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$652.16 |
| Max. Negotiated Rate |
$4,815.96 |
| Rate for Payer: Aetna Commercial |
$3,862.80
|
| Rate for Payer: Anthem Medicaid |
$1,725.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,912.96
|
| Rate for Payer: Cash Price |
$2,508.31
|
| Rate for Payer: Cigna Commercial |
$4,163.79
|
| Rate for Payer: First Health Commercial |
$4,765.79
|
| Rate for Payer: Humana Commercial |
$4,264.13
|
| Rate for Payer: Humana KY Medicaid |
$1,725.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1,742.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,113.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,702.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,504.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,759.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,414.63
|
| Rate for Payer: Ohio Health Group HMO |
$3,762.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,003.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$652.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,555.15
|
| Rate for Payer: PHCS Commercial |
$4,815.96
|
| Rate for Payer: United Healthcare All Payer |
$4,414.63
|
|
|
PLATE WDE LCK HD VDR 3H 62MM L
|
Facility
|
IP
|
$5,016.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$652.16 |
| Max. Negotiated Rate |
$4,815.96 |
| Rate for Payer: Aetna Commercial |
$3,862.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,912.96
|
| Rate for Payer: Cash Price |
$2,508.31
|
| Rate for Payer: Cigna Commercial |
$4,163.79
|
| Rate for Payer: First Health Commercial |
$4,765.79
|
| Rate for Payer: Humana Commercial |
$4,264.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,113.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,702.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,504.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,414.63
|
| Rate for Payer: Ohio Health Group HMO |
$3,762.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,003.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$652.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,555.15
|
| Rate for Payer: PHCS Commercial |
$4,815.96
|
| Rate for Payer: United Healthcare All Payer |
$4,414.63
|
|
|
PLATE WDE LCK HD VDR 3H 62MM R
|
Facility
|
OP
|
$5,016.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$652.16 |
| Max. Negotiated Rate |
$4,815.96 |
| Rate for Payer: Aetna Commercial |
$3,862.80
|
| Rate for Payer: Anthem Medicaid |
$1,725.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,912.96
|
| Rate for Payer: Cash Price |
$2,508.31
|
| Rate for Payer: Cigna Commercial |
$4,163.79
|
| Rate for Payer: First Health Commercial |
$4,765.79
|
| Rate for Payer: Humana Commercial |
$4,264.13
|
| Rate for Payer: Humana KY Medicaid |
$1,725.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1,742.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,113.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,702.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,504.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,759.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,414.63
|
| Rate for Payer: Ohio Health Group HMO |
$3,762.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,003.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$652.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,555.15
|
| Rate for Payer: PHCS Commercial |
$4,815.96
|
| Rate for Payer: United Healthcare All Payer |
$4,414.63
|
|
|
PLATE WDE LCK HD VDR 3H 62MM R
|
Facility
|
IP
|
$5,016.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$652.16 |
| Max. Negotiated Rate |
$4,815.96 |
| Rate for Payer: Aetna Commercial |
$3,862.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,912.96
|
| Rate for Payer: Cash Price |
$2,508.31
|
| Rate for Payer: Cigna Commercial |
$4,163.79
|
| Rate for Payer: First Health Commercial |
$4,765.79
|
| Rate for Payer: Humana Commercial |
$4,264.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,113.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,702.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,504.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,414.63
|
| Rate for Payer: Ohio Health Group HMO |
$3,762.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,003.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$652.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,555.15
|
| Rate for Payer: PHCS Commercial |
$4,815.96
|
| Rate for Payer: United Healthcare All Payer |
$4,414.63
|
|
|
PLATE WDE LCK HD VDR 5H 86MM L
|
Facility
|
IP
|
$5,184.98
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$674.05 |
| Max. Negotiated Rate |
$4,977.58 |
| Rate for Payer: Aetna Commercial |
$3,992.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,044.28
|
| Rate for Payer: Cash Price |
$2,592.49
|
| Rate for Payer: Cigna Commercial |
$4,303.53
|
| Rate for Payer: First Health Commercial |
$4,925.73
|
| Rate for Payer: Humana Commercial |
$4,407.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,251.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,826.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,555.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,562.78
|
| Rate for Payer: Ohio Health Group HMO |
$3,888.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,037.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$674.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,607.34
|
| Rate for Payer: PHCS Commercial |
$4,977.58
|
| Rate for Payer: United Healthcare All Payer |
$4,562.78
|
|
|
PLATE WDE LCK HD VDR 5H 86MM L
|
Facility
|
OP
|
$5,184.98
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$674.05 |
| Max. Negotiated Rate |
$4,977.58 |
| Rate for Payer: Aetna Commercial |
$3,992.43
|
| Rate for Payer: Anthem Medicaid |
$1,783.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,044.28
|
| Rate for Payer: Cash Price |
$2,592.49
|
| Rate for Payer: Cigna Commercial |
$4,303.53
|
| Rate for Payer: First Health Commercial |
$4,925.73
|
| Rate for Payer: Humana Commercial |
$4,407.23
|
| Rate for Payer: Humana KY Medicaid |
$1,783.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,801.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,251.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,826.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,555.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,818.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,562.78
|
| Rate for Payer: Ohio Health Group HMO |
$3,888.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,037.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$674.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,607.34
|
| Rate for Payer: PHCS Commercial |
$4,977.58
|
| Rate for Payer: United Healthcare All Payer |
$4,562.78
|
|
|
PLATE WDE LCK HD VDR 5H 86MM R
|
Facility
|
OP
|
$5,184.98
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$674.05 |
| Max. Negotiated Rate |
$4,977.58 |
| Rate for Payer: Aetna Commercial |
$3,992.43
|
| Rate for Payer: Anthem Medicaid |
$1,783.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,044.28
|
| Rate for Payer: Cash Price |
$2,592.49
|
| Rate for Payer: Cigna Commercial |
$4,303.53
|
| Rate for Payer: First Health Commercial |
$4,925.73
|
| Rate for Payer: Humana Commercial |
$4,407.23
|
| Rate for Payer: Humana KY Medicaid |
$1,783.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,801.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,251.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,826.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,555.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,818.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,562.78
|
| Rate for Payer: Ohio Health Group HMO |
$3,888.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,037.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$674.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,607.34
|
| Rate for Payer: PHCS Commercial |
$4,977.58
|
| Rate for Payer: United Healthcare All Payer |
$4,562.78
|
|
