|
BASE PLATE ASSEMBLY IJS-E
|
Facility
|
IP
|
$26,528.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,958.62 |
| Max. Negotiated Rate |
$25,467.60 |
| Rate for Payer: Aetna Commercial |
$20,427.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,692.42
|
| Rate for Payer: Cash Price |
$13,264.38
|
| Rate for Payer: Cigna Commercial |
$22,018.86
|
| Rate for Payer: First Health Commercial |
$25,202.31
|
| Rate for Payer: Humana Commercial |
$22,549.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,753.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,578.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,958.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,345.30
|
| Rate for Payer: Ohio Health Group HMO |
$19,896.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,223.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23,080.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,304.84
|
| Rate for Payer: PHCS Commercial |
$25,467.60
|
| Rate for Payer: United Healthcare All Payer |
$23,345.30
|
|
|
BASE PLATE ASSEMBLY IJS-E
|
Facility
|
OP
|
$26,528.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,958.62 |
| Max. Negotiated Rate |
$25,467.60 |
| Rate for Payer: Aetna Commercial |
$20,427.14
|
| Rate for Payer: Anthem Medicaid |
$9,123.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,692.42
|
| Rate for Payer: Cash Price |
$13,264.38
|
| Rate for Payer: Cigna Commercial |
$22,018.86
|
| Rate for Payer: First Health Commercial |
$25,202.31
|
| Rate for Payer: Humana Commercial |
$22,549.44
|
| Rate for Payer: Humana KY Medicaid |
$9,123.24
|
| Rate for Payer: Kentucky WC Medicaid |
$9,216.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,753.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,578.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,958.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,306.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,345.30
|
| Rate for Payer: Ohio Health Group HMO |
$19,896.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,223.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23,080.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,304.84
|
| Rate for Payer: PHCS Commercial |
$25,467.60
|
| Rate for Payer: United Healthcare All Payer |
$23,345.30
|
|
|
BASEPLATE GLENOID 28MM
|
Facility
|
OP
|
$10,840.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,252.00 |
| Max. Negotiated Rate |
$10,406.40 |
| Rate for Payer: Aetna Commercial |
$8,346.80
|
| Rate for Payer: Anthem Medicaid |
$3,727.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,455.20
|
| Rate for Payer: Cash Price |
$5,420.00
|
| Rate for Payer: Cigna Commercial |
$8,997.20
|
| Rate for Payer: First Health Commercial |
$10,298.00
|
| Rate for Payer: Humana Commercial |
$9,214.00
|
| Rate for Payer: Humana KY Medicaid |
$3,727.88
|
| Rate for Payer: Kentucky WC Medicaid |
$3,765.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,888.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,999.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,252.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,802.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,539.20
|
| Rate for Payer: Ohio Health Group HMO |
$8,130.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,672.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,430.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,479.60
|
| Rate for Payer: PHCS Commercial |
$10,406.40
|
| Rate for Payer: United Healthcare All Payer |
$9,539.20
|
|
|
BASEPLATE GLENOID 28MM
|
Facility
|
IP
|
$10,840.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,252.00 |
| Max. Negotiated Rate |
$10,406.40 |
| Rate for Payer: Aetna Commercial |
$8,346.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,455.20
|
| Rate for Payer: Cash Price |
$5,420.00
|
| Rate for Payer: Cigna Commercial |
$8,997.20
|
| Rate for Payer: First Health Commercial |
$10,298.00
|
| Rate for Payer: Humana Commercial |
$9,214.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,888.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,999.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,252.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,539.20
|
| Rate for Payer: Ohio Health Group HMO |
$8,130.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,672.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,430.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,479.60
|
| Rate for Payer: PHCS Commercial |
$10,406.40
|
| Rate for Payer: United Healthcare All Payer |
$9,539.20
|
|
|
BASEPLATE MB POST 24MM
|
Facility
|
IP
|
$16,055.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,816.50 |
| Max. Negotiated Rate |
$15,412.80 |
| Rate for Payer: Aetna Commercial |
$12,362.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,522.90
|
| Rate for Payer: Cash Price |
$8,027.50
|
| Rate for Payer: Cigna Commercial |
$13,325.65
|
| Rate for Payer: First Health Commercial |
$15,252.25
|
| Rate for Payer: Humana Commercial |
$13,646.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,165.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,848.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,816.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,128.40
|
| Rate for Payer: Ohio Health Group HMO |
$12,041.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,844.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,967.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,077.95
|
| Rate for Payer: PHCS Commercial |
$15,412.80
|
| Rate for Payer: United Healthcare All Payer |
$14,128.40
|
|
|
BASEPLATE MB POST 24MM
|
Facility
|
OP
|
$16,055.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,816.50 |
| Max. Negotiated Rate |
$15,412.80 |
| Rate for Payer: Aetna Commercial |
$12,362.35
|
| Rate for Payer: Anthem Medicaid |
$5,521.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,522.90
|
| Rate for Payer: Cash Price |
$8,027.50
|
| Rate for Payer: Cigna Commercial |
$13,325.65
|
| Rate for Payer: First Health Commercial |
$15,252.25
|
| Rate for Payer: Humana Commercial |
$13,646.75
|
| Rate for Payer: Humana KY Medicaid |
$5,521.31
|
| Rate for Payer: Kentucky WC Medicaid |
$5,577.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,165.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,848.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,816.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,632.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,128.40
|
| Rate for Payer: Ohio Health Group HMO |
$12,041.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,844.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,967.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,077.95
|
| Rate for Payer: PHCS Commercial |
$15,412.80
|
| Rate for Payer: United Healthcare All Payer |
$14,128.40
|
|
|
BASEPLATE MB POST 28MM
|
Facility
|
OP
|
$16,055.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,816.50 |
| Max. Negotiated Rate |
$15,412.80 |
| Rate for Payer: Aetna Commercial |
$12,362.35
|
| Rate for Payer: Anthem Medicaid |
$5,521.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,522.90
|
| Rate for Payer: Cash Price |
$8,027.50
|
| Rate for Payer: Cigna Commercial |
$13,325.65
|
| Rate for Payer: First Health Commercial |
$15,252.25
|
| Rate for Payer: Humana Commercial |
$13,646.75
|
| Rate for Payer: Humana KY Medicaid |
$5,521.31
|
| Rate for Payer: Kentucky WC Medicaid |
$5,577.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,165.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,848.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,816.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,632.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,128.40
|
| Rate for Payer: Ohio Health Group HMO |
$12,041.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,844.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,967.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,077.95
|
| Rate for Payer: PHCS Commercial |
$15,412.80
|
| Rate for Payer: United Healthcare All Payer |
$14,128.40
|
|
|
BASEPLATE MB POST 28MM
|
Facility
|
IP
|
$16,055.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,816.50 |
| Max. Negotiated Rate |
$15,412.80 |
| Rate for Payer: Aetna Commercial |
$12,362.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,522.90
|
| Rate for Payer: Cash Price |
$8,027.50
|
| Rate for Payer: Cigna Commercial |
$13,325.65
|
| Rate for Payer: First Health Commercial |
$15,252.25
|
| Rate for Payer: Humana Commercial |
$13,646.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,165.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,848.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,816.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,128.40
|
| Rate for Payer: Ohio Health Group HMO |
$12,041.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,844.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,967.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,077.95
|
| Rate for Payer: PHCS Commercial |
$15,412.80
|
| Rate for Payer: United Healthcare All Payer |
$14,128.40
|
|
|
BASEPLATE MB SCREW 24MM
|
Facility
|
OP
|
$16,055.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,816.50 |
| Max. Negotiated Rate |
$15,412.80 |
| Rate for Payer: Aetna Commercial |
$12,362.35
|
| Rate for Payer: Anthem Medicaid |
$5,521.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,522.90
|
| Rate for Payer: Cash Price |
$8,027.50
|
| Rate for Payer: Cigna Commercial |
$13,325.65
|
| Rate for Payer: First Health Commercial |
$15,252.25
|
| Rate for Payer: Humana Commercial |
$13,646.75
|
| Rate for Payer: Humana KY Medicaid |
$5,521.31
|
| Rate for Payer: Kentucky WC Medicaid |
$5,577.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,165.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,848.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,816.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,632.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,128.40
|
| Rate for Payer: Ohio Health Group HMO |
$12,041.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,844.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,967.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,077.95
|
| Rate for Payer: PHCS Commercial |
$15,412.80
|
| Rate for Payer: United Healthcare All Payer |
$14,128.40
|
|
|
BASEPLATE MB SCREW 24MM
|
Facility
|
IP
|
$16,055.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,816.50 |
| Max. Negotiated Rate |
$15,412.80 |
| Rate for Payer: Aetna Commercial |
$12,362.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,522.90
|
| Rate for Payer: Cash Price |
$8,027.50
|
| Rate for Payer: Cigna Commercial |
$13,325.65
|
| Rate for Payer: First Health Commercial |
$15,252.25
|
| Rate for Payer: Humana Commercial |
$13,646.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,165.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,848.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,816.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,128.40
|
| Rate for Payer: Ohio Health Group HMO |
$12,041.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,844.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,967.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,077.95
|
| Rate for Payer: PHCS Commercial |
$15,412.80
|
| Rate for Payer: United Healthcare All Payer |
$14,128.40
|
|
|
BASEPLATE MB SCREW 28MM
|
Facility
|
OP
|
$16,055.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,816.50 |
| Max. Negotiated Rate |
$15,412.80 |
| Rate for Payer: Aetna Commercial |
$12,362.35
|
| Rate for Payer: Anthem Medicaid |
$5,521.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,522.90
|
| Rate for Payer: Cash Price |
$8,027.50
|
| Rate for Payer: Cigna Commercial |
$13,325.65
|
| Rate for Payer: First Health Commercial |
$15,252.25
|
| Rate for Payer: Humana Commercial |
$13,646.75
|
| Rate for Payer: Humana KY Medicaid |
$5,521.31
|
| Rate for Payer: Kentucky WC Medicaid |
$5,577.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,165.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,848.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,816.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,632.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,128.40
|
| Rate for Payer: Ohio Health Group HMO |
$12,041.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,844.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,967.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,077.95
|
| Rate for Payer: PHCS Commercial |
$15,412.80
|
| Rate for Payer: United Healthcare All Payer |
$14,128.40
|
|
|
BASEPLATE MB SCREW 28MM
|
Facility
|
IP
|
$16,055.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,816.50 |
| Max. Negotiated Rate |
$15,412.80 |
| Rate for Payer: Aetna Commercial |
$12,362.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,522.90
|
| Rate for Payer: Cash Price |
$8,027.50
|
| Rate for Payer: Cigna Commercial |
$13,325.65
|
| Rate for Payer: First Health Commercial |
$15,252.25
|
| Rate for Payer: Humana Commercial |
$13,646.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,165.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,848.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,816.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,128.40
|
| Rate for Payer: Ohio Health Group HMO |
$12,041.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,844.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,967.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,077.95
|
| Rate for Payer: PHCS Commercial |
$15,412.80
|
| Rate for Payer: United Healthcare All Payer |
$14,128.40
|
|
|
BASEPLATE MOD 24+2 LAT
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem Medicaid |
$3,980.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Humana KY Medicaid |
$3,980.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,020.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,060.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
BASEPLATE MOD 24+2 LAT
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
BASEPLATE MOD 24+4 LAT
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem Medicaid |
$3,980.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Humana KY Medicaid |
$3,980.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,020.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,060.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
BASEPLATE MOD 24+4 LAT
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
BASEPLATE MOD 28+2 LAT
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
BASEPLATE MOD 28+2 LAT
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem Medicaid |
$3,980.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Humana KY Medicaid |
$3,980.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,020.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,060.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
BASEPLATE MOD 28+4 LAT
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem Medicaid |
$3,980.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Humana KY Medicaid |
$3,980.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,020.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,060.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
BASEPLATE MOD 28+4 LAT
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
BASEPLATE MODULAR 24MM
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
BASEPLATE MODULAR 24MM
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem Medicaid |
$3,980.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Humana KY Medicaid |
$3,980.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,020.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,060.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
BASEPLATE MODULAR 28MM
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
BASEPLATE MODULAR 28MM
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem Medicaid |
$3,980.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Humana KY Medicaid |
$3,980.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,020.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,060.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
BASIC COMP AUDIOLOGY
|
Facility
|
OP
|
$340.00
|
|
|
Service Code
|
HCPCS 92557
|
| Hospital Charge Code |
47000012
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$116.93 |
| Max. Negotiated Rate |
$326.40 |
| Rate for Payer: Aetna Commercial |
$261.80
|
| Rate for Payer: Anthem Medicaid |
$116.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$144.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$265.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$202.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$195.17
|
| Rate for Payer: Cash Price |
$170.00
|
| Rate for Payer: Cash Price |
$170.00
|
| Rate for Payer: Cigna Commercial |
$282.20
|
| Rate for Payer: First Health Commercial |
$323.00
|
| Rate for Payer: Humana Commercial |
$289.00
|
| Rate for Payer: Humana KY Medicaid |
$116.93
|
| Rate for Payer: Humana Medicare Advantage |
$144.57
|
| Rate for Payer: Kentucky WC Medicaid |
$118.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$278.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$250.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$119.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$299.20
|
| Rate for Payer: Ohio Health Group HMO |
$255.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$272.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$295.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$234.60
|
| Rate for Payer: PHCS Commercial |
$326.40
|
| Rate for Payer: United Healthcare All Payer |
$299.20
|
|
