|
AMBI PLATE 14 SLOT 140*300MM
|
Facility
|
OP
|
$4,118.35
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$535.39 |
| Max. Negotiated Rate |
$3,953.62 |
| Rate for Payer: Aetna Commercial |
$3,171.13
|
| Rate for Payer: Anthem Medicaid |
$1,416.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,212.31
|
| Rate for Payer: Cash Price |
$2,059.18
|
| Rate for Payer: Cigna Commercial |
$3,418.23
|
| Rate for Payer: First Health Commercial |
$3,912.43
|
| Rate for Payer: Humana Commercial |
$3,500.60
|
| Rate for Payer: Humana KY Medicaid |
$1,416.30
|
| Rate for Payer: Kentucky WC Medicaid |
$1,430.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,377.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,039.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,235.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,444.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,624.15
|
| Rate for Payer: Ohio Health Group HMO |
$3,088.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$823.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$535.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,276.69
|
| Rate for Payer: PHCS Commercial |
$3,953.62
|
| Rate for Payer: United Healthcare All Payer |
$3,624.15
|
|
|
AMBI PLATE 14 SLOT 140*300MM
|
Facility
|
IP
|
$4,118.35
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$535.39 |
| Max. Negotiated Rate |
$3,953.62 |
| Rate for Payer: Aetna Commercial |
$3,171.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,212.31
|
| Rate for Payer: Cash Price |
$2,059.18
|
| Rate for Payer: Cigna Commercial |
$3,418.23
|
| Rate for Payer: First Health Commercial |
$3,912.43
|
| Rate for Payer: Humana Commercial |
$3,500.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,377.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,039.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,235.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,624.15
|
| Rate for Payer: Ohio Health Group HMO |
$3,088.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$823.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$535.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,276.69
|
| Rate for Payer: PHCS Commercial |
$3,953.62
|
| Rate for Payer: United Healthcare All Payer |
$3,624.15
|
|
|
AMBI PLATE 14 SLOT 145*300MM
|
Facility
|
IP
|
$5,608.82
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$729.15 |
| Max. Negotiated Rate |
$5,384.47 |
| Rate for Payer: Aetna Commercial |
$4,318.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,374.88
|
| Rate for Payer: Cash Price |
$2,804.41
|
| Rate for Payer: Cigna Commercial |
$4,655.32
|
| Rate for Payer: First Health Commercial |
$5,328.38
|
| Rate for Payer: Humana Commercial |
$4,767.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,599.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,139.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,935.76
|
| Rate for Payer: Ohio Health Group HMO |
$4,206.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,121.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$729.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,738.73
|
| Rate for Payer: PHCS Commercial |
$5,384.47
|
| Rate for Payer: United Healthcare All Payer |
$4,935.76
|
|
|
AMBI PLATE 14 SLOT 145*300MM
|
Facility
|
OP
|
$5,608.82
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$729.15 |
| Max. Negotiated Rate |
$5,384.47 |
| Rate for Payer: Aetna Commercial |
$4,318.79
|
| Rate for Payer: Anthem Medicaid |
$1,928.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,374.88
|
| Rate for Payer: Cash Price |
$2,804.41
|
| Rate for Payer: Cigna Commercial |
$4,655.32
|
| Rate for Payer: First Health Commercial |
$5,328.38
|
| Rate for Payer: Humana Commercial |
$4,767.50
|
| Rate for Payer: Humana KY Medicaid |
$1,928.87
|
| Rate for Payer: Kentucky WC Medicaid |
$1,948.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,599.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,139.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,967.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,935.76
|
| Rate for Payer: Ohio Health Group HMO |
$4,206.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,121.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$729.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,738.73
|
| Rate for Payer: PHCS Commercial |
$5,384.47
|
| Rate for Payer: United Healthcare All Payer |
$4,935.76
|
|
|
AMBI PLATE 2 SLOT 130*60MM
|
Facility
|
IP
|
$3,764.15
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$489.34 |
| Max. Negotiated Rate |
$3,613.58 |
| Rate for Payer: Aetna Commercial |
$2,898.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,936.04
|
| Rate for Payer: Cash Price |
$1,882.08
|
| Rate for Payer: Cigna Commercial |
$3,124.24
|
| Rate for Payer: First Health Commercial |
$3,575.94
|
| Rate for Payer: Humana Commercial |
$3,199.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,086.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,777.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,129.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,312.45
|
| Rate for Payer: Ohio Health Group HMO |
$2,823.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$752.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$489.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,166.89
|
| Rate for Payer: PHCS Commercial |
$3,613.58
|
| Rate for Payer: United Healthcare All Payer |
$3,312.45
|
|
|
AMBI PLATE 2 SLOT 130*60MM
|
Facility
|
OP
|
$3,764.15
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$489.34 |
| Max. Negotiated Rate |
$3,613.58 |
| Rate for Payer: Aetna Commercial |
$2,898.40
|
| Rate for Payer: Anthem Medicaid |
$1,294.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,936.04
|
| Rate for Payer: Cash Price |
$1,882.08
|
| Rate for Payer: Cigna Commercial |
$3,124.24
|
| Rate for Payer: First Health Commercial |
$3,575.94
|
| Rate for Payer: Humana Commercial |
$3,199.53
|
| Rate for Payer: Humana KY Medicaid |
$1,294.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1,307.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,086.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,777.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,129.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,320.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,312.45
|
| Rate for Payer: Ohio Health Group HMO |
$2,823.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$752.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$489.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,166.89
|
| Rate for Payer: PHCS Commercial |
$3,613.58
|
| Rate for Payer: United Healthcare All Payer |
$3,312.45
|
|
|
AMBI PLATE 2 SLOT 135*60MM
|
Facility
|
IP
|
$3,764.15
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$489.34 |
| Max. Negotiated Rate |
$3,613.58 |
| Rate for Payer: Aetna Commercial |
$2,898.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,936.04
|
| Rate for Payer: Cash Price |
$1,882.08
|
| Rate for Payer: Cigna Commercial |
$3,124.24
|
| Rate for Payer: First Health Commercial |
$3,575.94
|
| Rate for Payer: Humana Commercial |
$3,199.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,086.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,777.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,129.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,312.45
|
| Rate for Payer: Ohio Health Group HMO |
$2,823.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$752.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$489.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,166.89
|
| Rate for Payer: PHCS Commercial |
$3,613.58
|
| Rate for Payer: United Healthcare All Payer |
$3,312.45
|
|
|
AMBI PLATE 2 SLOT 135*60MM
|
Facility
|
OP
|
$3,764.15
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$489.34 |
| Max. Negotiated Rate |
$3,613.58 |
| Rate for Payer: Aetna Commercial |
$2,898.40
|
| Rate for Payer: Anthem Medicaid |
$1,294.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,936.04
|
| Rate for Payer: Cash Price |
$1,882.08
|
| Rate for Payer: Cigna Commercial |
$3,124.24
|
| Rate for Payer: First Health Commercial |
$3,575.94
|
| Rate for Payer: Humana Commercial |
$3,199.53
|
| Rate for Payer: Humana KY Medicaid |
$1,294.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1,307.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,086.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,777.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,129.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,320.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,312.45
|
| Rate for Payer: Ohio Health Group HMO |
$2,823.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$752.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$489.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,166.89
|
| Rate for Payer: PHCS Commercial |
$3,613.58
|
| Rate for Payer: United Healthcare All Payer |
$3,312.45
|
|
|
AMBI PLATE 2 SLOT 140*60MM
|
Facility
|
OP
|
$3,764.15
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$489.34 |
| Max. Negotiated Rate |
$3,613.58 |
| Rate for Payer: Aetna Commercial |
$2,898.40
|
| Rate for Payer: Anthem Medicaid |
$1,294.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,936.04
|
| Rate for Payer: Cash Price |
$1,882.08
|
| Rate for Payer: Cigna Commercial |
$3,124.24
|
| Rate for Payer: First Health Commercial |
$3,575.94
|
| Rate for Payer: Humana Commercial |
$3,199.53
|
| Rate for Payer: Humana KY Medicaid |
$1,294.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1,307.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,086.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,777.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,129.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,320.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,312.45
|
| Rate for Payer: Ohio Health Group HMO |
$2,823.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$752.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$489.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,166.89
|
| Rate for Payer: PHCS Commercial |
$3,613.58
|
| Rate for Payer: United Healthcare All Payer |
$3,312.45
|
|
|
AMBI PLATE 2 SLOT 140*60MM
|
Facility
|
IP
|
$3,764.15
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$489.34 |
| Max. Negotiated Rate |
$3,613.58 |
| Rate for Payer: Aetna Commercial |
$2,898.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,936.04
|
| Rate for Payer: Cash Price |
$1,882.08
|
| Rate for Payer: Cigna Commercial |
$3,124.24
|
| Rate for Payer: First Health Commercial |
$3,575.94
|
| Rate for Payer: Humana Commercial |
$3,199.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,086.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,777.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,129.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,312.45
|
| Rate for Payer: Ohio Health Group HMO |
$2,823.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$752.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$489.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,166.89
|
| Rate for Payer: PHCS Commercial |
$3,613.58
|
| Rate for Payer: United Healthcare All Payer |
$3,312.45
|
|
|
AMBI PLATE 2 SLOT 145*60MM
|
Facility
|
OP
|
$3,764.15
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$489.34 |
| Max. Negotiated Rate |
$3,613.58 |
| Rate for Payer: Aetna Commercial |
$2,898.40
|
| Rate for Payer: Anthem Medicaid |
$1,294.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,936.04
|
| Rate for Payer: Cash Price |
$1,882.08
|
| Rate for Payer: Cigna Commercial |
$3,124.24
|
| Rate for Payer: First Health Commercial |
$3,575.94
|
| Rate for Payer: Humana Commercial |
$3,199.53
|
| Rate for Payer: Humana KY Medicaid |
$1,294.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1,307.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,086.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,777.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,129.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,320.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,312.45
|
| Rate for Payer: Ohio Health Group HMO |
$2,823.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$752.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$489.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,166.89
|
| Rate for Payer: PHCS Commercial |
$3,613.58
|
| Rate for Payer: United Healthcare All Payer |
$3,312.45
|
|
|
AMBI PLATE 2 SLOT 145*60MM
|
Facility
|
IP
|
$3,764.15
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$489.34 |
| Max. Negotiated Rate |
$3,613.58 |
| Rate for Payer: Aetna Commercial |
$2,898.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,936.04
|
| Rate for Payer: Cash Price |
$1,882.08
|
| Rate for Payer: Cigna Commercial |
$3,124.24
|
| Rate for Payer: First Health Commercial |
$3,575.94
|
| Rate for Payer: Humana Commercial |
$3,199.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,086.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,777.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,129.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,312.45
|
| Rate for Payer: Ohio Health Group HMO |
$2,823.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$752.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$489.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,166.89
|
| Rate for Payer: PHCS Commercial |
$3,613.58
|
| Rate for Payer: United Healthcare All Payer |
$3,312.45
|
|
|
AMBI PLATE 2 SLOT 150*60MM
|
Facility
|
IP
|
$3,764.15
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$489.34 |
| Max. Negotiated Rate |
$3,613.58 |
| Rate for Payer: Aetna Commercial |
$2,898.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,936.04
|
| Rate for Payer: Cash Price |
$1,882.08
|
| Rate for Payer: Cigna Commercial |
$3,124.24
|
| Rate for Payer: First Health Commercial |
$3,575.94
|
| Rate for Payer: Humana Commercial |
$3,199.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,086.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,777.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,129.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,312.45
|
| Rate for Payer: Ohio Health Group HMO |
$2,823.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$752.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$489.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,166.89
|
| Rate for Payer: PHCS Commercial |
$3,613.58
|
| Rate for Payer: United Healthcare All Payer |
$3,312.45
|
|
|
AMBI PLATE 2 SLOT 150*60MM
|
Facility
|
OP
|
$3,764.15
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$489.34 |
| Max. Negotiated Rate |
$3,613.58 |
| Rate for Payer: Anthem Medicaid |
$1,294.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,936.04
|
| Rate for Payer: Cash Price |
$1,882.08
|
| Rate for Payer: Cigna Commercial |
$3,124.24
|
| Rate for Payer: First Health Commercial |
$3,575.94
|
| Rate for Payer: Humana Commercial |
$3,199.53
|
| Rate for Payer: Humana KY Medicaid |
$1,294.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1,307.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,086.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,777.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,129.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,320.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,312.45
|
| Rate for Payer: Ohio Health Group HMO |
$2,823.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$752.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$489.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,166.89
|
| Rate for Payer: PHCS Commercial |
$3,613.58
|
| Rate for Payer: United Healthcare All Payer |
$3,312.45
|
| Rate for Payer: Aetna Commercial |
$2,898.40
|
|
|
AMBI PLATE 3 SLOT 130*80MM
|
Facility
|
IP
|
$3,859.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$501.67 |
| Max. Negotiated Rate |
$3,704.64 |
| Rate for Payer: Aetna Commercial |
$2,971.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,010.02
|
| Rate for Payer: Cash Price |
$1,929.50
|
| Rate for Payer: Cigna Commercial |
$3,202.97
|
| Rate for Payer: First Health Commercial |
$3,666.05
|
| Rate for Payer: Humana Commercial |
$3,280.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,164.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,847.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,157.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,395.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,894.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$771.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$501.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,196.29
|
| Rate for Payer: PHCS Commercial |
$3,704.64
|
| Rate for Payer: United Healthcare All Payer |
$3,395.92
|
|
|
AMBI PLATE 3 SLOT 130*80MM
|
Facility
|
OP
|
$3,859.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$501.67 |
| Max. Negotiated Rate |
$3,704.64 |
| Rate for Payer: Aetna Commercial |
$2,971.43
|
| Rate for Payer: Anthem Medicaid |
$1,327.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,010.02
|
| Rate for Payer: Cash Price |
$1,929.50
|
| Rate for Payer: Cigna Commercial |
$3,202.97
|
| Rate for Payer: First Health Commercial |
$3,666.05
|
| Rate for Payer: Humana Commercial |
$3,280.15
|
| Rate for Payer: Humana KY Medicaid |
$1,327.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,340.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,164.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,847.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,157.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,353.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,395.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,894.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$771.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$501.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,196.29
|
| Rate for Payer: PHCS Commercial |
$3,704.64
|
| Rate for Payer: United Healthcare All Payer |
$3,395.92
|
|
|
AMBI PLATE 3 SLOT 135*80MM
|
Facility
|
IP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
AMBI PLATE 3 SLOT 135*80MM
|
Facility
|
OP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem Medicaid |
$1,418.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Humana KY Medicaid |
$1,418.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,433.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,447.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
AMBI PLATE 3 SLOT 140*80MM
|
Facility
|
IP
|
$4,069.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$528.97 |
| Max. Negotiated Rate |
$3,906.24 |
| Rate for Payer: Aetna Commercial |
$3,133.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,173.82
|
| Rate for Payer: Cash Price |
$2,034.50
|
| Rate for Payer: Cigna Commercial |
$3,377.27
|
| Rate for Payer: First Health Commercial |
$3,865.55
|
| Rate for Payer: Humana Commercial |
$3,458.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,336.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,002.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,220.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,580.72
|
| Rate for Payer: Ohio Health Group HMO |
$3,051.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$813.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$528.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,261.39
|
| Rate for Payer: PHCS Commercial |
$3,906.24
|
| Rate for Payer: United Healthcare All Payer |
$3,580.72
|
|
|
AMBI PLATE 3 SLOT 140*80MM
|
Facility
|
OP
|
$4,069.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$528.97 |
| Max. Negotiated Rate |
$3,906.24 |
| Rate for Payer: Aetna Commercial |
$3,133.13
|
| Rate for Payer: Anthem Medicaid |
$1,399.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,173.82
|
| Rate for Payer: Cash Price |
$2,034.50
|
| Rate for Payer: Cigna Commercial |
$3,377.27
|
| Rate for Payer: First Health Commercial |
$3,865.55
|
| Rate for Payer: Humana Commercial |
$3,458.65
|
| Rate for Payer: Humana KY Medicaid |
$1,399.33
|
| Rate for Payer: Kentucky WC Medicaid |
$1,413.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,336.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,002.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,220.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,427.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,580.72
|
| Rate for Payer: Ohio Health Group HMO |
$3,051.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$813.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$528.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,261.39
|
| Rate for Payer: PHCS Commercial |
$3,906.24
|
| Rate for Payer: United Healthcare All Payer |
$3,580.72
|
|
|
AMBI PLATE 3 SLOT 145*80MM
|
Facility
|
IP
|
$3,859.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$501.67 |
| Max. Negotiated Rate |
$3,704.64 |
| Rate for Payer: Aetna Commercial |
$2,971.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,010.02
|
| Rate for Payer: Cash Price |
$1,929.50
|
| Rate for Payer: Cigna Commercial |
$3,202.97
|
| Rate for Payer: First Health Commercial |
$3,666.05
|
| Rate for Payer: Humana Commercial |
$3,280.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,164.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,847.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,157.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,395.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,894.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$771.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$501.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,196.29
|
| Rate for Payer: PHCS Commercial |
$3,704.64
|
| Rate for Payer: United Healthcare All Payer |
$3,395.92
|
|
|
AMBI PLATE 3 SLOT 145*80MM
|
Facility
|
OP
|
$3,859.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$501.67 |
| Max. Negotiated Rate |
$3,704.64 |
| Rate for Payer: Aetna Commercial |
$2,971.43
|
| Rate for Payer: Anthem Medicaid |
$1,327.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,010.02
|
| Rate for Payer: Cash Price |
$1,929.50
|
| Rate for Payer: Cigna Commercial |
$3,202.97
|
| Rate for Payer: First Health Commercial |
$3,666.05
|
| Rate for Payer: Humana Commercial |
$3,280.15
|
| Rate for Payer: Humana KY Medicaid |
$1,327.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,340.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,164.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,847.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,157.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,353.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,395.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,894.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$771.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$501.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,196.29
|
| Rate for Payer: PHCS Commercial |
$3,704.64
|
| Rate for Payer: United Healthcare All Payer |
$3,395.92
|
|
|
AMBI PLATE 3 SLOT 150*80MM
|
Facility
|
IP
|
$3,859.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$501.67 |
| Max. Negotiated Rate |
$3,704.64 |
| Rate for Payer: Aetna Commercial |
$2,971.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,010.02
|
| Rate for Payer: Cash Price |
$1,929.50
|
| Rate for Payer: Cigna Commercial |
$3,202.97
|
| Rate for Payer: First Health Commercial |
$3,666.05
|
| Rate for Payer: Humana Commercial |
$3,280.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,164.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,847.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,157.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,395.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,894.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$771.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$501.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,196.29
|
| Rate for Payer: PHCS Commercial |
$3,704.64
|
| Rate for Payer: United Healthcare All Payer |
$3,395.92
|
|
|
AMBI PLATE 3 SLOT 150*80MM
|
Facility
|
OP
|
$3,859.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$501.67 |
| Max. Negotiated Rate |
$3,704.64 |
| Rate for Payer: Aetna Commercial |
$2,971.43
|
| Rate for Payer: Anthem Medicaid |
$1,327.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,010.02
|
| Rate for Payer: Cash Price |
$1,929.50
|
| Rate for Payer: Cigna Commercial |
$3,202.97
|
| Rate for Payer: First Health Commercial |
$3,666.05
|
| Rate for Payer: Humana Commercial |
$3,280.15
|
| Rate for Payer: Humana KY Medicaid |
$1,327.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,340.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,164.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,847.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,157.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,353.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,395.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,894.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$771.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$501.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,196.29
|
| Rate for Payer: PHCS Commercial |
$3,704.64
|
| Rate for Payer: United Healthcare All Payer |
$3,395.92
|
|
|
AMBI PLATE 4 SLOT 130*100MM
|
Facility
|
OP
|
$3,814.38
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$495.87 |
| Max. Negotiated Rate |
$3,661.80 |
| Rate for Payer: Aetna Commercial |
$2,937.07
|
| Rate for Payer: Anthem Medicaid |
$1,311.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,975.22
|
| Rate for Payer: Cash Price |
$1,907.19
|
| Rate for Payer: Cigna Commercial |
$3,165.94
|
| Rate for Payer: First Health Commercial |
$3,623.66
|
| Rate for Payer: Humana Commercial |
$3,242.22
|
| Rate for Payer: Humana KY Medicaid |
$1,311.77
|
| Rate for Payer: Kentucky WC Medicaid |
$1,325.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,127.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,815.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,144.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,338.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,356.65
|
| Rate for Payer: Ohio Health Group HMO |
$2,860.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$762.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$495.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,182.46
|
| Rate for Payer: PHCS Commercial |
$3,661.80
|
| Rate for Payer: United Healthcare All Payer |
$3,356.65
|
|
