|
AMBI PLATE 10 SLOT 90*204MM
|
Facility
|
OP
|
$4,613.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,384.12 |
| Max. Negotiated Rate |
$4,429.20 |
| Rate for Payer: Aetna Commercial |
$3,552.59
|
| Rate for Payer: Anthem Medicaid |
$1,586.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,598.72
|
| Rate for Payer: Cash Price |
$2,306.88
|
| Rate for Payer: Cigna Commercial |
$3,829.41
|
| Rate for Payer: First Health Commercial |
$4,383.06
|
| Rate for Payer: Humana Commercial |
$3,921.69
|
| Rate for Payer: Humana KY Medicaid |
$1,586.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1,602.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,783.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,404.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,384.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,618.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,060.10
|
| Rate for Payer: Ohio Health Group HMO |
$3,460.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,691.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,013.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,183.49
|
| Rate for Payer: PHCS Commercial |
$4,429.20
|
| Rate for Payer: United Healthcare All Payer |
$4,060.10
|
|
|
AMBI PLATE 10 SLOT 90*204MM
|
Facility
|
IP
|
$4,613.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,384.12 |
| Max. Negotiated Rate |
$4,429.20 |
| Rate for Payer: Aetna Commercial |
$3,552.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,598.72
|
| Rate for Payer: Cash Price |
$2,306.88
|
| Rate for Payer: Cigna Commercial |
$3,829.41
|
| Rate for Payer: First Health Commercial |
$4,383.06
|
| Rate for Payer: Humana Commercial |
$3,921.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,783.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,404.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,384.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,060.10
|
| Rate for Payer: Ohio Health Group HMO |
$3,460.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,691.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,013.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,183.49
|
| Rate for Payer: PHCS Commercial |
$4,429.20
|
| Rate for Payer: United Healthcare All Payer |
$4,060.10
|
|
|
AMBI PLATE 10 SLOT 95*204MM
|
Facility
|
IP
|
$4,621.44
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,386.43 |
| Max. Negotiated Rate |
$4,436.58 |
| Rate for Payer: Aetna Commercial |
$3,558.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,604.72
|
| Rate for Payer: Cash Price |
$2,310.72
|
| Rate for Payer: Cigna Commercial |
$3,835.80
|
| Rate for Payer: First Health Commercial |
$4,390.37
|
| Rate for Payer: Humana Commercial |
$3,928.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,789.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,410.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,386.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,066.87
|
| Rate for Payer: Ohio Health Group HMO |
$3,466.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,697.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,020.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,188.79
|
| Rate for Payer: PHCS Commercial |
$4,436.58
|
| Rate for Payer: United Healthcare All Payer |
$4,066.87
|
|
|
AMBI PLATE 10 SLOT 95*204MM
|
Facility
|
OP
|
$4,621.44
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,386.43 |
| Max. Negotiated Rate |
$4,436.58 |
| Rate for Payer: Aetna Commercial |
$3,558.51
|
| Rate for Payer: Anthem Medicaid |
$1,589.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,604.72
|
| Rate for Payer: Cash Price |
$2,310.72
|
| Rate for Payer: Cigna Commercial |
$3,835.80
|
| Rate for Payer: First Health Commercial |
$4,390.37
|
| Rate for Payer: Humana Commercial |
$3,928.22
|
| Rate for Payer: Humana KY Medicaid |
$1,589.31
|
| Rate for Payer: Kentucky WC Medicaid |
$1,605.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,789.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,410.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,386.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,621.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,066.87
|
| Rate for Payer: Ohio Health Group HMO |
$3,466.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,697.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,020.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,188.79
|
| Rate for Payer: PHCS Commercial |
$4,436.58
|
| Rate for Payer: United Healthcare All Payer |
$4,066.87
|
|
|
AMBI PLATE 12 SLOT 135*260MM
|
Facility
|
IP
|
$4,921.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,476.38 |
| Max. Negotiated Rate |
$4,724.40 |
| Rate for Payer: Aetna Commercial |
$3,789.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,838.57
|
| Rate for Payer: Cash Price |
$2,460.62
|
| Rate for Payer: Cigna Commercial |
$4,084.64
|
| Rate for Payer: First Health Commercial |
$4,675.19
|
| Rate for Payer: Humana Commercial |
$4,183.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,035.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,631.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,476.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,330.70
|
| Rate for Payer: Ohio Health Group HMO |
$3,690.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,937.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,281.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,395.66
|
| Rate for Payer: PHCS Commercial |
$4,724.40
|
| Rate for Payer: United Healthcare All Payer |
$4,330.70
|
|
|
AMBI PLATE 12 SLOT 135*260MM
|
Facility
|
OP
|
$4,921.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,476.38 |
| Max. Negotiated Rate |
$4,724.40 |
| Rate for Payer: Aetna Commercial |
$3,789.36
|
| Rate for Payer: Anthem Medicaid |
$1,692.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,838.57
|
| Rate for Payer: Cash Price |
$2,460.62
|
| Rate for Payer: Cigna Commercial |
$4,084.64
|
| Rate for Payer: First Health Commercial |
$4,675.19
|
| Rate for Payer: Humana Commercial |
$4,183.06
|
| Rate for Payer: Humana KY Medicaid |
$1,692.42
|
| Rate for Payer: Kentucky WC Medicaid |
$1,709.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,035.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,631.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,476.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,726.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,330.70
|
| Rate for Payer: Ohio Health Group HMO |
$3,690.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,937.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,281.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,395.66
|
| Rate for Payer: PHCS Commercial |
$4,724.40
|
| Rate for Payer: United Healthcare All Payer |
$4,330.70
|
|
|
AMBI PLATE 12 SLOT 140*260MM
|
Facility
|
IP
|
$4,055.38
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,216.61 |
| Max. Negotiated Rate |
$3,893.16 |
| Rate for Payer: Aetna Commercial |
$3,122.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,163.20
|
| Rate for Payer: Cash Price |
$2,027.69
|
| Rate for Payer: Cigna Commercial |
$3,365.97
|
| Rate for Payer: First Health Commercial |
$3,852.61
|
| Rate for Payer: Humana Commercial |
$3,447.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,325.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,992.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,216.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,568.73
|
| Rate for Payer: Ohio Health Group HMO |
$3,041.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,244.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,528.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,798.21
|
| Rate for Payer: PHCS Commercial |
$3,893.16
|
| Rate for Payer: United Healthcare All Payer |
$3,568.73
|
|
|
AMBI PLATE 12 SLOT 140*260MM
|
Facility
|
OP
|
$4,055.38
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,216.61 |
| Max. Negotiated Rate |
$3,893.16 |
| Rate for Payer: Aetna Commercial |
$3,122.64
|
| Rate for Payer: Anthem Medicaid |
$1,394.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,163.20
|
| Rate for Payer: Cash Price |
$2,027.69
|
| Rate for Payer: Cigna Commercial |
$3,365.97
|
| Rate for Payer: First Health Commercial |
$3,852.61
|
| Rate for Payer: Humana Commercial |
$3,447.07
|
| Rate for Payer: Humana KY Medicaid |
$1,394.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1,408.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,325.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,992.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,216.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,422.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,568.73
|
| Rate for Payer: Ohio Health Group HMO |
$3,041.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,244.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,528.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,798.21
|
| Rate for Payer: PHCS Commercial |
$3,893.16
|
| Rate for Payer: United Healthcare All Payer |
$3,568.73
|
|
|
AMBI PLATE 12 SLOT 145*260MM
|
Facility
|
OP
|
$4,921.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,476.38 |
| Max. Negotiated Rate |
$4,724.40 |
| Rate for Payer: Aetna Commercial |
$3,789.36
|
| Rate for Payer: Anthem Medicaid |
$1,692.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,838.57
|
| Rate for Payer: Cash Price |
$2,460.62
|
| Rate for Payer: Cigna Commercial |
$4,084.64
|
| Rate for Payer: First Health Commercial |
$4,675.19
|
| Rate for Payer: Humana Commercial |
$4,183.06
|
| Rate for Payer: Humana KY Medicaid |
$1,692.42
|
| Rate for Payer: Kentucky WC Medicaid |
$1,709.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,035.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,631.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,476.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,726.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,330.70
|
| Rate for Payer: Ohio Health Group HMO |
$3,690.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,937.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,281.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,395.66
|
| Rate for Payer: PHCS Commercial |
$4,724.40
|
| Rate for Payer: United Healthcare All Payer |
$4,330.70
|
|
|
AMBI PLATE 12 SLOT 145*260MM
|
Facility
|
IP
|
$4,921.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,476.38 |
| Max. Negotiated Rate |
$4,724.40 |
| Rate for Payer: Aetna Commercial |
$3,789.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,838.57
|
| Rate for Payer: Cash Price |
$2,460.62
|
| Rate for Payer: Cigna Commercial |
$4,084.64
|
| Rate for Payer: First Health Commercial |
$4,675.19
|
| Rate for Payer: Humana Commercial |
$4,183.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,035.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,631.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,476.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,330.70
|
| Rate for Payer: Ohio Health Group HMO |
$3,690.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,937.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,281.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,395.66
|
| Rate for Payer: PHCS Commercial |
$4,724.40
|
| Rate for Payer: United Healthcare All Payer |
$4,330.70
|
|
|
AMBI PLATE 12 SLOT 90*244MM
|
Facility
|
OP
|
$4,959.69
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,487.91 |
| Max. Negotiated Rate |
$4,761.30 |
| Rate for Payer: Aetna Commercial |
$3,818.96
|
| Rate for Payer: Anthem Medicaid |
$1,705.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,868.56
|
| Rate for Payer: Cash Price |
$2,479.84
|
| Rate for Payer: Cigna Commercial |
$4,116.54
|
| Rate for Payer: First Health Commercial |
$4,711.71
|
| Rate for Payer: Humana Commercial |
$4,215.74
|
| Rate for Payer: Humana KY Medicaid |
$1,705.64
|
| Rate for Payer: Kentucky WC Medicaid |
$1,723.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,066.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,660.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,487.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,739.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,364.53
|
| Rate for Payer: Ohio Health Group HMO |
$3,719.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,967.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,314.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,422.19
|
| Rate for Payer: PHCS Commercial |
$4,761.30
|
| Rate for Payer: United Healthcare All Payer |
$4,364.53
|
|
|
AMBI PLATE 12 SLOT 90*244MM
|
Facility
|
IP
|
$4,959.69
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,487.91 |
| Max. Negotiated Rate |
$4,761.30 |
| Rate for Payer: Aetna Commercial |
$3,818.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,868.56
|
| Rate for Payer: Cash Price |
$2,479.84
|
| Rate for Payer: Cigna Commercial |
$4,116.54
|
| Rate for Payer: First Health Commercial |
$4,711.71
|
| Rate for Payer: Humana Commercial |
$4,215.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,066.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,660.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,487.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,364.53
|
| Rate for Payer: Ohio Health Group HMO |
$3,719.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,967.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,314.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,422.19
|
| Rate for Payer: PHCS Commercial |
$4,761.30
|
| Rate for Payer: United Healthcare All Payer |
$4,364.53
|
|
|
AMBI PLATE 12 SLOT 95*244MM
|
Facility
|
IP
|
$4,959.69
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,487.91 |
| Max. Negotiated Rate |
$4,761.30 |
| Rate for Payer: Aetna Commercial |
$3,818.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,868.56
|
| Rate for Payer: Cash Price |
$2,479.84
|
| Rate for Payer: Cigna Commercial |
$4,116.54
|
| Rate for Payer: First Health Commercial |
$4,711.71
|
| Rate for Payer: Humana Commercial |
$4,215.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,066.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,660.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,487.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,364.53
|
| Rate for Payer: Ohio Health Group HMO |
$3,719.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,967.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,314.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,422.19
|
| Rate for Payer: PHCS Commercial |
$4,761.30
|
| Rate for Payer: United Healthcare All Payer |
$4,364.53
|
|
|
AMBI PLATE 12 SLOT 95*244MM
|
Facility
|
OP
|
$4,959.69
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,487.91 |
| Max. Negotiated Rate |
$4,761.30 |
| Rate for Payer: Aetna Commercial |
$3,818.96
|
| Rate for Payer: Anthem Medicaid |
$1,705.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,868.56
|
| Rate for Payer: Cash Price |
$2,479.84
|
| Rate for Payer: Cigna Commercial |
$4,116.54
|
| Rate for Payer: First Health Commercial |
$4,711.71
|
| Rate for Payer: Humana Commercial |
$4,215.74
|
| Rate for Payer: Humana KY Medicaid |
$1,705.64
|
| Rate for Payer: Kentucky WC Medicaid |
$1,723.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,066.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,660.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,487.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,739.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,364.53
|
| Rate for Payer: Ohio Health Group HMO |
$3,719.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,967.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,314.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,422.19
|
| Rate for Payer: PHCS Commercial |
$4,761.30
|
| Rate for Payer: United Healthcare All Payer |
$4,364.53
|
|
|
AMBI PLATE 14 SLOT 135*300MM
|
Facility
|
OP
|
$5,651.56
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,695.47 |
| Max. Negotiated Rate |
$5,425.50 |
| Rate for Payer: Aetna Commercial |
$4,351.70
|
| Rate for Payer: Anthem Medicaid |
$1,943.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,408.22
|
| Rate for Payer: Cash Price |
$2,825.78
|
| Rate for Payer: Cigna Commercial |
$4,690.79
|
| Rate for Payer: First Health Commercial |
$5,368.98
|
| Rate for Payer: Humana Commercial |
$4,803.83
|
| Rate for Payer: Humana KY Medicaid |
$1,943.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1,963.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,634.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,170.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,695.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,982.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,973.37
|
| Rate for Payer: Ohio Health Group HMO |
$4,238.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,521.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,916.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,899.58
|
| Rate for Payer: PHCS Commercial |
$5,425.50
|
| Rate for Payer: United Healthcare All Payer |
$4,973.37
|
|
|
AMBI PLATE 14 SLOT 135*300MM
|
Facility
|
IP
|
$5,651.56
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,695.47 |
| Max. Negotiated Rate |
$5,425.50 |
| Rate for Payer: Aetna Commercial |
$4,351.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,408.22
|
| Rate for Payer: Cash Price |
$2,825.78
|
| Rate for Payer: Cigna Commercial |
$4,690.79
|
| Rate for Payer: First Health Commercial |
$5,368.98
|
| Rate for Payer: Humana Commercial |
$4,803.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,634.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,170.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,695.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,973.37
|
| Rate for Payer: Ohio Health Group HMO |
$4,238.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,521.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,916.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,899.58
|
| Rate for Payer: PHCS Commercial |
$5,425.50
|
| Rate for Payer: United Healthcare All Payer |
$4,973.37
|
|
|
AMBI PLATE 14 SLOT 140*300MM
|
Facility
|
OP
|
$4,055.38
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,216.61 |
| Max. Negotiated Rate |
$3,893.16 |
| Rate for Payer: Aetna Commercial |
$3,122.64
|
| Rate for Payer: Anthem Medicaid |
$1,394.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,163.20
|
| Rate for Payer: Cash Price |
$2,027.69
|
| Rate for Payer: Cigna Commercial |
$3,365.97
|
| Rate for Payer: First Health Commercial |
$3,852.61
|
| Rate for Payer: Humana Commercial |
$3,447.07
|
| Rate for Payer: Humana KY Medicaid |
$1,394.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1,408.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,325.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,992.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,216.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,422.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,568.73
|
| Rate for Payer: Ohio Health Group HMO |
$3,041.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,244.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,528.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,798.21
|
| Rate for Payer: PHCS Commercial |
$3,893.16
|
| Rate for Payer: United Healthcare All Payer |
$3,568.73
|
|
|
AMBI PLATE 14 SLOT 140*300MM
|
Facility
|
IP
|
$4,055.38
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,216.61 |
| Max. Negotiated Rate |
$3,893.16 |
| Rate for Payer: Aetna Commercial |
$3,122.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,163.20
|
| Rate for Payer: Cash Price |
$2,027.69
|
| Rate for Payer: Cigna Commercial |
$3,365.97
|
| Rate for Payer: First Health Commercial |
$3,852.61
|
| Rate for Payer: Humana Commercial |
$3,447.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,325.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,992.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,216.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,568.73
|
| Rate for Payer: Ohio Health Group HMO |
$3,041.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,244.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,528.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,798.21
|
| Rate for Payer: PHCS Commercial |
$3,893.16
|
| Rate for Payer: United Healthcare All Payer |
$3,568.73
|
|
|
AMBI PLATE 14 SLOT 145*300MM
|
Facility
|
IP
|
$5,652.31
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,695.69 |
| Max. Negotiated Rate |
$5,426.22 |
| Rate for Payer: Aetna Commercial |
$4,352.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,408.80
|
| Rate for Payer: Cash Price |
$2,826.16
|
| Rate for Payer: Cigna Commercial |
$4,691.42
|
| Rate for Payer: First Health Commercial |
$5,369.69
|
| Rate for Payer: Humana Commercial |
$4,804.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,634.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,171.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,695.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,974.03
|
| Rate for Payer: Ohio Health Group HMO |
$4,239.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,521.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,917.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,900.09
|
| Rate for Payer: PHCS Commercial |
$5,426.22
|
| Rate for Payer: United Healthcare All Payer |
$4,974.03
|
|
|
AMBI PLATE 14 SLOT 145*300MM
|
Facility
|
OP
|
$5,652.31
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,695.69 |
| Max. Negotiated Rate |
$5,426.22 |
| Rate for Payer: Aetna Commercial |
$4,352.28
|
| Rate for Payer: Anthem Medicaid |
$1,943.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,408.80
|
| Rate for Payer: Cash Price |
$2,826.16
|
| Rate for Payer: Cigna Commercial |
$4,691.42
|
| Rate for Payer: First Health Commercial |
$5,369.69
|
| Rate for Payer: Humana Commercial |
$4,804.46
|
| Rate for Payer: Humana KY Medicaid |
$1,943.83
|
| Rate for Payer: Kentucky WC Medicaid |
$1,963.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,634.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,171.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,695.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,982.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,974.03
|
| Rate for Payer: Ohio Health Group HMO |
$4,239.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,521.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,917.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,900.09
|
| Rate for Payer: PHCS Commercial |
$5,426.22
|
| Rate for Payer: United Healthcare All Payer |
$4,974.03
|
|
|
AMBI PLATE 2 SLOT 130*60MM
|
Facility
|
IP
|
$3,675.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,102.76 |
| Max. Negotiated Rate |
$3,528.84 |
| Rate for Payer: Aetna Commercial |
$2,830.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,867.19
|
| Rate for Payer: Cash Price |
$1,837.94
|
| Rate for Payer: Cigna Commercial |
$3,050.98
|
| Rate for Payer: First Health Commercial |
$3,492.09
|
| Rate for Payer: Humana Commercial |
$3,124.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,014.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,712.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,102.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,234.77
|
| Rate for Payer: Ohio Health Group HMO |
$2,756.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,940.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,198.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,536.36
|
| Rate for Payer: PHCS Commercial |
$3,528.84
|
| Rate for Payer: United Healthcare All Payer |
$3,234.77
|
|
|
AMBI PLATE 2 SLOT 130*60MM
|
Facility
|
OP
|
$3,675.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,102.76 |
| Max. Negotiated Rate |
$3,528.84 |
| Rate for Payer: Aetna Commercial |
$2,830.43
|
| Rate for Payer: Anthem Medicaid |
$1,264.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,867.19
|
| Rate for Payer: Cash Price |
$1,837.94
|
| Rate for Payer: Cigna Commercial |
$3,050.98
|
| Rate for Payer: First Health Commercial |
$3,492.09
|
| Rate for Payer: Humana Commercial |
$3,124.50
|
| Rate for Payer: Humana KY Medicaid |
$1,264.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,277.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,014.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,712.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,102.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,289.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,234.77
|
| Rate for Payer: Ohio Health Group HMO |
$2,756.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,940.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,198.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,536.36
|
| Rate for Payer: PHCS Commercial |
$3,528.84
|
| Rate for Payer: United Healthcare All Payer |
$3,234.77
|
|
|
AMBI PLATE 2 SLOT 135*60MM
|
Facility
|
OP
|
$3,675.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,102.76 |
| Max. Negotiated Rate |
$3,528.84 |
| Rate for Payer: Aetna Commercial |
$2,830.43
|
| Rate for Payer: Anthem Medicaid |
$1,264.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,867.19
|
| Rate for Payer: Cash Price |
$1,837.94
|
| Rate for Payer: Cigna Commercial |
$3,050.98
|
| Rate for Payer: First Health Commercial |
$3,492.09
|
| Rate for Payer: Humana Commercial |
$3,124.50
|
| Rate for Payer: Humana KY Medicaid |
$1,264.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,277.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,014.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,712.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,102.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,289.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,234.77
|
| Rate for Payer: Ohio Health Group HMO |
$2,756.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,940.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,198.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,536.36
|
| Rate for Payer: PHCS Commercial |
$3,528.84
|
| Rate for Payer: United Healthcare All Payer |
$3,234.77
|
|
|
AMBI PLATE 2 SLOT 135*60MM
|
Facility
|
IP
|
$3,675.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,102.76 |
| Max. Negotiated Rate |
$3,528.84 |
| Rate for Payer: Aetna Commercial |
$2,830.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,867.19
|
| Rate for Payer: Cash Price |
$1,837.94
|
| Rate for Payer: Cigna Commercial |
$3,050.98
|
| Rate for Payer: First Health Commercial |
$3,492.09
|
| Rate for Payer: Humana Commercial |
$3,124.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,014.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,712.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,102.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,234.77
|
| Rate for Payer: Ohio Health Group HMO |
$2,756.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,940.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,198.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,536.36
|
| Rate for Payer: PHCS Commercial |
$3,528.84
|
| Rate for Payer: United Healthcare All Payer |
$3,234.77
|
|
|
AMBI PLATE 2 SLOT 140*60MM
|
Facility
|
IP
|
$3,675.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,102.76 |
| Max. Negotiated Rate |
$3,528.84 |
| Rate for Payer: Aetna Commercial |
$2,830.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,867.19
|
| Rate for Payer: Cash Price |
$1,837.94
|
| Rate for Payer: Cigna Commercial |
$3,050.98
|
| Rate for Payer: First Health Commercial |
$3,492.09
|
| Rate for Payer: Humana Commercial |
$3,124.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,014.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,712.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,102.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,234.77
|
| Rate for Payer: Ohio Health Group HMO |
$2,756.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,940.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,198.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,536.36
|
| Rate for Payer: PHCS Commercial |
$3,528.84
|
| Rate for Payer: United Healthcare All Payer |
$3,234.77
|
|
