|
AMBI PLATE 4 SLOT 130*100MM
|
Facility
|
IP
|
$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 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: 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: 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
|
|
|
AMBI PLATE 4 SLOT 135*100MM
|
Facility
|
OP
|
$3,862.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$502.12 |
| Max. Negotiated Rate |
$3,708.00 |
| Rate for Payer: Aetna Commercial |
$2,974.12
|
| Rate for Payer: Anthem Medicaid |
$1,328.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,012.75
|
| Rate for Payer: Cash Price |
$1,931.25
|
| Rate for Payer: Cigna Commercial |
$3,205.88
|
| Rate for Payer: First Health Commercial |
$3,669.38
|
| Rate for Payer: Humana Commercial |
$3,283.12
|
| Rate for Payer: Humana KY Medicaid |
$1,328.31
|
| Rate for Payer: Kentucky WC Medicaid |
$1,341.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,167.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,850.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,158.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,354.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,399.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,896.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$772.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$502.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,197.38
|
| Rate for Payer: PHCS Commercial |
$3,708.00
|
| Rate for Payer: United Healthcare All Payer |
$3,399.00
|
|
|
AMBI PLATE 4 SLOT 135*100MM
|
Facility
|
IP
|
$3,862.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$502.12 |
| Max. Negotiated Rate |
$3,708.00 |
| Rate for Payer: Humana Commercial |
$3,283.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,167.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,850.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,158.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,399.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,896.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$772.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$502.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,197.38
|
| Rate for Payer: PHCS Commercial |
$3,708.00
|
| Rate for Payer: United Healthcare All Payer |
$3,399.00
|
| Rate for Payer: Aetna Commercial |
$2,974.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,012.75
|
| Rate for Payer: Cash Price |
$1,931.25
|
| Rate for Payer: Cigna Commercial |
$3,205.88
|
| Rate for Payer: First Health Commercial |
$3,669.38
|
|
|
AMBI PLATE 4 SLOT 140*100MM
|
Facility
|
OP
|
$3,355.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$436.15 |
| Max. Negotiated Rate |
$3,220.80 |
| Rate for Payer: Aetna Commercial |
$2,583.35
|
| Rate for Payer: Anthem Medicaid |
$1,153.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,616.90
|
| Rate for Payer: Cash Price |
$1,677.50
|
| Rate for Payer: Cigna Commercial |
$2,784.65
|
| Rate for Payer: First Health Commercial |
$3,187.25
|
| Rate for Payer: Humana Commercial |
$2,851.75
|
| Rate for Payer: Humana KY Medicaid |
$1,153.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1,165.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,751.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,475.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,006.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,176.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,952.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,516.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$671.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$436.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,040.05
|
| Rate for Payer: PHCS Commercial |
$3,220.80
|
| Rate for Payer: United Healthcare All Payer |
$2,952.40
|
|
|
AMBI PLATE 4 SLOT 140*100MM
|
Facility
|
IP
|
$3,355.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$436.15 |
| Max. Negotiated Rate |
$3,220.80 |
| Rate for Payer: Aetna Commercial |
$2,583.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,616.90
|
| Rate for Payer: Cash Price |
$1,677.50
|
| Rate for Payer: Cigna Commercial |
$2,784.65
|
| Rate for Payer: First Health Commercial |
$3,187.25
|
| Rate for Payer: Humana Commercial |
$2,851.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,751.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,475.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,006.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,952.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,516.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$671.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$436.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,040.05
|
| Rate for Payer: PHCS Commercial |
$3,220.80
|
| Rate for Payer: United Healthcare All Payer |
$2,952.40
|
|
|
AMBI PLATE 4 SLOT 145*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: Aetna Commercial |
$2,997.84
|
| Rate for Payer: Anthem Medicaid |
$1,311.77
|
| Rate for Payer: Anthem Medicaid |
$1,338.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,975.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,036.77
|
| Rate for Payer: Cash Price |
$1,907.19
|
| Rate for Payer: Cash Price |
$1,946.65
|
| Rate for Payer: Cigna Commercial |
$3,231.44
|
| Rate for Payer: Cigna Commercial |
$3,165.94
|
| Rate for Payer: First Health Commercial |
$3,698.64
|
| Rate for Payer: First Health Commercial |
$3,623.66
|
| Rate for Payer: Humana Commercial |
$3,242.22
|
| Rate for Payer: Humana Commercial |
$3,309.30
|
| Rate for Payer: Humana KY Medicaid |
$1,311.77
|
| Rate for Payer: Humana KY Medicaid |
$1,338.91
|
| Rate for Payer: Kentucky WC Medicaid |
$1,352.53
|
| 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 HMO |
$3,192.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,873.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,815.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,167.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,144.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,338.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,365.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,356.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,426.10
|
| Rate for Payer: Ohio Health Group HMO |
$2,860.78
|
| Rate for Payer: Ohio Health Group HMO |
$2,919.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$762.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$778.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$495.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$506.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,182.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,206.92
|
| Rate for Payer: PHCS Commercial |
$3,737.57
|
| Rate for Payer: PHCS Commercial |
$3,661.80
|
| Rate for Payer: United Healthcare All Payer |
$3,426.10
|
| Rate for Payer: United Healthcare All Payer |
$3,356.65
|
|
|
AMBI PLATE 4 SLOT 145*100MM
|
Facility
|
IP
|
$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: Aetna Commercial |
$2,997.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,975.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,036.77
|
| Rate for Payer: Cash Price |
$1,907.19
|
| Rate for Payer: Cash Price |
$1,946.65
|
| Rate for Payer: Cigna Commercial |
$3,165.94
|
| Rate for Payer: Cigna Commercial |
$3,231.44
|
| Rate for Payer: First Health Commercial |
$3,698.64
|
| Rate for Payer: First Health Commercial |
$3,623.66
|
| Rate for Payer: Humana Commercial |
$3,309.30
|
| Rate for Payer: Humana Commercial |
$3,242.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,127.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,192.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,815.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,873.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,167.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,144.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,356.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,426.10
|
| Rate for Payer: Ohio Health Group HMO |
$2,860.78
|
| Rate for Payer: Ohio Health Group HMO |
$2,919.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$762.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$778.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$495.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$506.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,206.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,182.46
|
| Rate for Payer: PHCS Commercial |
$3,661.80
|
| Rate for Payer: PHCS Commercial |
$3,737.57
|
| Rate for Payer: United Healthcare All Payer |
$3,356.65
|
| Rate for Payer: United Healthcare All Payer |
$3,426.10
|
|
|
AMBI PLATE 4 SLOT 150*100MM
|
Facility
|
IP
|
$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: Aetna Commercial |
$2,997.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,975.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,036.77
|
| Rate for Payer: Cash Price |
$1,907.19
|
| Rate for Payer: Cash Price |
$1,946.65
|
| Rate for Payer: Cigna Commercial |
$3,165.94
|
| Rate for Payer: Cigna Commercial |
$3,231.44
|
| Rate for Payer: First Health Commercial |
$3,698.64
|
| Rate for Payer: First Health Commercial |
$3,623.66
|
| Rate for Payer: Humana Commercial |
$3,309.30
|
| Rate for Payer: Humana Commercial |
$3,242.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,127.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,192.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,815.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,873.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,167.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,144.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,356.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,426.10
|
| Rate for Payer: Ohio Health Group HMO |
$2,860.78
|
| Rate for Payer: Ohio Health Group HMO |
$2,919.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$762.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$778.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$495.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$506.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,206.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,182.46
|
| Rate for Payer: PHCS Commercial |
$3,661.80
|
| Rate for Payer: PHCS Commercial |
$3,737.57
|
| Rate for Payer: United Healthcare All Payer |
$3,356.65
|
| Rate for Payer: United Healthcare All Payer |
$3,426.10
|
|
|
AMBI PLATE 4 SLOT 150*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: Aetna Commercial |
$2,997.84
|
| Rate for Payer: Anthem Medicaid |
$1,311.77
|
| Rate for Payer: Anthem Medicaid |
$1,338.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,975.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,036.77
|
| Rate for Payer: Cash Price |
$1,907.19
|
| Rate for Payer: Cash Price |
$1,946.65
|
| Rate for Payer: Cigna Commercial |
$3,231.44
|
| Rate for Payer: Cigna Commercial |
$3,165.94
|
| Rate for Payer: First Health Commercial |
$3,698.64
|
| Rate for Payer: First Health Commercial |
$3,623.66
|
| Rate for Payer: Humana Commercial |
$3,242.22
|
| Rate for Payer: Humana Commercial |
$3,309.30
|
| Rate for Payer: Humana KY Medicaid |
$1,311.77
|
| Rate for Payer: Humana KY Medicaid |
$1,338.91
|
| Rate for Payer: Kentucky WC Medicaid |
$1,352.53
|
| 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 HMO |
$3,192.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,873.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,815.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,167.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,144.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,338.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,365.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,356.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,426.10
|
| Rate for Payer: Ohio Health Group HMO |
$2,860.78
|
| Rate for Payer: Ohio Health Group HMO |
$2,919.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$762.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$778.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$495.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$506.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,182.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,206.92
|
| Rate for Payer: PHCS Commercial |
$3,737.57
|
| Rate for Payer: PHCS Commercial |
$3,661.80
|
| Rate for Payer: United Healthcare All Payer |
$3,426.10
|
| Rate for Payer: United Healthcare All Payer |
$3,356.65
|
|
|
AMBI PLATE 5 SLOT 130*120MM
|
Facility
|
IP
|
$3,445.48
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$447.91 |
| Max. Negotiated Rate |
$3,307.66 |
| Rate for Payer: Aetna Commercial |
$2,653.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,687.47
|
| Rate for Payer: Cash Price |
$1,722.74
|
| Rate for Payer: Cigna Commercial |
$2,859.75
|
| Rate for Payer: First Health Commercial |
$3,273.21
|
| Rate for Payer: Humana Commercial |
$2,928.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,825.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,542.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,033.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,032.02
|
| Rate for Payer: Ohio Health Group HMO |
$2,584.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$689.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$447.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,068.10
|
| Rate for Payer: PHCS Commercial |
$3,307.66
|
| Rate for Payer: United Healthcare All Payer |
$3,032.02
|
|
|
AMBI PLATE 5 SLOT 130*120MM
|
Facility
|
OP
|
$3,445.48
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$447.91 |
| Max. Negotiated Rate |
$3,307.66 |
| Rate for Payer: Aetna Commercial |
$2,653.02
|
| Rate for Payer: Anthem Medicaid |
$1,184.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,687.47
|
| Rate for Payer: Cash Price |
$1,722.74
|
| Rate for Payer: Cigna Commercial |
$2,859.75
|
| Rate for Payer: First Health Commercial |
$3,273.21
|
| Rate for Payer: Humana Commercial |
$2,928.66
|
| Rate for Payer: Humana KY Medicaid |
$1,184.90
|
| Rate for Payer: Kentucky WC Medicaid |
$1,196.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,825.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,542.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,033.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,208.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,032.02
|
| Rate for Payer: Ohio Health Group HMO |
$2,584.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$689.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$447.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,068.10
|
| Rate for Payer: PHCS Commercial |
$3,307.66
|
| Rate for Payer: United Healthcare All Payer |
$3,032.02
|
|
|
AMBI PLATE 5 SLOT 135*120MM
|
Facility
|
OP
|
$4,261.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$554.00 |
| Max. Negotiated Rate |
$4,091.04 |
| Rate for Payer: Aetna Commercial |
$3,281.36
|
| Rate for Payer: Anthem Medicaid |
$1,465.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,323.97
|
| Rate for Payer: Cash Price |
$2,130.75
|
| Rate for Payer: Cigna Commercial |
$3,537.04
|
| Rate for Payer: First Health Commercial |
$4,048.42
|
| Rate for Payer: Humana Commercial |
$3,622.28
|
| Rate for Payer: Humana KY Medicaid |
$1,465.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1,480.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,494.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,144.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,278.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,494.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,750.12
|
| Rate for Payer: Ohio Health Group HMO |
$3,196.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$852.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$554.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,321.06
|
| Rate for Payer: PHCS Commercial |
$4,091.04
|
| Rate for Payer: United Healthcare All Payer |
$3,750.12
|
|
|
AMBI PLATE 5 SLOT 135*120MM
|
Facility
|
IP
|
$4,261.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$554.00 |
| Max. Negotiated Rate |
$4,091.04 |
| Rate for Payer: Aetna Commercial |
$3,281.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,323.97
|
| Rate for Payer: Cash Price |
$2,130.75
|
| Rate for Payer: Cigna Commercial |
$3,537.04
|
| Rate for Payer: First Health Commercial |
$4,048.42
|
| Rate for Payer: Humana Commercial |
$3,622.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,494.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,144.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,278.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,750.12
|
| Rate for Payer: Ohio Health Group HMO |
$3,196.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$852.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$554.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,321.06
|
| Rate for Payer: PHCS Commercial |
$4,091.04
|
| Rate for Payer: United Healthcare All Payer |
$3,750.12
|
|
|
AMBI PLATE 5 SLOT 140*120MM
|
Facility
|
IP
|
$3,248.32
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$422.28 |
| Max. Negotiated Rate |
$3,118.39 |
| Rate for Payer: Aetna Commercial |
$2,501.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,533.69
|
| Rate for Payer: Cash Price |
$1,624.16
|
| Rate for Payer: Cigna Commercial |
$2,696.11
|
| Rate for Payer: First Health Commercial |
$3,085.90
|
| Rate for Payer: Humana Commercial |
$2,761.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,663.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,397.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$974.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,858.52
|
| Rate for Payer: Ohio Health Group HMO |
$2,436.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$649.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$422.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,006.98
|
| Rate for Payer: PHCS Commercial |
$3,118.39
|
| Rate for Payer: United Healthcare All Payer |
$2,858.52
|
|
|
AMBI PLATE 5 SLOT 140*120MM
|
Facility
|
OP
|
$3,248.32
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$422.28 |
| Max. Negotiated Rate |
$3,118.39 |
| Rate for Payer: Aetna Commercial |
$2,501.21
|
| Rate for Payer: Anthem Medicaid |
$1,117.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,533.69
|
| Rate for Payer: Cash Price |
$1,624.16
|
| Rate for Payer: Cigna Commercial |
$2,696.11
|
| Rate for Payer: First Health Commercial |
$3,085.90
|
| Rate for Payer: Humana Commercial |
$2,761.07
|
| Rate for Payer: Humana KY Medicaid |
$1,117.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,128.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,663.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,397.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$974.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,139.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,858.52
|
| Rate for Payer: Ohio Health Group HMO |
$2,436.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$649.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$422.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,006.98
|
| Rate for Payer: PHCS Commercial |
$3,118.39
|
| Rate for Payer: United Healthcare All Payer |
$2,858.52
|
|
|
AMBI PLATE 5 SLOT 145*120MM
|
Facility
|
OP
|
$3,248.32
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$422.28 |
| Max. Negotiated Rate |
$3,118.39 |
| Rate for Payer: Aetna Commercial |
$2,501.21
|
| Rate for Payer: Anthem Medicaid |
$1,117.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,533.69
|
| Rate for Payer: Cash Price |
$1,624.16
|
| Rate for Payer: Cigna Commercial |
$2,696.11
|
| Rate for Payer: First Health Commercial |
$3,085.90
|
| Rate for Payer: Humana Commercial |
$2,761.07
|
| Rate for Payer: Humana KY Medicaid |
$1,117.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,128.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,663.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,397.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$974.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,139.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,858.52
|
| Rate for Payer: Ohio Health Group HMO |
$2,436.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$649.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$422.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,006.98
|
| Rate for Payer: PHCS Commercial |
$3,118.39
|
| Rate for Payer: United Healthcare All Payer |
$2,858.52
|
|
|
AMBI PLATE 5 SLOT 145*120MM
|
Facility
|
IP
|
$3,248.32
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$422.28 |
| Max. Negotiated Rate |
$3,118.39 |
| Rate for Payer: Aetna Commercial |
$2,501.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,533.69
|
| Rate for Payer: Cash Price |
$1,624.16
|
| Rate for Payer: Cigna Commercial |
$2,696.11
|
| Rate for Payer: First Health Commercial |
$3,085.90
|
| Rate for Payer: Humana Commercial |
$2,761.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,663.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,397.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$974.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,858.52
|
| Rate for Payer: Ohio Health Group HMO |
$2,436.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$649.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$422.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,006.98
|
| Rate for Payer: PHCS Commercial |
$3,118.39
|
| Rate for Payer: United Healthcare All Payer |
$2,858.52
|
|
|
AMBI PLATE 5 SLOT 150*120MM
|
Facility
|
IP
|
$3,929.18
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$510.79 |
| Max. Negotiated Rate |
$3,772.01 |
| Rate for Payer: Aetna Commercial |
$3,025.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,064.76
|
| Rate for Payer: Cash Price |
$1,964.59
|
| Rate for Payer: Cigna Commercial |
$3,261.22
|
| Rate for Payer: First Health Commercial |
$3,732.72
|
| Rate for Payer: Humana Commercial |
$3,339.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,221.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,899.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,178.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,457.68
|
| Rate for Payer: Ohio Health Group HMO |
$2,946.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$785.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$510.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,218.05
|
| Rate for Payer: PHCS Commercial |
$3,772.01
|
| Rate for Payer: United Healthcare All Payer |
$3,457.68
|
|
|
AMBI PLATE 5 SLOT 150*120MM
|
Facility
|
OP
|
$3,929.18
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$510.79 |
| Max. Negotiated Rate |
$3,772.01 |
| Rate for Payer: Aetna Commercial |
$3,025.47
|
| Rate for Payer: Anthem Medicaid |
$1,351.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,064.76
|
| Rate for Payer: Cash Price |
$1,964.59
|
| Rate for Payer: Cigna Commercial |
$3,261.22
|
| Rate for Payer: First Health Commercial |
$3,732.72
|
| Rate for Payer: Humana Commercial |
$3,339.80
|
| Rate for Payer: Humana KY Medicaid |
$1,351.25
|
| Rate for Payer: Kentucky WC Medicaid |
$1,365.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,221.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,899.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,178.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,378.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,457.68
|
| Rate for Payer: Ohio Health Group HMO |
$2,946.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$785.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$510.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,218.05
|
| Rate for Payer: PHCS Commercial |
$3,772.01
|
| Rate for Payer: United Healthcare All Payer |
$3,457.68
|
|
|
AMBI PLATE 6 SLOT 135*140MM
|
Facility
|
IP
|
$3,284.37
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$426.97 |
| Max. Negotiated Rate |
$3,153.00 |
| Rate for Payer: Humana Commercial |
$2,791.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,693.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,423.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$985.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,890.25
|
| Rate for Payer: Ohio Health Group HMO |
$2,463.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$656.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$426.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,018.15
|
| Rate for Payer: PHCS Commercial |
$3,153.00
|
| Rate for Payer: United Healthcare All Payer |
$2,890.25
|
| Rate for Payer: Aetna Commercial |
$2,528.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,561.81
|
| Rate for Payer: Cash Price |
$1,642.18
|
| Rate for Payer: Cigna Commercial |
$2,726.03
|
| Rate for Payer: First Health Commercial |
$3,120.15
|
|
|
AMBI PLATE 6 SLOT 135*140MM
|
Facility
|
OP
|
$3,284.37
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$426.97 |
| Max. Negotiated Rate |
$3,153.00 |
| Rate for Payer: Aetna Commercial |
$2,528.96
|
| Rate for Payer: Anthem Medicaid |
$1,129.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,561.81
|
| Rate for Payer: Cash Price |
$1,642.18
|
| Rate for Payer: Cigna Commercial |
$2,726.03
|
| Rate for Payer: First Health Commercial |
$3,120.15
|
| Rate for Payer: Humana Commercial |
$2,791.71
|
| Rate for Payer: Humana KY Medicaid |
$1,129.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1,140.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,693.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,423.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$985.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,152.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,890.25
|
| Rate for Payer: Ohio Health Group HMO |
$2,463.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$656.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$426.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,018.15
|
| Rate for Payer: PHCS Commercial |
$3,153.00
|
| Rate for Payer: United Healthcare All Payer |
$2,890.25
|
|
|
AMBI PLATE 6 SLOT 140*140MM
|
Facility
|
OP
|
$3,477.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$452.08 |
| Max. Negotiated Rate |
$3,338.40 |
| Rate for Payer: Aetna Commercial |
$2,677.68
|
| Rate for Payer: Anthem Medicaid |
$1,195.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,712.45
|
| Rate for Payer: Cash Price |
$1,738.75
|
| Rate for Payer: Cigna Commercial |
$2,886.32
|
| Rate for Payer: First Health Commercial |
$3,303.62
|
| Rate for Payer: Humana Commercial |
$2,955.88
|
| Rate for Payer: Humana KY Medicaid |
$1,195.91
|
| Rate for Payer: Kentucky WC Medicaid |
$1,208.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,851.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,566.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,043.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,219.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,060.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,608.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$695.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$452.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,078.02
|
| Rate for Payer: PHCS Commercial |
$3,338.40
|
| Rate for Payer: United Healthcare All Payer |
$3,060.20
|
|
|
AMBI PLATE 6 SLOT 140*140MM
|
Facility
|
IP
|
$3,477.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$452.08 |
| Max. Negotiated Rate |
$3,338.40 |
| Rate for Payer: Aetna Commercial |
$2,677.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,712.45
|
| Rate for Payer: Cash Price |
$1,738.75
|
| Rate for Payer: Cigna Commercial |
$2,886.32
|
| Rate for Payer: First Health Commercial |
$3,303.62
|
| Rate for Payer: Humana Commercial |
$2,955.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,851.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,566.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,043.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,060.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,608.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$695.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$452.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,078.02
|
| Rate for Payer: PHCS Commercial |
$3,338.40
|
| Rate for Payer: United Healthcare All Payer |
$3,060.20
|
|
|
AMBI PLATE 6 SLOT 145*140MM
|
Facility
|
OP
|
$3,284.37
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$426.97 |
| Max. Negotiated Rate |
$3,153.00 |
| Rate for Payer: Aetna Commercial |
$2,528.96
|
| Rate for Payer: Anthem Medicaid |
$1,129.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,561.81
|
| Rate for Payer: Cash Price |
$1,642.18
|
| Rate for Payer: Cigna Commercial |
$2,726.03
|
| Rate for Payer: First Health Commercial |
$3,120.15
|
| Rate for Payer: Humana Commercial |
$2,791.71
|
| Rate for Payer: Humana KY Medicaid |
$1,129.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1,140.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,693.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,423.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$985.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,152.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,890.25
|
| Rate for Payer: Ohio Health Group HMO |
$2,463.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$656.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$426.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,018.15
|
| Rate for Payer: PHCS Commercial |
$3,153.00
|
| Rate for Payer: United Healthcare All Payer |
$2,890.25
|
|
|
AMBI PLATE 6 SLOT 145*140MM
|
Facility
|
IP
|
$3,284.37
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$426.97 |
| Max. Negotiated Rate |
$3,153.00 |
| Rate for Payer: Aetna Commercial |
$2,528.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,561.81
|
| Rate for Payer: Cash Price |
$1,642.18
|
| Rate for Payer: Cigna Commercial |
$2,726.03
|
| Rate for Payer: First Health Commercial |
$3,120.15
|
| Rate for Payer: Humana Commercial |
$2,791.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,693.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,423.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$985.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,890.25
|
| Rate for Payer: Ohio Health Group HMO |
$2,463.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$656.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$426.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,018.15
|
| Rate for Payer: PHCS Commercial |
$3,153.00
|
| Rate for Payer: United Healthcare All Payer |
$2,890.25
|
|
