|
AMBI PLATE 5 SLOT 130*120MM
|
Facility
|
IP
|
$3,334.44
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,000.33 |
| Max. Negotiated Rate |
$3,201.06 |
| Rate for Payer: Aetna Commercial |
$2,567.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,600.86
|
| Rate for Payer: Cash Price |
$1,667.22
|
| Rate for Payer: Cigna Commercial |
$2,767.59
|
| Rate for Payer: First Health Commercial |
$3,167.72
|
| Rate for Payer: Humana Commercial |
$2,834.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,734.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,460.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,000.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,934.31
|
| Rate for Payer: Ohio Health Group HMO |
$2,500.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,667.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,900.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,300.76
|
| Rate for Payer: PHCS Commercial |
$3,201.06
|
| Rate for Payer: United Healthcare All Payer |
$2,934.31
|
|
|
AMBI PLATE 5 SLOT 130*120MM
|
Facility
|
OP
|
$3,334.44
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,000.33 |
| Max. Negotiated Rate |
$3,201.06 |
| Rate for Payer: Aetna Commercial |
$2,567.52
|
| Rate for Payer: Anthem Medicaid |
$1,146.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,600.86
|
| Rate for Payer: Cash Price |
$1,667.22
|
| Rate for Payer: Cigna Commercial |
$2,767.59
|
| Rate for Payer: First Health Commercial |
$3,167.72
|
| Rate for Payer: Humana Commercial |
$2,834.27
|
| Rate for Payer: Humana KY Medicaid |
$1,146.71
|
| Rate for Payer: Kentucky WC Medicaid |
$1,158.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,734.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,460.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,000.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,169.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,934.31
|
| Rate for Payer: Ohio Health Group HMO |
$2,500.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,667.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,900.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,300.76
|
| Rate for Payer: PHCS Commercial |
$3,201.06
|
| Rate for Payer: United Healthcare All Payer |
$2,934.31
|
|
|
AMBI PLATE 5 SLOT 135*120MM
|
Facility
|
IP
|
$4,208.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,262.62 |
| Max. Negotiated Rate |
$4,040.40 |
| Rate for Payer: Aetna Commercial |
$3,240.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,282.82
|
| Rate for Payer: Cash Price |
$2,104.38
|
| Rate for Payer: Cigna Commercial |
$3,493.26
|
| Rate for Payer: First Health Commercial |
$3,998.31
|
| Rate for Payer: Humana Commercial |
$3,577.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,451.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,106.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,262.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,703.70
|
| Rate for Payer: Ohio Health Group HMO |
$3,156.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,367.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,661.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,904.04
|
| Rate for Payer: PHCS Commercial |
$4,040.40
|
| Rate for Payer: United Healthcare All Payer |
$3,703.70
|
|
|
AMBI PLATE 5 SLOT 135*120MM
|
Facility
|
OP
|
$4,208.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,262.62 |
| Max. Negotiated Rate |
$4,040.40 |
| Rate for Payer: Aetna Commercial |
$3,240.74
|
| Rate for Payer: Anthem Medicaid |
$1,447.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,282.82
|
| Rate for Payer: Cash Price |
$2,104.38
|
| Rate for Payer: Cigna Commercial |
$3,493.26
|
| Rate for Payer: First Health Commercial |
$3,998.31
|
| Rate for Payer: Humana Commercial |
$3,577.44
|
| Rate for Payer: Humana KY Medicaid |
$1,447.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,462.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,451.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,106.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,262.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,476.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,703.70
|
| Rate for Payer: Ohio Health Group HMO |
$3,156.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,367.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,661.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,904.04
|
| Rate for Payer: PHCS Commercial |
$4,040.40
|
| Rate for Payer: United Healthcare All Payer |
$3,703.70
|
|
|
AMBI PLATE 5 SLOT 140*120MM
|
Facility
|
OP
|
$3,123.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$936.96 |
| Max. Negotiated Rate |
$2,998.27 |
| Rate for Payer: Aetna Commercial |
$2,404.86
|
| Rate for Payer: Anthem Medicaid |
$1,074.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,436.10
|
| Rate for Payer: Cash Price |
$1,561.60
|
| Rate for Payer: Cigna Commercial |
$2,592.26
|
| Rate for Payer: First Health Commercial |
$2,967.04
|
| Rate for Payer: Humana Commercial |
$2,654.72
|
| Rate for Payer: Humana KY Medicaid |
$1,074.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,085.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,561.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,304.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$936.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,095.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,748.42
|
| Rate for Payer: Ohio Health Group HMO |
$2,342.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,498.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,717.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,155.01
|
| Rate for Payer: PHCS Commercial |
$2,998.27
|
| Rate for Payer: United Healthcare All Payer |
$2,748.42
|
|
|
AMBI PLATE 5 SLOT 140*120MM
|
Facility
|
IP
|
$3,123.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$936.96 |
| Max. Negotiated Rate |
$2,998.27 |
| Rate for Payer: Aetna Commercial |
$2,404.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,436.10
|
| Rate for Payer: Cash Price |
$1,561.60
|
| Rate for Payer: Cigna Commercial |
$2,592.26
|
| Rate for Payer: First Health Commercial |
$2,967.04
|
| Rate for Payer: Humana Commercial |
$2,654.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,561.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,304.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$936.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,748.42
|
| Rate for Payer: Ohio Health Group HMO |
$2,342.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,498.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,717.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,155.01
|
| Rate for Payer: PHCS Commercial |
$2,998.27
|
| Rate for Payer: United Healthcare All Payer |
$2,748.42
|
|
|
AMBI PLATE 5 SLOT 145*120MM
|
Facility
|
IP
|
$3,123.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$936.96 |
| Max. Negotiated Rate |
$2,998.27 |
| Rate for Payer: Aetna Commercial |
$2,404.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,436.10
|
| Rate for Payer: Cash Price |
$1,561.60
|
| Rate for Payer: Cigna Commercial |
$2,592.26
|
| Rate for Payer: First Health Commercial |
$2,967.04
|
| Rate for Payer: Humana Commercial |
$2,654.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,561.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,304.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$936.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,748.42
|
| Rate for Payer: Ohio Health Group HMO |
$2,342.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,498.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,717.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,155.01
|
| Rate for Payer: PHCS Commercial |
$2,998.27
|
| Rate for Payer: United Healthcare All Payer |
$2,748.42
|
|
|
AMBI PLATE 5 SLOT 145*120MM
|
Facility
|
OP
|
$3,123.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$936.96 |
| Max. Negotiated Rate |
$2,998.27 |
| Rate for Payer: Aetna Commercial |
$2,404.86
|
| Rate for Payer: Anthem Medicaid |
$1,074.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,436.10
|
| Rate for Payer: Cash Price |
$1,561.60
|
| Rate for Payer: Cigna Commercial |
$2,592.26
|
| Rate for Payer: First Health Commercial |
$2,967.04
|
| Rate for Payer: Humana Commercial |
$2,654.72
|
| Rate for Payer: Humana KY Medicaid |
$1,074.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,085.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,561.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,304.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$936.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,095.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,748.42
|
| Rate for Payer: Ohio Health Group HMO |
$2,342.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,498.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,717.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,155.01
|
| Rate for Payer: PHCS Commercial |
$2,998.27
|
| Rate for Payer: United Healthcare All Payer |
$2,748.42
|
|
|
AMBI PLATE 5 SLOT 150*120MM
|
Facility
|
IP
|
$3,852.69
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,155.81 |
| Max. Negotiated Rate |
$3,698.58 |
| Rate for Payer: Aetna Commercial |
$2,966.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,005.10
|
| Rate for Payer: Cash Price |
$1,926.34
|
| Rate for Payer: Cigna Commercial |
$3,197.73
|
| Rate for Payer: First Health Commercial |
$3,660.06
|
| Rate for Payer: Humana Commercial |
$3,274.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,159.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,843.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,155.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,390.37
|
| Rate for Payer: Ohio Health Group HMO |
$2,889.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,082.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,351.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,658.36
|
| Rate for Payer: PHCS Commercial |
$3,698.58
|
| Rate for Payer: United Healthcare All Payer |
$3,390.37
|
|
|
AMBI PLATE 5 SLOT 150*120MM
|
Facility
|
OP
|
$3,852.69
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,155.81 |
| Max. Negotiated Rate |
$3,698.58 |
| Rate for Payer: Aetna Commercial |
$2,966.57
|
| Rate for Payer: Anthem Medicaid |
$1,324.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,005.10
|
| Rate for Payer: Cash Price |
$1,926.34
|
| Rate for Payer: Cigna Commercial |
$3,197.73
|
| Rate for Payer: First Health Commercial |
$3,660.06
|
| Rate for Payer: Humana Commercial |
$3,274.79
|
| Rate for Payer: Humana KY Medicaid |
$1,324.94
|
| Rate for Payer: Kentucky WC Medicaid |
$1,338.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,159.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,843.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,155.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,351.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,390.37
|
| Rate for Payer: Ohio Health Group HMO |
$2,889.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,082.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,351.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,658.36
|
| Rate for Payer: PHCS Commercial |
$3,698.58
|
| Rate for Payer: United Healthcare All Payer |
$3,390.37
|
|
|
AMBI PLATE 6 SLOT 135*140MM
|
Facility
|
IP
|
$3,161.82
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$948.55 |
| Max. Negotiated Rate |
$3,035.35 |
| Rate for Payer: Aetna Commercial |
$2,434.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,466.22
|
| Rate for Payer: Cash Price |
$1,580.91
|
| Rate for Payer: Cigna Commercial |
$2,624.31
|
| Rate for Payer: First Health Commercial |
$3,003.73
|
| Rate for Payer: Humana Commercial |
$2,687.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,592.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,333.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$948.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,782.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,371.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,529.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,750.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,181.66
|
| Rate for Payer: PHCS Commercial |
$3,035.35
|
| Rate for Payer: United Healthcare All Payer |
$2,782.40
|
|
|
AMBI PLATE 6 SLOT 135*140MM
|
Facility
|
OP
|
$3,161.82
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$948.55 |
| Max. Negotiated Rate |
$3,035.35 |
| Rate for Payer: Aetna Commercial |
$2,434.60
|
| Rate for Payer: Anthem Medicaid |
$1,087.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,466.22
|
| Rate for Payer: Cash Price |
$1,580.91
|
| Rate for Payer: Cigna Commercial |
$2,624.31
|
| Rate for Payer: First Health Commercial |
$3,003.73
|
| Rate for Payer: Humana Commercial |
$2,687.55
|
| Rate for Payer: Humana KY Medicaid |
$1,087.35
|
| Rate for Payer: Kentucky WC Medicaid |
$1,098.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,592.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,333.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$948.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,109.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,782.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,371.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,529.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,750.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,181.66
|
| Rate for Payer: PHCS Commercial |
$3,035.35
|
| Rate for Payer: United Healthcare All Payer |
$2,782.40
|
|
|
AMBI PLATE 6 SLOT 140*140MM
|
Facility
|
OP
|
$3,368.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,010.62 |
| Max. Negotiated Rate |
$3,234.00 |
| Rate for Payer: Aetna Commercial |
$2,593.94
|
| Rate for Payer: Anthem Medicaid |
$1,158.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,627.62
|
| Rate for Payer: Cash Price |
$1,684.38
|
| Rate for Payer: Cigna Commercial |
$2,796.06
|
| Rate for Payer: First Health Commercial |
$3,200.31
|
| Rate for Payer: Humana Commercial |
$2,863.44
|
| Rate for Payer: Humana KY Medicaid |
$1,158.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1,170.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,762.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,486.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,010.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,181.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,964.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,526.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,695.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,930.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,324.44
|
| Rate for Payer: PHCS Commercial |
$3,234.00
|
| Rate for Payer: United Healthcare All Payer |
$2,964.50
|
|
|
AMBI PLATE 6 SLOT 140*140MM
|
Facility
|
IP
|
$3,368.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,010.62 |
| Max. Negotiated Rate |
$3,234.00 |
| Rate for Payer: Aetna Commercial |
$2,593.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,627.62
|
| Rate for Payer: Cash Price |
$1,684.38
|
| Rate for Payer: Cigna Commercial |
$2,796.06
|
| Rate for Payer: First Health Commercial |
$3,200.31
|
| Rate for Payer: Humana Commercial |
$2,863.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,762.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,486.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,010.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,964.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,526.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,695.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,930.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,324.44
|
| Rate for Payer: PHCS Commercial |
$3,234.00
|
| Rate for Payer: United Healthcare All Payer |
$2,964.50
|
|
|
AMBI PLATE 6 SLOT 145*140MM
|
Facility
|
IP
|
$3,161.82
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$948.55 |
| Max. Negotiated Rate |
$3,035.35 |
| Rate for Payer: Aetna Commercial |
$2,434.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,466.22
|
| Rate for Payer: Cash Price |
$1,580.91
|
| Rate for Payer: Cigna Commercial |
$2,624.31
|
| Rate for Payer: First Health Commercial |
$3,003.73
|
| Rate for Payer: Humana Commercial |
$2,687.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,592.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,333.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$948.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,782.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,371.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,529.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,750.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,181.66
|
| Rate for Payer: PHCS Commercial |
$3,035.35
|
| Rate for Payer: United Healthcare All Payer |
$2,782.40
|
|
|
AMBI PLATE 6 SLOT 145*140MM
|
Facility
|
OP
|
$3,161.82
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$948.55 |
| Max. Negotiated Rate |
$3,035.35 |
| Rate for Payer: Aetna Commercial |
$2,434.60
|
| Rate for Payer: Anthem Medicaid |
$1,087.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,466.22
|
| Rate for Payer: Cash Price |
$1,580.91
|
| Rate for Payer: Cigna Commercial |
$2,624.31
|
| Rate for Payer: First Health Commercial |
$3,003.73
|
| Rate for Payer: Humana Commercial |
$2,687.55
|
| Rate for Payer: Humana KY Medicaid |
$1,087.35
|
| Rate for Payer: Kentucky WC Medicaid |
$1,098.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,592.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,333.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$948.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,109.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,782.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,371.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,529.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,750.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,181.66
|
| Rate for Payer: PHCS Commercial |
$3,035.35
|
| Rate for Payer: United Healthcare All Payer |
$2,782.40
|
|
|
AMBI PLATE 6 SLOT 150*140MM
|
Facility
|
IP
|
$3,921.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,176.56 |
| Max. Negotiated Rate |
$3,765.00 |
| Rate for Payer: Aetna Commercial |
$3,019.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,059.07
|
| Rate for Payer: Cash Price |
$1,960.94
|
| Rate for Payer: Cigna Commercial |
$3,255.16
|
| Rate for Payer: First Health Commercial |
$3,725.79
|
| Rate for Payer: Humana Commercial |
$3,333.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,215.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,894.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,176.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,451.25
|
| Rate for Payer: Ohio Health Group HMO |
$2,941.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,137.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,412.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,706.10
|
| Rate for Payer: PHCS Commercial |
$3,765.00
|
| Rate for Payer: United Healthcare All Payer |
$3,451.25
|
|
|
AMBI PLATE 6 SLOT 150*140MM
|
Facility
|
OP
|
$3,921.88
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,176.56 |
| Max. Negotiated Rate |
$3,765.00 |
| Rate for Payer: Aetna Commercial |
$3,019.85
|
| Rate for Payer: Anthem Medicaid |
$1,348.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,059.07
|
| Rate for Payer: Cash Price |
$1,960.94
|
| Rate for Payer: Cigna Commercial |
$3,255.16
|
| Rate for Payer: First Health Commercial |
$3,725.79
|
| Rate for Payer: Humana Commercial |
$3,333.60
|
| Rate for Payer: Humana KY Medicaid |
$1,348.73
|
| Rate for Payer: Kentucky WC Medicaid |
$1,362.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,215.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,894.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,176.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,375.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,451.25
|
| Rate for Payer: Ohio Health Group HMO |
$2,941.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,137.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,412.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,706.10
|
| Rate for Payer: PHCS Commercial |
$3,765.00
|
| Rate for Payer: United Healthcare All Payer |
$3,451.25
|
|
|
AMBI PLATE 6 SLOT 90*124MM
|
Facility
|
IP
|
$4,317.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,295.25 |
| Max. Negotiated Rate |
$4,144.80 |
| Rate for Payer: Aetna Commercial |
$3,324.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,367.65
|
| Rate for Payer: Cash Price |
$2,158.75
|
| Rate for Payer: Cigna Commercial |
$3,583.53
|
| Rate for Payer: First Health Commercial |
$4,101.62
|
| Rate for Payer: Humana Commercial |
$3,669.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,540.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,186.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,295.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,799.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,238.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,454.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,756.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,979.07
|
| Rate for Payer: PHCS Commercial |
$4,144.80
|
| Rate for Payer: United Healthcare All Payer |
$3,799.40
|
|
|
AMBI PLATE 6 SLOT 90*124MM
|
Facility
|
OP
|
$4,317.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,295.25 |
| Max. Negotiated Rate |
$4,144.80 |
| Rate for Payer: Aetna Commercial |
$3,324.47
|
| Rate for Payer: Anthem Medicaid |
$1,484.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,367.65
|
| Rate for Payer: Cash Price |
$2,158.75
|
| Rate for Payer: Cigna Commercial |
$3,583.53
|
| Rate for Payer: First Health Commercial |
$4,101.62
|
| Rate for Payer: Humana Commercial |
$3,669.88
|
| Rate for Payer: Humana KY Medicaid |
$1,484.79
|
| Rate for Payer: Kentucky WC Medicaid |
$1,499.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,540.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,186.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,295.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,514.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,799.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,238.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,454.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,756.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,979.07
|
| Rate for Payer: PHCS Commercial |
$4,144.80
|
| Rate for Payer: United Healthcare All Payer |
$3,799.40
|
|
|
AMBI PLATE 6 SLOT 95*124MM
|
Facility
|
IP
|
$4,444.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,333.39 |
| Max. Negotiated Rate |
$4,266.84 |
| Rate for Payer: Aetna Commercial |
$3,422.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,466.80
|
| Rate for Payer: Cash Price |
$2,222.31
|
| Rate for Payer: Cigna Commercial |
$3,689.03
|
| Rate for Payer: First Health Commercial |
$4,222.39
|
| Rate for Payer: Humana Commercial |
$3,777.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,644.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,280.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,333.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,911.27
|
| Rate for Payer: Ohio Health Group HMO |
$3,333.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,555.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,866.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,066.79
|
| Rate for Payer: PHCS Commercial |
$4,266.84
|
| Rate for Payer: United Healthcare All Payer |
$3,911.27
|
|
|
AMBI PLATE 6 SLOT 95*124MM
|
Facility
|
OP
|
$4,444.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,333.39 |
| Max. Negotiated Rate |
$4,266.84 |
| Rate for Payer: Aetna Commercial |
$3,422.36
|
| Rate for Payer: Anthem Medicaid |
$1,528.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,466.80
|
| Rate for Payer: Cash Price |
$2,222.31
|
| Rate for Payer: Cigna Commercial |
$3,689.03
|
| Rate for Payer: First Health Commercial |
$4,222.39
|
| Rate for Payer: Humana Commercial |
$3,777.93
|
| Rate for Payer: Humana KY Medicaid |
$1,528.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,544.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,644.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,280.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,333.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,559.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,911.27
|
| Rate for Payer: Ohio Health Group HMO |
$3,333.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,555.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,866.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,066.79
|
| Rate for Payer: PHCS Commercial |
$4,266.84
|
| Rate for Payer: United Healthcare All Payer |
$3,911.27
|
|
|
AMBI PLATE 8 SLOT 130*180MM
|
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 8 SLOT 130*180MM
|
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 8 SLOT 135*180MM
|
Facility
|
IP
|
$4,337.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,301.10 |
| Max. Negotiated Rate |
$4,163.52 |
| Rate for Payer: Aetna Commercial |
$3,339.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,382.86
|
| Rate for Payer: Cash Price |
$2,168.50
|
| Rate for Payer: Cigna Commercial |
$3,599.71
|
| Rate for Payer: First Health Commercial |
$4,120.15
|
| Rate for Payer: Humana Commercial |
$3,686.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,556.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,200.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,301.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,816.56
|
| Rate for Payer: Ohio Health Group HMO |
$3,252.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,469.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,773.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,992.53
|
| Rate for Payer: PHCS Commercial |
$4,163.52
|
| Rate for Payer: United Healthcare All Payer |
$3,816.56
|
|
