|
GFT HEMASHIELD STRAIGHT 16*30
|
Facility
|
OP
|
$3,451.81
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$448.74 |
| Max. Negotiated Rate |
$3,313.74 |
| Rate for Payer: Aetna Commercial |
$2,657.89
|
| Rate for Payer: Anthem Medicaid |
$1,187.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,692.41
|
| Rate for Payer: Cash Price |
$1,725.90
|
| Rate for Payer: Cigna Commercial |
$2,865.00
|
| Rate for Payer: First Health Commercial |
$3,279.22
|
| Rate for Payer: Humana Commercial |
$2,934.04
|
| Rate for Payer: Humana KY Medicaid |
$1,187.08
|
| Rate for Payer: Kentucky WC Medicaid |
$1,199.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,830.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,547.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,035.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,210.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,037.59
|
| Rate for Payer: Ohio Health Group HMO |
$2,588.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$690.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$448.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,070.06
|
| Rate for Payer: PHCS Commercial |
$3,313.74
|
| Rate for Payer: United Healthcare All Payer |
$3,037.59
|
|
|
GFT HEMASHIELD STRAIGHT 18*30
|
Facility
|
IP
|
$3,451.81
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$448.74 |
| Max. Negotiated Rate |
$3,313.74 |
| Rate for Payer: Aetna Commercial |
$2,657.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,692.41
|
| Rate for Payer: Cash Price |
$1,725.90
|
| Rate for Payer: Cigna Commercial |
$2,865.00
|
| Rate for Payer: First Health Commercial |
$3,279.22
|
| Rate for Payer: Humana Commercial |
$2,934.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,830.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,547.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,035.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,037.59
|
| Rate for Payer: Ohio Health Group HMO |
$2,588.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$690.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$448.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,070.06
|
| Rate for Payer: PHCS Commercial |
$3,313.74
|
| Rate for Payer: United Healthcare All Payer |
$3,037.59
|
|
|
GFT HEMASHIELD STRAIGHT 18*30
|
Facility
|
OP
|
$3,451.81
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$448.74 |
| Max. Negotiated Rate |
$3,313.74 |
| Rate for Payer: Aetna Commercial |
$2,657.89
|
| Rate for Payer: Anthem Medicaid |
$1,187.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,692.41
|
| Rate for Payer: Cash Price |
$1,725.90
|
| Rate for Payer: Cigna Commercial |
$2,865.00
|
| Rate for Payer: First Health Commercial |
$3,279.22
|
| Rate for Payer: Humana Commercial |
$2,934.04
|
| Rate for Payer: Humana KY Medicaid |
$1,187.08
|
| Rate for Payer: Kentucky WC Medicaid |
$1,199.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,830.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,547.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,035.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,210.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,037.59
|
| Rate for Payer: Ohio Health Group HMO |
$2,588.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$690.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$448.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,070.06
|
| Rate for Payer: PHCS Commercial |
$3,313.74
|
| Rate for Payer: United Healthcare All Payer |
$3,037.59
|
|
|
GFT HEMSHLD PLAT PTCH 0.8*15.2
|
Facility
|
IP
|
$1,754.88
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$228.13 |
| Max. Negotiated Rate |
$1,684.68 |
| Rate for Payer: Aetna Commercial |
$1,351.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,368.81
|
| Rate for Payer: Cash Price |
$877.44
|
| Rate for Payer: Cigna Commercial |
$1,456.55
|
| Rate for Payer: First Health Commercial |
$1,667.14
|
| Rate for Payer: Humana Commercial |
$1,491.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,439.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,295.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$526.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,544.29
|
| Rate for Payer: Ohio Health Group HMO |
$1,316.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$228.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$544.01
|
| Rate for Payer: PHCS Commercial |
$1,684.68
|
| Rate for Payer: United Healthcare All Payer |
$1,544.29
|
|
|
GFT HEMSHLD PLAT PTCH 0.8*15.2
|
Facility
|
OP
|
$1,754.88
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$228.13 |
| Max. Negotiated Rate |
$1,684.68 |
| Rate for Payer: Aetna Commercial |
$1,351.26
|
| Rate for Payer: Anthem Medicaid |
$603.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,368.81
|
| Rate for Payer: Cash Price |
$877.44
|
| Rate for Payer: Cigna Commercial |
$1,456.55
|
| Rate for Payer: First Health Commercial |
$1,667.14
|
| Rate for Payer: Humana Commercial |
$1,491.65
|
| Rate for Payer: Humana KY Medicaid |
$603.50
|
| Rate for Payer: Kentucky WC Medicaid |
$609.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,439.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,295.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$526.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$615.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,544.29
|
| Rate for Payer: Ohio Health Group HMO |
$1,316.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$228.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$544.01
|
| Rate for Payer: PHCS Commercial |
$1,684.68
|
| Rate for Payer: United Healthcare All Payer |
$1,544.29
|
|
|
GFT ILIAC EXT OVTN IX 10*10*45
|
Facility
|
IP
|
$23,046.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,996.03 |
| Max. Negotiated Rate |
$22,124.50 |
| Rate for Payer: Aetna Commercial |
$17,745.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,976.15
|
| Rate for Payer: Cash Price |
$11,523.17
|
| Rate for Payer: Cigna Commercial |
$19,128.47
|
| Rate for Payer: First Health Commercial |
$21,894.03
|
| Rate for Payer: Humana Commercial |
$19,589.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,898.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,008.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,913.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,280.79
|
| Rate for Payer: Ohio Health Group HMO |
$17,284.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,609.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,996.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,144.37
|
| Rate for Payer: PHCS Commercial |
$22,124.50
|
| Rate for Payer: United Healthcare All Payer |
$20,280.79
|
|
|
GFT ILIAC EXT OVTN IX 10*10*45
|
Facility
|
OP
|
$23,046.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,996.03 |
| Max. Negotiated Rate |
$22,124.50 |
| Rate for Payer: Aetna Commercial |
$17,745.69
|
| Rate for Payer: Anthem Medicaid |
$7,925.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,976.15
|
| Rate for Payer: Cash Price |
$11,523.17
|
| Rate for Payer: Cigna Commercial |
$19,128.47
|
| Rate for Payer: First Health Commercial |
$21,894.03
|
| Rate for Payer: Humana Commercial |
$19,589.40
|
| Rate for Payer: Humana KY Medicaid |
$7,925.64
|
| Rate for Payer: Kentucky WC Medicaid |
$8,006.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,898.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,008.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,913.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,084.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,280.79
|
| Rate for Payer: Ohio Health Group HMO |
$17,284.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,609.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,996.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,144.37
|
| Rate for Payer: PHCS Commercial |
$22,124.50
|
| Rate for Payer: United Healthcare All Payer |
$20,280.79
|
|
|
GFT ILIAC EXT OVTN IX 12*12*45
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
GFT ILIAC EXT OVTN IX 12*12*45
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
GFT ILIAC EXT OVTN IX 14*14*45
|
Facility
|
OP
|
$25,601.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,328.18 |
| Max. Negotiated Rate |
$24,577.30 |
| Rate for Payer: Aetna Commercial |
$19,713.04
|
| Rate for Payer: Anthem Medicaid |
$8,804.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,969.05
|
| Rate for Payer: Cash Price |
$12,800.67
|
| Rate for Payer: Cigna Commercial |
$21,249.12
|
| Rate for Payer: First Health Commercial |
$24,321.28
|
| Rate for Payer: Humana Commercial |
$21,761.15
|
| Rate for Payer: Humana KY Medicaid |
$8,804.30
|
| Rate for Payer: Kentucky WC Medicaid |
$8,893.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,993.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,893.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,680.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,980.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,529.19
|
| Rate for Payer: Ohio Health Group HMO |
$19,201.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,120.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,328.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,936.42
|
| Rate for Payer: PHCS Commercial |
$24,577.30
|
| Rate for Payer: United Healthcare All Payer |
$22,529.19
|
|
|
GFT ILIAC EXT OVTN IX 14*14*45
|
Facility
|
IP
|
$25,601.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,328.18 |
| Max. Negotiated Rate |
$24,577.30 |
| Rate for Payer: Aetna Commercial |
$19,713.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,969.05
|
| Rate for Payer: Cash Price |
$12,800.67
|
| Rate for Payer: Cigna Commercial |
$21,249.12
|
| Rate for Payer: First Health Commercial |
$24,321.28
|
| Rate for Payer: Humana Commercial |
$21,761.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,993.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,893.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,680.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,529.19
|
| Rate for Payer: Ohio Health Group HMO |
$19,201.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,120.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,328.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,936.42
|
| Rate for Payer: PHCS Commercial |
$24,577.30
|
| Rate for Payer: United Healthcare All Payer |
$22,529.19
|
|
|
GFT ILIAC EXT OVTN IX 18*18*45
|
Facility
|
OP
|
$25,601.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,328.18 |
| Max. Negotiated Rate |
$24,577.30 |
| Rate for Payer: Aetna Commercial |
$19,713.04
|
| Rate for Payer: Anthem Medicaid |
$8,804.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,969.05
|
| Rate for Payer: Cash Price |
$12,800.67
|
| Rate for Payer: Cigna Commercial |
$21,249.12
|
| Rate for Payer: First Health Commercial |
$24,321.28
|
| Rate for Payer: Humana Commercial |
$21,761.15
|
| Rate for Payer: Humana KY Medicaid |
$8,804.30
|
| Rate for Payer: Kentucky WC Medicaid |
$8,893.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,993.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,893.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,680.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,980.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,529.19
|
| Rate for Payer: Ohio Health Group HMO |
$19,201.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,120.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,328.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,936.42
|
| Rate for Payer: PHCS Commercial |
$24,577.30
|
| Rate for Payer: United Healthcare All Payer |
$22,529.19
|
|
|
GFT ILIAC EXT OVTN IX 18*18*45
|
Facility
|
IP
|
$25,601.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,328.18 |
| Max. Negotiated Rate |
$24,577.30 |
| Rate for Payer: Aetna Commercial |
$19,713.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,969.05
|
| Rate for Payer: Cash Price |
$12,800.67
|
| Rate for Payer: Cigna Commercial |
$21,249.12
|
| Rate for Payer: First Health Commercial |
$24,321.28
|
| Rate for Payer: Humana Commercial |
$21,761.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,993.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,893.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,680.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,529.19
|
| Rate for Payer: Ohio Health Group HMO |
$19,201.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,120.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,328.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,936.42
|
| Rate for Payer: PHCS Commercial |
$24,577.30
|
| Rate for Payer: United Healthcare All Payer |
$22,529.19
|
|
|
GFT ILIAC EXT OVTN IX 28*28*45
|
Facility
|
OP
|
$25,601.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,328.18 |
| Max. Negotiated Rate |
$24,577.30 |
| Rate for Payer: Aetna Commercial |
$19,713.04
|
| Rate for Payer: Anthem Medicaid |
$8,804.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,969.05
|
| Rate for Payer: Cash Price |
$12,800.67
|
| Rate for Payer: Cigna Commercial |
$21,249.12
|
| Rate for Payer: First Health Commercial |
$24,321.28
|
| Rate for Payer: Humana Commercial |
$21,761.15
|
| Rate for Payer: Humana KY Medicaid |
$8,804.30
|
| Rate for Payer: Kentucky WC Medicaid |
$8,893.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,993.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,893.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,680.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,980.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,529.19
|
| Rate for Payer: Ohio Health Group HMO |
$19,201.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,120.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,328.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,936.42
|
| Rate for Payer: PHCS Commercial |
$24,577.30
|
| Rate for Payer: United Healthcare All Payer |
$22,529.19
|
|
|
GFT ILIAC EXT OVTN IX 28*28*45
|
Facility
|
IP
|
$25,601.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,328.18 |
| Max. Negotiated Rate |
$24,577.30 |
| Rate for Payer: Aetna Commercial |
$19,713.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,969.05
|
| Rate for Payer: Cash Price |
$12,800.67
|
| Rate for Payer: Cigna Commercial |
$21,249.12
|
| Rate for Payer: First Health Commercial |
$24,321.28
|
| Rate for Payer: Humana Commercial |
$21,761.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,993.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,893.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,680.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,529.19
|
| Rate for Payer: Ohio Health Group HMO |
$19,201.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,120.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,328.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,936.42
|
| Rate for Payer: PHCS Commercial |
$24,577.30
|
| Rate for Payer: United Healthcare All Payer |
$22,529.19
|
|
|
GFT ILIAC EXT OVTN P 10*10*45
|
Facility
|
OP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem Medicaid |
$6,671.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Humana KY Medicaid |
$6,671.66
|
| Rate for Payer: Kentucky WC Medicaid |
$6,739.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,805.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GFT ILIAC EXT OVTN P 10*10*45
|
Facility
|
IP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GFT ILIAC EXT OVTN P 12*12*45
|
Facility
|
IP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GFT ILIAC EXT OVTN P 12*12*45
|
Facility
|
OP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem Medicaid |
$6,671.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Humana KY Medicaid |
$6,671.66
|
| Rate for Payer: Kentucky WC Medicaid |
$6,739.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,805.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GFT ILIAC EXT OVTN P 14*14*45
|
Facility
|
IP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GFT ILIAC EXT OVTN P 14*14*45
|
Facility
|
OP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem Medicaid |
$6,671.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Humana KY Medicaid |
$6,671.66
|
| Rate for Payer: Kentucky WC Medicaid |
$6,739.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,805.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GFT ILIAC EXT OVTN P 16*16*45
|
Facility
|
OP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem Medicaid |
$6,671.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Humana KY Medicaid |
$6,671.66
|
| Rate for Payer: Kentucky WC Medicaid |
$6,739.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,805.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GFT ILIAC EXT OVTN P 16*16*45
|
Facility
|
IP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GFT ILIAC EXT OVTN P 18*18*45
|
Facility
|
IP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GFT ILIAC EXT OVTN P 18*18*45
|
Facility
|
OP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem Medicaid |
$6,671.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Humana KY Medicaid |
$6,671.66
|
| Rate for Payer: Kentucky WC Medicaid |
$6,739.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,805.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
