|
GFT ILIAC EXT OVTN P 22*22*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 22*22*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 R I16-16/C55F SA
|
Facility
|
OP
|
$13,392.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,740.99 |
| Max. Negotiated Rate |
$12,856.56 |
| Rate for Payer: Aetna Commercial |
$10,312.03
|
| Rate for Payer: Anthem Medicaid |
$4,605.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,445.96
|
| Rate for Payer: Cash Price |
$6,696.12
|
| Rate for Payer: Cigna Commercial |
$11,115.57
|
| Rate for Payer: First Health Commercial |
$12,722.64
|
| Rate for Payer: Humana Commercial |
$11,383.41
|
| Rate for Payer: Humana KY Medicaid |
$4,605.59
|
| Rate for Payer: Kentucky WC Medicaid |
$4,652.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,981.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,883.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,017.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,698.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,785.18
|
| Rate for Payer: Ohio Health Group HMO |
$10,044.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,678.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,740.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,151.60
|
| Rate for Payer: PHCS Commercial |
$12,856.56
|
| Rate for Payer: United Healthcare All Payer |
$11,785.18
|
|
|
GFT ILIAC EXT R I16-16/C55F SA
|
Facility
|
IP
|
$13,392.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,740.99 |
| Max. Negotiated Rate |
$12,856.56 |
| Rate for Payer: Aetna Commercial |
$10,312.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,445.96
|
| Rate for Payer: Cash Price |
$6,696.12
|
| Rate for Payer: Cigna Commercial |
$11,115.57
|
| Rate for Payer: First Health Commercial |
$12,722.64
|
| Rate for Payer: Humana Commercial |
$11,383.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,981.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,883.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,017.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,785.18
|
| Rate for Payer: Ohio Health Group HMO |
$10,044.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,678.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,740.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,151.60
|
| Rate for Payer: PHCS Commercial |
$12,856.56
|
| Rate for Payer: United Healthcare All Payer |
$11,785.18
|
|
|
GFT ILIAC EXT R I16-16/C88 SA
|
Facility
|
OP
|
$15,702.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,041.26 |
| Max. Negotiated Rate |
$15,073.92 |
| Rate for Payer: Aetna Commercial |
$12,090.54
|
| Rate for Payer: Anthem Medicaid |
$5,399.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,247.56
|
| Rate for Payer: Cash Price |
$7,851.00
|
| Rate for Payer: Cigna Commercial |
$13,032.66
|
| Rate for Payer: First Health Commercial |
$14,916.90
|
| Rate for Payer: Humana Commercial |
$13,346.70
|
| Rate for Payer: Humana KY Medicaid |
$5,399.92
|
| Rate for Payer: Kentucky WC Medicaid |
$5,454.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,875.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,588.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,710.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,508.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,817.76
|
| Rate for Payer: Ohio Health Group HMO |
$11,776.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,140.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,041.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,867.62
|
| Rate for Payer: PHCS Commercial |
$15,073.92
|
| Rate for Payer: United Healthcare All Payer |
$13,817.76
|
|
|
GFT ILIAC EXT R I16-16/C88 SA
|
Facility
|
IP
|
$15,702.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,041.26 |
| Max. Negotiated Rate |
$15,073.92 |
| Rate for Payer: Aetna Commercial |
$12,090.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,247.56
|
| Rate for Payer: Cash Price |
$7,851.00
|
| Rate for Payer: Cigna Commercial |
$13,032.66
|
| Rate for Payer: First Health Commercial |
$14,916.90
|
| Rate for Payer: Humana Commercial |
$13,346.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,875.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,588.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,710.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,817.76
|
| Rate for Payer: Ohio Health Group HMO |
$11,776.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,140.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,041.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,867.62
|
| Rate for Payer: PHCS Commercial |
$15,073.92
|
| Rate for Payer: United Healthcare All Payer |
$13,817.76
|
|
|
GFT ILIAC EXT R I20-13/C70F SA
|
Facility
|
IP
|
$16,368.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,127.84 |
| Max. Negotiated Rate |
$15,713.28 |
| Rate for Payer: Aetna Commercial |
$12,603.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,767.04
|
| Rate for Payer: Cash Price |
$8,184.00
|
| Rate for Payer: Cigna Commercial |
$13,585.44
|
| Rate for Payer: First Health Commercial |
$15,549.60
|
| Rate for Payer: Humana Commercial |
$13,912.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,421.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,079.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,910.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,403.84
|
| Rate for Payer: Ohio Health Group HMO |
$12,276.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,273.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,127.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,074.08
|
| Rate for Payer: PHCS Commercial |
$15,713.28
|
| Rate for Payer: United Healthcare All Payer |
$14,403.84
|
|
|
GFT ILIAC EXT R I20-13/C70F SA
|
Facility
|
OP
|
$16,368.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,127.84 |
| Max. Negotiated Rate |
$15,713.28 |
| Rate for Payer: Aetna Commercial |
$12,603.36
|
| Rate for Payer: Anthem Medicaid |
$5,628.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,767.04
|
| Rate for Payer: Cash Price |
$8,184.00
|
| Rate for Payer: Cigna Commercial |
$13,585.44
|
| Rate for Payer: First Health Commercial |
$15,549.60
|
| Rate for Payer: Humana Commercial |
$13,912.80
|
| Rate for Payer: Humana KY Medicaid |
$5,628.96
|
| Rate for Payer: Kentucky WC Medicaid |
$5,686.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,421.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,079.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,910.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,741.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,403.84
|
| Rate for Payer: Ohio Health Group HMO |
$12,276.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,273.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,127.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,074.08
|
| Rate for Payer: PHCS Commercial |
$15,713.28
|
| Rate for Payer: United Healthcare All Payer |
$14,403.84
|
|
|
GFT ILIAC EXT R I20-13/C88F SA
|
Facility
|
OP
|
$20,126.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,616.43 |
| Max. Negotiated Rate |
$19,321.30 |
| Rate for Payer: Aetna Commercial |
$15,497.29
|
| Rate for Payer: Anthem Medicaid |
$6,921.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,698.55
|
| Rate for Payer: Cash Price |
$10,063.17
|
| Rate for Payer: Cigna Commercial |
$16,704.87
|
| Rate for Payer: First Health Commercial |
$19,120.03
|
| Rate for Payer: Humana Commercial |
$17,107.40
|
| Rate for Payer: Humana KY Medicaid |
$6,921.45
|
| Rate for Payer: Kentucky WC Medicaid |
$6,991.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,503.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,853.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,037.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,060.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,711.19
|
| Rate for Payer: Ohio Health Group HMO |
$15,094.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,025.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,616.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,239.17
|
| Rate for Payer: PHCS Commercial |
$19,321.30
|
| Rate for Payer: United Healthcare All Payer |
$17,711.19
|
|
|
GFT ILIAC EXT R I20-13/C88F SA
|
Facility
|
IP
|
$20,126.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,616.43 |
| Max. Negotiated Rate |
$19,321.30 |
| Rate for Payer: Aetna Commercial |
$15,497.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,698.55
|
| Rate for Payer: Cash Price |
$10,063.17
|
| Rate for Payer: Cigna Commercial |
$16,704.87
|
| Rate for Payer: First Health Commercial |
$19,120.03
|
| Rate for Payer: Humana Commercial |
$17,107.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,503.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,853.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,037.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,711.19
|
| Rate for Payer: Ohio Health Group HMO |
$15,094.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,025.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,616.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,239.17
|
| Rate for Payer: PHCS Commercial |
$19,321.30
|
| Rate for Payer: United Healthcare All Payer |
$17,711.19
|
|
|
GFT ILIAC EXT R I20-20/C55F SA
|
Facility
|
IP
|
$13,392.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,740.99 |
| Max. Negotiated Rate |
$12,856.56 |
| Rate for Payer: Aetna Commercial |
$10,312.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,445.96
|
| Rate for Payer: Cash Price |
$6,696.12
|
| Rate for Payer: Cigna Commercial |
$11,115.57
|
| Rate for Payer: First Health Commercial |
$12,722.64
|
| Rate for Payer: Humana Commercial |
$11,383.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,981.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,883.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,017.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,785.18
|
| Rate for Payer: Ohio Health Group HMO |
$10,044.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,678.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,740.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,151.60
|
| Rate for Payer: PHCS Commercial |
$12,856.56
|
| Rate for Payer: United Healthcare All Payer |
$11,785.18
|
|
|
GFT ILIAC EXT R I20-20/C55F SA
|
Facility
|
OP
|
$13,392.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,740.99 |
| Max. Negotiated Rate |
$12,856.56 |
| Rate for Payer: Aetna Commercial |
$10,312.03
|
| Rate for Payer: Anthem Medicaid |
$4,605.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,445.96
|
| Rate for Payer: Cash Price |
$6,696.12
|
| Rate for Payer: Cigna Commercial |
$11,115.57
|
| Rate for Payer: First Health Commercial |
$12,722.64
|
| Rate for Payer: Humana Commercial |
$11,383.41
|
| Rate for Payer: Humana KY Medicaid |
$4,605.59
|
| Rate for Payer: Kentucky WC Medicaid |
$4,652.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,981.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,883.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,017.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,698.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,785.18
|
| Rate for Payer: Ohio Health Group HMO |
$10,044.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,678.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,740.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,151.60
|
| Rate for Payer: PHCS Commercial |
$12,856.56
|
| Rate for Payer: United Healthcare All Payer |
$11,785.18
|
|
|
GFT ILIAC EXT R IS20-25/C65 SA
|
Facility
|
OP
|
$20,126.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,616.43 |
| Max. Negotiated Rate |
$19,321.30 |
| Rate for Payer: Aetna Commercial |
$15,497.29
|
| Rate for Payer: Anthem Medicaid |
$6,921.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,698.55
|
| Rate for Payer: Cash Price |
$10,063.17
|
| Rate for Payer: Cigna Commercial |
$16,704.87
|
| Rate for Payer: First Health Commercial |
$19,120.03
|
| Rate for Payer: Humana Commercial |
$17,107.40
|
| Rate for Payer: Humana KY Medicaid |
$6,921.45
|
| Rate for Payer: Kentucky WC Medicaid |
$6,991.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,503.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,853.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,037.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,060.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,711.19
|
| Rate for Payer: Ohio Health Group HMO |
$15,094.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,025.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,616.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,239.17
|
| Rate for Payer: PHCS Commercial |
$19,321.30
|
| Rate for Payer: United Healthcare All Payer |
$17,711.19
|
|
|
GFT ILIAC EXT R IS20-25/C65 SA
|
Facility
|
IP
|
$20,126.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,616.43 |
| Max. Negotiated Rate |
$19,321.30 |
| Rate for Payer: Aetna Commercial |
$15,497.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,698.55
|
| Rate for Payer: Cash Price |
$10,063.17
|
| Rate for Payer: Cigna Commercial |
$16,704.87
|
| Rate for Payer: First Health Commercial |
$19,120.03
|
| Rate for Payer: Humana Commercial |
$17,107.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,503.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,853.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,037.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,711.19
|
| Rate for Payer: Ohio Health Group HMO |
$15,094.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,025.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,616.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,239.17
|
| Rate for Payer: PHCS Commercial |
$19,321.30
|
| Rate for Payer: United Healthcare All Payer |
$17,711.19
|
|
|
GFT ILIAC LMBOVTN IX 14*10*140
|
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 LMBOVTN IX 14*10*140
|
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 LMBOVTN IX 14*10*160
|
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 LMBOVTN IX 14*10*160
|
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 LMB OVTN IX 14*10*80
|
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 LMB OVTN IX 14*10*80
|
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 LMBOVTN IX 14*12*100
|
Facility
|
OP
|
$26,882.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,494.72 |
| Max. Negotiated Rate |
$25,807.20 |
| Rate for Payer: Aetna Commercial |
$20,699.52
|
| Rate for Payer: Anthem Medicaid |
$9,244.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,968.35
|
| Rate for Payer: Cash Price |
$13,441.25
|
| Rate for Payer: Cigna Commercial |
$22,312.48
|
| Rate for Payer: First Health Commercial |
$25,538.38
|
| Rate for Payer: Humana Commercial |
$22,850.12
|
| Rate for Payer: Humana KY Medicaid |
$9,244.89
|
| Rate for Payer: Kentucky WC Medicaid |
$9,338.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,043.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,839.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,064.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,430.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,656.60
|
| Rate for Payer: Ohio Health Group HMO |
$20,161.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,376.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,494.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,333.58
|
| Rate for Payer: PHCS Commercial |
$25,807.20
|
| Rate for Payer: United Healthcare All Payer |
$23,656.60
|
|
|
GFT ILIAC LMBOVTN IX 14*12*100
|
Facility
|
IP
|
$26,882.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,494.72 |
| Max. Negotiated Rate |
$25,807.20 |
| Rate for Payer: Aetna Commercial |
$20,699.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,968.35
|
| Rate for Payer: Cash Price |
$13,441.25
|
| Rate for Payer: Cigna Commercial |
$22,312.48
|
| Rate for Payer: First Health Commercial |
$25,538.38
|
| Rate for Payer: Humana Commercial |
$22,850.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,043.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,839.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,064.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,656.60
|
| Rate for Payer: Ohio Health Group HMO |
$20,161.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,376.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,494.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,333.58
|
| Rate for Payer: PHCS Commercial |
$25,807.20
|
| Rate for Payer: United Healthcare All Payer |
$23,656.60
|
|
|
GFT ILIAC LMBOVTN IX 14*12*140
|
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 LMBOVTN IX 14*12*140
|
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 LMBOVTN IX 14*12*160
|
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
|
|
