|
GFT ILIAC LMBOVTN IX 14*12*160
|
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 LMB OVTN IX 14*12*80
|
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 LMB OVTN IX 14*12*80
|
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*14*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*14*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*14*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
|
|
|
GFT ILIAC LMBOVTN IX 14*14*160
|
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 LMB OVTN IX 14*14*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 LMB OVTN IX 14*14*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 LMBOVTN IX 14*16*100
|
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*16*100
|
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*16*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*16*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*16*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
|
|
|
GFT ILIAC LMBOVTN IX 14*16*160
|
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 LMB OVTN IX 14*16*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 LMB OVTN IX 14*16*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 LMBOVTN IX 14*18*100
|
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 LMBOVTN IX 14*18*100
|
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*18*120
|
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*18*120
|
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*18*140
|
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 LMBOVTN IX 14*18*140
|
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*18*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
|
|
|
GFT ILIAC LMBOVTN IX 14*18*160
|
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
|
|
