|
GFT ILIAC LMB OVTN IX 14*18*80
|
Facility
|
OP
|
$25,528.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,318.69 |
| Max. Negotiated Rate |
$24,507.22 |
| Rate for Payer: Aetna Commercial |
$19,656.83
|
| Rate for Payer: Anthem Medicaid |
$8,779.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,912.11
|
| Rate for Payer: Cash Price |
$12,764.17
|
| Rate for Payer: Cigna Commercial |
$21,188.53
|
| Rate for Payer: First Health Commercial |
$24,251.93
|
| Rate for Payer: Humana Commercial |
$21,699.10
|
| Rate for Payer: Humana KY Medicaid |
$8,779.20
|
| Rate for Payer: Kentucky WC Medicaid |
$8,868.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,933.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,839.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,658.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,955.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,464.95
|
| Rate for Payer: Ohio Health Group HMO |
$19,146.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,105.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,318.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,913.79
|
| Rate for Payer: PHCS Commercial |
$24,507.22
|
| Rate for Payer: United Healthcare All Payer |
$22,464.95
|
|
|
GFT ILIAC LMB OVTN IX 14*18*80
|
Facility
|
IP
|
$25,528.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,318.69 |
| Max. Negotiated Rate |
$24,507.22 |
| Rate for Payer: Aetna Commercial |
$19,656.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,912.11
|
| Rate for Payer: Cash Price |
$12,764.17
|
| Rate for Payer: Cigna Commercial |
$21,188.53
|
| Rate for Payer: First Health Commercial |
$24,251.93
|
| Rate for Payer: Humana Commercial |
$21,699.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,933.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,839.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,658.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,464.95
|
| Rate for Payer: Ohio Health Group HMO |
$19,146.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,105.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,318.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,913.79
|
| Rate for Payer: PHCS Commercial |
$24,507.22
|
| Rate for Payer: United Healthcare All Payer |
$22,464.95
|
|
|
GFT ILIAC LMBOVTN IX 14*22*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*22*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*22*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*22*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*22*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*22*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*22*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*22*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*22*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*22*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*28*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*28*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*28*120
|
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*28*120
|
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*28*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*28*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*28*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*28*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*28*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*28*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 P 14*10*100
|
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 LMB OVTN P 14*10*100
|
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 LMB OVTN P 14*10*120
|
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
|
|
