|
GFT MAIN BDY BIFUR 28*70*16*30
|
Facility
|
IP
|
$71,188.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,254.44 |
| Max. Negotiated Rate |
$68,340.48 |
| Rate for Payer: Aetna Commercial |
$54,814.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55,526.64
|
| Rate for Payer: Cash Price |
$35,594.00
|
| Rate for Payer: Cigna Commercial |
$59,086.04
|
| Rate for Payer: First Health Commercial |
$67,628.60
|
| Rate for Payer: Humana Commercial |
$60,509.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58,374.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52,536.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,356.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$62,645.44
|
| Rate for Payer: Ohio Health Group HMO |
$53,391.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,237.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,254.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,068.28
|
| Rate for Payer: PHCS Commercial |
$68,340.48
|
| Rate for Payer: United Healthcare All Payer |
$62,645.44
|
|
|
GFT MAIN BDY BIFUR 28*70*16*30
|
Facility
|
OP
|
$71,188.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,254.44 |
| Max. Negotiated Rate |
$68,340.48 |
| Rate for Payer: Aetna Commercial |
$54,814.76
|
| Rate for Payer: Anthem Medicaid |
$24,481.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55,526.64
|
| Rate for Payer: Cash Price |
$35,594.00
|
| Rate for Payer: Cigna Commercial |
$59,086.04
|
| Rate for Payer: First Health Commercial |
$67,628.60
|
| Rate for Payer: Humana Commercial |
$60,509.80
|
| Rate for Payer: Humana KY Medicaid |
$24,481.55
|
| Rate for Payer: Kentucky WC Medicaid |
$24,730.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58,374.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52,536.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,356.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$24,972.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$62,645.44
|
| Rate for Payer: Ohio Health Group HMO |
$53,391.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,237.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,254.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,068.28
|
| Rate for Payer: PHCS Commercial |
$68,340.48
|
| Rate for Payer: United Healthcare All Payer |
$62,645.44
|
|
|
GFT MN BDY EXT 36*54 RX13654ZT
|
Facility
|
IP
|
$24,991.80
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,248.93 |
| Max. Negotiated Rate |
$23,992.13 |
| Rate for Payer: Aetna Commercial |
$19,243.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,493.60
|
| Rate for Payer: Cash Price |
$12,495.90
|
| Rate for Payer: Cigna Commercial |
$20,743.19
|
| Rate for Payer: First Health Commercial |
$23,742.21
|
| Rate for Payer: Humana Commercial |
$21,243.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,493.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,443.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,497.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,992.78
|
| Rate for Payer: Ohio Health Group HMO |
$18,743.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,998.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,248.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,747.46
|
| Rate for Payer: PHCS Commercial |
$23,992.13
|
| Rate for Payer: United Healthcare All Payer |
$21,992.78
|
|
|
GFT MN BDY EXT 36*54 RX13654ZT
|
Facility
|
OP
|
$24,991.80
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,248.93 |
| Max. Negotiated Rate |
$23,992.13 |
| Rate for Payer: Aetna Commercial |
$19,243.69
|
| Rate for Payer: Anthem Medicaid |
$8,594.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,493.60
|
| Rate for Payer: Cash Price |
$12,495.90
|
| Rate for Payer: Cigna Commercial |
$20,743.19
|
| Rate for Payer: First Health Commercial |
$23,742.21
|
| Rate for Payer: Humana Commercial |
$21,243.03
|
| Rate for Payer: Humana KY Medicaid |
$8,594.68
|
| Rate for Payer: Kentucky WC Medicaid |
$8,682.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,493.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,443.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,497.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,767.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,992.78
|
| Rate for Payer: Ohio Health Group HMO |
$18,743.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,998.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,248.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,747.46
|
| Rate for Payer: PHCS Commercial |
$23,992.13
|
| Rate for Payer: United Healthcare All Payer |
$21,992.78
|
|
|
GFT PROX EXT TALENT 26*26*50MM
|
Facility
|
OP
|
$24,875.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,233.75 |
| Max. Negotiated Rate |
$23,880.00 |
| Rate for Payer: Aetna Commercial |
$19,153.75
|
| Rate for Payer: Anthem Medicaid |
$8,554.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,402.50
|
| Rate for Payer: Cash Price |
$12,437.50
|
| Rate for Payer: Cigna Commercial |
$20,646.25
|
| Rate for Payer: First Health Commercial |
$23,631.25
|
| Rate for Payer: Humana Commercial |
$21,143.75
|
| Rate for Payer: Humana KY Medicaid |
$8,554.51
|
| Rate for Payer: Kentucky WC Medicaid |
$8,641.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,397.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,357.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,462.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,726.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,890.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,233.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,711.25
|
| Rate for Payer: PHCS Commercial |
$23,880.00
|
| Rate for Payer: United Healthcare All Payer |
$21,890.00
|
|
|
GFT PROX EXT TALENT 26*26*50MM
|
Facility
|
IP
|
$24,875.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,233.75 |
| Max. Negotiated Rate |
$23,880.00 |
| Rate for Payer: Aetna Commercial |
$19,153.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,402.50
|
| Rate for Payer: Cash Price |
$12,437.50
|
| Rate for Payer: Cigna Commercial |
$20,646.25
|
| Rate for Payer: First Health Commercial |
$23,631.25
|
| Rate for Payer: Humana Commercial |
$21,143.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,397.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,357.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,462.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,890.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,233.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,711.25
|
| Rate for Payer: PHCS Commercial |
$23,880.00
|
| Rate for Payer: United Healthcare All Payer |
$21,890.00
|
|
|
GFT PROX EXT TALENT 28*28*49MM
|
Facility
|
IP
|
$24,875.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,233.75 |
| Max. Negotiated Rate |
$23,880.00 |
| Rate for Payer: Aetna Commercial |
$19,153.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,402.50
|
| Rate for Payer: Cash Price |
$12,437.50
|
| Rate for Payer: Cigna Commercial |
$20,646.25
|
| Rate for Payer: First Health Commercial |
$23,631.25
|
| Rate for Payer: Humana Commercial |
$21,143.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,397.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,357.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,462.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,890.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,233.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,711.25
|
| Rate for Payer: PHCS Commercial |
$23,880.00
|
| Rate for Payer: United Healthcare All Payer |
$21,890.00
|
|
|
GFT PROX EXT TALENT 28*28*49MM
|
Facility
|
OP
|
$24,875.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,233.75 |
| Max. Negotiated Rate |
$23,880.00 |
| Rate for Payer: Aetna Commercial |
$19,153.75
|
| Rate for Payer: Anthem Medicaid |
$8,554.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,402.50
|
| Rate for Payer: Cash Price |
$12,437.50
|
| Rate for Payer: Cigna Commercial |
$20,646.25
|
| Rate for Payer: First Health Commercial |
$23,631.25
|
| Rate for Payer: Humana Commercial |
$21,143.75
|
| Rate for Payer: Humana KY Medicaid |
$8,554.51
|
| Rate for Payer: Kentucky WC Medicaid |
$8,641.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,397.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,357.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,462.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,726.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,890.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,233.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,711.25
|
| Rate for Payer: PHCS Commercial |
$23,880.00
|
| Rate for Payer: United Healthcare All Payer |
$21,890.00
|
|
|
GFT PROX EXT TALENT 30*30*48MM
|
Facility
|
IP
|
$24,875.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,233.75 |
| Max. Negotiated Rate |
$23,880.00 |
| Rate for Payer: Aetna Commercial |
$19,153.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,402.50
|
| Rate for Payer: Cash Price |
$12,437.50
|
| Rate for Payer: Cigna Commercial |
$20,646.25
|
| Rate for Payer: First Health Commercial |
$23,631.25
|
| Rate for Payer: Humana Commercial |
$21,143.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,397.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,357.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,462.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,890.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,233.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,711.25
|
| Rate for Payer: PHCS Commercial |
$23,880.00
|
| Rate for Payer: United Healthcare All Payer |
$21,890.00
|
|
|
GFT PROX EXT TALENT 30*30*48MM
|
Facility
|
OP
|
$24,875.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,233.75 |
| Max. Negotiated Rate |
$23,880.00 |
| Rate for Payer: Aetna Commercial |
$19,153.75
|
| Rate for Payer: Anthem Medicaid |
$8,554.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,402.50
|
| Rate for Payer: Cash Price |
$12,437.50
|
| Rate for Payer: Cigna Commercial |
$20,646.25
|
| Rate for Payer: First Health Commercial |
$23,631.25
|
| Rate for Payer: Humana Commercial |
$21,143.75
|
| Rate for Payer: Humana KY Medicaid |
$8,554.51
|
| Rate for Payer: Kentucky WC Medicaid |
$8,641.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,397.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,357.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,462.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,726.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,890.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,233.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,711.25
|
| Rate for Payer: PHCS Commercial |
$23,880.00
|
| Rate for Payer: United Healthcare All Payer |
$21,890.00
|
|
|
GFT PROX EXT TALENT 32*32*49MM
|
Facility
|
IP
|
$24,875.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,233.75 |
| Max. Negotiated Rate |
$23,880.00 |
| Rate for Payer: Aetna Commercial |
$19,153.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,402.50
|
| Rate for Payer: Cash Price |
$12,437.50
|
| Rate for Payer: Cigna Commercial |
$20,646.25
|
| Rate for Payer: First Health Commercial |
$23,631.25
|
| Rate for Payer: Humana Commercial |
$21,143.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,397.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,357.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,462.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,890.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,233.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,711.25
|
| Rate for Payer: PHCS Commercial |
$23,880.00
|
| Rate for Payer: United Healthcare All Payer |
$21,890.00
|
|
|
GFT PROX EXT TALENT 32*32*49MM
|
Facility
|
OP
|
$24,875.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,233.75 |
| Max. Negotiated Rate |
$23,880.00 |
| Rate for Payer: Aetna Commercial |
$19,153.75
|
| Rate for Payer: Anthem Medicaid |
$8,554.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,402.50
|
| Rate for Payer: Cash Price |
$12,437.50
|
| Rate for Payer: Cigna Commercial |
$20,646.25
|
| Rate for Payer: First Health Commercial |
$23,631.25
|
| Rate for Payer: Humana Commercial |
$21,143.75
|
| Rate for Payer: Humana KY Medicaid |
$8,554.51
|
| Rate for Payer: Kentucky WC Medicaid |
$8,641.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,397.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,357.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,462.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,726.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,890.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,233.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,711.25
|
| Rate for Payer: PHCS Commercial |
$23,880.00
|
| Rate for Payer: United Healthcare All Payer |
$21,890.00
|
|
|
GFT PROX EXT TALENT 34*34*48MM
|
Facility
|
IP
|
$24,875.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,233.75 |
| Max. Negotiated Rate |
$23,880.00 |
| Rate for Payer: Aetna Commercial |
$19,153.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,402.50
|
| Rate for Payer: Cash Price |
$12,437.50
|
| Rate for Payer: Cigna Commercial |
$20,646.25
|
| Rate for Payer: First Health Commercial |
$23,631.25
|
| Rate for Payer: Humana Commercial |
$21,143.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,397.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,357.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,462.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,890.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,233.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,711.25
|
| Rate for Payer: PHCS Commercial |
$23,880.00
|
| Rate for Payer: United Healthcare All Payer |
$21,890.00
|
|
|
GFT PROX EXT TALENT 34*34*48MM
|
Facility
|
OP
|
$24,875.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,233.75 |
| Max. Negotiated Rate |
$23,880.00 |
| Rate for Payer: Aetna Commercial |
$19,153.75
|
| Rate for Payer: Anthem Medicaid |
$8,554.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,402.50
|
| Rate for Payer: Cash Price |
$12,437.50
|
| Rate for Payer: Cigna Commercial |
$20,646.25
|
| Rate for Payer: First Health Commercial |
$23,631.25
|
| Rate for Payer: Humana Commercial |
$21,143.75
|
| Rate for Payer: Humana KY Medicaid |
$8,554.51
|
| Rate for Payer: Kentucky WC Medicaid |
$8,641.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,397.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,357.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,462.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,726.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,890.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,233.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,711.25
|
| Rate for Payer: PHCS Commercial |
$23,880.00
|
| Rate for Payer: United Healthcare All Payer |
$21,890.00
|
|
|
GFT PROX EXT TALENT 36*36*46MM
|
Facility
|
IP
|
$24,875.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,233.75 |
| Max. Negotiated Rate |
$23,880.00 |
| Rate for Payer: Aetna Commercial |
$19,153.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,402.50
|
| Rate for Payer: Cash Price |
$12,437.50
|
| Rate for Payer: Cigna Commercial |
$20,646.25
|
| Rate for Payer: First Health Commercial |
$23,631.25
|
| Rate for Payer: Humana Commercial |
$21,143.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,397.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,357.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,462.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,890.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,233.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,711.25
|
| Rate for Payer: PHCS Commercial |
$23,880.00
|
| Rate for Payer: United Healthcare All Payer |
$21,890.00
|
|
|
GFT PROX EXT TALENT 36*36*46MM
|
Facility
|
OP
|
$24,875.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,233.75 |
| Max. Negotiated Rate |
$23,880.00 |
| Rate for Payer: Aetna Commercial |
$19,153.75
|
| Rate for Payer: Anthem Medicaid |
$8,554.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,402.50
|
| Rate for Payer: Cash Price |
$12,437.50
|
| Rate for Payer: Cigna Commercial |
$20,646.25
|
| Rate for Payer: First Health Commercial |
$23,631.25
|
| Rate for Payer: Humana Commercial |
$21,143.75
|
| Rate for Payer: Humana KY Medicaid |
$8,554.51
|
| Rate for Payer: Kentucky WC Medicaid |
$8,641.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,397.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,357.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,462.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,726.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,890.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,233.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,711.25
|
| Rate for Payer: PHCS Commercial |
$23,880.00
|
| Rate for Payer: United Healthcare All Payer |
$21,890.00
|
|
|
GFT PROX EXT TALENT 38*38*46MM
|
Facility
|
OP
|
$24,875.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,233.75 |
| Max. Negotiated Rate |
$23,880.00 |
| Rate for Payer: Aetna Commercial |
$19,153.75
|
| Rate for Payer: Anthem Medicaid |
$8,554.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,402.50
|
| Rate for Payer: Cash Price |
$12,437.50
|
| Rate for Payer: Cigna Commercial |
$20,646.25
|
| Rate for Payer: First Health Commercial |
$23,631.25
|
| Rate for Payer: Humana Commercial |
$21,143.75
|
| Rate for Payer: Humana KY Medicaid |
$8,554.51
|
| Rate for Payer: Kentucky WC Medicaid |
$8,641.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,397.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,357.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,462.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,726.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,890.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,233.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,711.25
|
| Rate for Payer: PHCS Commercial |
$23,880.00
|
| Rate for Payer: United Healthcare All Payer |
$21,890.00
|
|
|
GFT PROX EXT TALENT 38*38*46MM
|
Facility
|
IP
|
$24,875.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,233.75 |
| Max. Negotiated Rate |
$23,880.00 |
| Rate for Payer: Aetna Commercial |
$19,153.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,402.50
|
| Rate for Payer: Cash Price |
$12,437.50
|
| Rate for Payer: Cigna Commercial |
$20,646.25
|
| Rate for Payer: First Health Commercial |
$23,631.25
|
| Rate for Payer: Humana Commercial |
$21,143.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,397.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,357.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,462.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,890.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,233.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,711.25
|
| Rate for Payer: PHCS Commercial |
$23,880.00
|
| Rate for Payer: United Healthcare All Payer |
$21,890.00
|
|
|
GFT PROX EXT TALENT 40*40*46MM
|
Facility
|
OP
|
$24,875.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,233.75 |
| Max. Negotiated Rate |
$23,880.00 |
| Rate for Payer: Aetna Commercial |
$19,153.75
|
| Rate for Payer: Anthem Medicaid |
$8,554.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,402.50
|
| Rate for Payer: Cash Price |
$12,437.50
|
| Rate for Payer: Cigna Commercial |
$20,646.25
|
| Rate for Payer: First Health Commercial |
$23,631.25
|
| Rate for Payer: Humana Commercial |
$21,143.75
|
| Rate for Payer: Humana KY Medicaid |
$8,554.51
|
| Rate for Payer: Kentucky WC Medicaid |
$8,641.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,397.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,357.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,462.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,726.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,890.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,233.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,711.25
|
| Rate for Payer: PHCS Commercial |
$23,880.00
|
| Rate for Payer: United Healthcare All Payer |
$21,890.00
|
|
|
GFT PROX EXT TALENT 40*40*46MM
|
Facility
|
IP
|
$24,875.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,233.75 |
| Max. Negotiated Rate |
$23,880.00 |
| Rate for Payer: Aetna Commercial |
$19,153.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,402.50
|
| Rate for Payer: Cash Price |
$12,437.50
|
| Rate for Payer: Cigna Commercial |
$20,646.25
|
| Rate for Payer: First Health Commercial |
$23,631.25
|
| Rate for Payer: Humana Commercial |
$21,143.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,397.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,357.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,462.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,890.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,233.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,711.25
|
| Rate for Payer: PHCS Commercial |
$23,880.00
|
| Rate for Payer: United Healthcare All Payer |
$21,890.00
|
|
|
GFT PROX EXT TALENT 42*42*54MM
|
Facility
|
OP
|
$24,875.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,233.75 |
| Max. Negotiated Rate |
$23,880.00 |
| Rate for Payer: Aetna Commercial |
$19,153.75
|
| Rate for Payer: Anthem Medicaid |
$8,554.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,402.50
|
| Rate for Payer: Cash Price |
$12,437.50
|
| Rate for Payer: Cigna Commercial |
$20,646.25
|
| Rate for Payer: First Health Commercial |
$23,631.25
|
| Rate for Payer: Humana Commercial |
$21,143.75
|
| Rate for Payer: Humana KY Medicaid |
$8,554.51
|
| Rate for Payer: Kentucky WC Medicaid |
$8,641.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,397.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,357.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,462.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,726.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,890.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,233.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,711.25
|
| Rate for Payer: PHCS Commercial |
$23,880.00
|
| Rate for Payer: United Healthcare All Payer |
$21,890.00
|
|
|
GFT PROX EXT TALENT 42*42*54MM
|
Facility
|
IP
|
$24,875.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,233.75 |
| Max. Negotiated Rate |
$23,880.00 |
| Rate for Payer: Aetna Commercial |
$19,153.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,402.50
|
| Rate for Payer: Cash Price |
$12,437.50
|
| Rate for Payer: Cigna Commercial |
$20,646.25
|
| Rate for Payer: First Health Commercial |
$23,631.25
|
| Rate for Payer: Humana Commercial |
$21,143.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,397.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,357.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,462.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,890.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,233.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,711.25
|
| Rate for Payer: PHCS Commercial |
$23,880.00
|
| Rate for Payer: United Healthcare All Payer |
$21,890.00
|
|
|
GFT PROX EXT TALENT 44*44*54MM
|
Facility
|
OP
|
$24,875.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,233.75 |
| Max. Negotiated Rate |
$23,880.00 |
| Rate for Payer: Aetna Commercial |
$19,153.75
|
| Rate for Payer: Anthem Medicaid |
$8,554.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,402.50
|
| Rate for Payer: Cash Price |
$12,437.50
|
| Rate for Payer: Cigna Commercial |
$20,646.25
|
| Rate for Payer: First Health Commercial |
$23,631.25
|
| Rate for Payer: Humana Commercial |
$21,143.75
|
| Rate for Payer: Humana KY Medicaid |
$8,554.51
|
| Rate for Payer: Kentucky WC Medicaid |
$8,641.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,397.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,357.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,462.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,726.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,890.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,233.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,711.25
|
| Rate for Payer: PHCS Commercial |
$23,880.00
|
| Rate for Payer: United Healthcare All Payer |
$21,890.00
|
|
|
GFT PROX EXT TALENT 44*44*54MM
|
Facility
|
IP
|
$24,875.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,233.75 |
| Max. Negotiated Rate |
$23,880.00 |
| Rate for Payer: Aetna Commercial |
$19,153.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,402.50
|
| Rate for Payer: Cash Price |
$12,437.50
|
| Rate for Payer: Cigna Commercial |
$20,646.25
|
| Rate for Payer: First Health Commercial |
$23,631.25
|
| Rate for Payer: Humana Commercial |
$21,143.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,397.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,357.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,462.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,890.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,233.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,711.25
|
| Rate for Payer: PHCS Commercial |
$23,880.00
|
| Rate for Payer: United Healthcare All Payer |
$21,890.00
|
|
|
GFT PROX EXT TALENT 46*46*52MM
|
Facility
|
IP
|
$24,875.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,233.75 |
| Max. Negotiated Rate |
$23,880.00 |
| Rate for Payer: Aetna Commercial |
$19,153.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,402.50
|
| Rate for Payer: Cash Price |
$12,437.50
|
| Rate for Payer: Cigna Commercial |
$20,646.25
|
| Rate for Payer: First Health Commercial |
$23,631.25
|
| Rate for Payer: Humana Commercial |
$21,143.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,397.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,357.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,462.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,890.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,233.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,711.25
|
| Rate for Payer: PHCS Commercial |
$23,880.00
|
| Rate for Payer: United Healthcare All Payer |
$21,890.00
|
|
