|
GNS II POR TIB SZ 1 RIGHT
|
Facility
|
IP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
|
GNS II POR TIB SZ 1 RIGHT
|
Facility
|
OP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem Medicaid |
$2,831.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Humana KY Medicaid |
$2,831.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,860.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,888.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
|
GNS II POR TIB SZ 2 LEFT
|
Facility
|
OP
|
$9,258.67
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,203.63 |
| Max. Negotiated Rate |
$8,888.32 |
| Rate for Payer: Aetna Commercial |
$7,129.18
|
| Rate for Payer: Anthem Medicaid |
$3,184.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,221.76
|
| Rate for Payer: Cash Price |
$4,629.34
|
| Rate for Payer: Cigna Commercial |
$7,684.70
|
| Rate for Payer: First Health Commercial |
$8,795.74
|
| Rate for Payer: Humana Commercial |
$7,869.87
|
| Rate for Payer: Humana KY Medicaid |
$3,184.06
|
| Rate for Payer: Kentucky WC Medicaid |
$3,216.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,592.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,832.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,777.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,247.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,147.63
|
| Rate for Payer: Ohio Health Group HMO |
$6,944.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,851.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,203.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,870.19
|
| Rate for Payer: PHCS Commercial |
$8,888.32
|
| Rate for Payer: United Healthcare All Payer |
$8,147.63
|
|
|
GNS II POR TIB SZ 2 LEFT
|
Facility
|
IP
|
$9,258.67
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,203.63 |
| Max. Negotiated Rate |
$8,888.32 |
| Rate for Payer: Aetna Commercial |
$7,129.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,221.76
|
| Rate for Payer: Cash Price |
$4,629.34
|
| Rate for Payer: Cigna Commercial |
$7,684.70
|
| Rate for Payer: First Health Commercial |
$8,795.74
|
| Rate for Payer: Humana Commercial |
$7,869.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,592.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,832.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,777.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,147.63
|
| Rate for Payer: Ohio Health Group HMO |
$6,944.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,851.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,203.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,870.19
|
| Rate for Payer: PHCS Commercial |
$8,888.32
|
| Rate for Payer: United Healthcare All Payer |
$8,147.63
|
|
|
GNS II POR TIB SZ 2 RIGHT
|
Facility
|
OP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem Medicaid |
$2,831.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Humana KY Medicaid |
$2,831.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,860.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,888.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
|
GNS II POR TIB SZ 2 RIGHT
|
Facility
|
IP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
|
GNS II POR TIB SZ 3 LEFT
|
Facility
|
IP
|
$9,258.67
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,203.63 |
| Max. Negotiated Rate |
$8,888.32 |
| Rate for Payer: Aetna Commercial |
$7,129.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,221.76
|
| Rate for Payer: Cash Price |
$4,629.34
|
| Rate for Payer: Cigna Commercial |
$7,684.70
|
| Rate for Payer: First Health Commercial |
$8,795.74
|
| Rate for Payer: Humana Commercial |
$7,869.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,592.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,832.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,777.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,147.63
|
| Rate for Payer: Ohio Health Group HMO |
$6,944.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,851.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,203.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,870.19
|
| Rate for Payer: PHCS Commercial |
$8,888.32
|
| Rate for Payer: United Healthcare All Payer |
$8,147.63
|
|
|
GNS II POR TIB SZ 3 LEFT
|
Facility
|
OP
|
$9,258.67
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,203.63 |
| Max. Negotiated Rate |
$8,888.32 |
| Rate for Payer: Aetna Commercial |
$7,129.18
|
| Rate for Payer: Anthem Medicaid |
$3,184.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,221.76
|
| Rate for Payer: Cash Price |
$4,629.34
|
| Rate for Payer: Cigna Commercial |
$7,684.70
|
| Rate for Payer: First Health Commercial |
$8,795.74
|
| Rate for Payer: Humana Commercial |
$7,869.87
|
| Rate for Payer: Humana KY Medicaid |
$3,184.06
|
| Rate for Payer: Kentucky WC Medicaid |
$3,216.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,592.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,832.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,777.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,247.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,147.63
|
| Rate for Payer: Ohio Health Group HMO |
$6,944.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,851.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,203.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,870.19
|
| Rate for Payer: PHCS Commercial |
$8,888.32
|
| Rate for Payer: United Healthcare All Payer |
$8,147.63
|
|
|
GNS II POR TIB SZ 3 RIGHT
|
Facility
|
IP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
|
GNS II POR TIB SZ 3 RIGHT
|
Facility
|
OP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem Medicaid |
$2,831.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Humana KY Medicaid |
$2,831.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,860.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,888.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
|
GNS II POR TIB SZ 4 LEFT
|
Facility
|
IP
|
$9,258.67
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,203.63 |
| Max. Negotiated Rate |
$8,888.32 |
| Rate for Payer: Aetna Commercial |
$7,129.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,221.76
|
| Rate for Payer: Cash Price |
$4,629.34
|
| Rate for Payer: Cigna Commercial |
$7,684.70
|
| Rate for Payer: First Health Commercial |
$8,795.74
|
| Rate for Payer: Humana Commercial |
$7,869.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,592.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,832.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,777.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,147.63
|
| Rate for Payer: Ohio Health Group HMO |
$6,944.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,851.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,203.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,870.19
|
| Rate for Payer: PHCS Commercial |
$8,888.32
|
| Rate for Payer: United Healthcare All Payer |
$8,147.63
|
|
|
GNS II POR TIB SZ 4 LEFT
|
Facility
|
OP
|
$9,258.67
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,203.63 |
| Max. Negotiated Rate |
$8,888.32 |
| Rate for Payer: Aetna Commercial |
$7,129.18
|
| Rate for Payer: Anthem Medicaid |
$3,184.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,221.76
|
| Rate for Payer: Cash Price |
$4,629.34
|
| Rate for Payer: Cigna Commercial |
$7,684.70
|
| Rate for Payer: First Health Commercial |
$8,795.74
|
| Rate for Payer: Humana Commercial |
$7,869.87
|
| Rate for Payer: Humana KY Medicaid |
$3,184.06
|
| Rate for Payer: Kentucky WC Medicaid |
$3,216.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,592.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,832.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,777.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,247.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,147.63
|
| Rate for Payer: Ohio Health Group HMO |
$6,944.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,851.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,203.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,870.19
|
| Rate for Payer: PHCS Commercial |
$8,888.32
|
| Rate for Payer: United Healthcare All Payer |
$8,147.63
|
|
|
GNS II POR TIB SZ 4 RIGHT
|
Facility
|
OP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem Medicaid |
$2,831.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Humana KY Medicaid |
$2,831.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,860.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,888.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
|
GNS II POR TIB SZ 4 RIGHT
|
Facility
|
IP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
|
GNS II POR TIB SZ 5 LEFT
|
Facility
|
IP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
|
GNS II POR TIB SZ 5 LEFT
|
Facility
|
OP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem Medicaid |
$2,831.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Humana KY Medicaid |
$2,831.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,860.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,888.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
|
GNS II POR TIB SZ 5 RIGHT
|
Facility
|
IP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
|
GNS II POR TIB SZ 5 RIGHT
|
Facility
|
OP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem Medicaid |
$2,831.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Humana KY Medicaid |
$2,831.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,860.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,888.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
|
GNS II POR TIB SZ 6 LEFT
|
Facility
|
OP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem Medicaid |
$2,831.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Humana KY Medicaid |
$2,831.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,860.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,888.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
|
GNS II POR TIB SZ 6 LEFT
|
Facility
|
IP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
|
GNS II POR TIB SZ 6 RIGHT
|
Facility
|
IP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
|
GNS II POR TIB SZ 6 RIGHT
|
Facility
|
OP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem Medicaid |
$2,831.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Humana KY Medicaid |
$2,831.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,860.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,888.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
|
GNS II POR TIB SZ 7 LEFT
|
Facility
|
OP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem Medicaid |
$2,831.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Humana KY Medicaid |
$2,831.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,860.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,888.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
|
GNS II POR TIB SZ 7 LEFT
|
Facility
|
IP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
|
GNS II POR TIB SZ 7 RIGHT
|
Facility
|
IP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
