|
GFT AORTC BDY OVATION P 23*80
|
Facility
|
OP
|
$33,125.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,937.50 |
| Max. Negotiated Rate |
$31,800.00 |
| Rate for Payer: Aetna Commercial |
$25,506.25
|
| Rate for Payer: Anthem Medicaid |
$11,391.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,837.50
|
| Rate for Payer: Cash Price |
$16,562.50
|
| Rate for Payer: Cigna Commercial |
$27,493.75
|
| Rate for Payer: First Health Commercial |
$31,468.75
|
| Rate for Payer: Humana Commercial |
$28,156.25
|
| Rate for Payer: Humana KY Medicaid |
$11,391.69
|
| Rate for Payer: Kentucky WC Medicaid |
$11,507.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,162.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,446.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,937.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,620.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,150.00
|
| Rate for Payer: Ohio Health Group HMO |
$24,843.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,818.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,856.25
|
| Rate for Payer: PHCS Commercial |
$31,800.00
|
| Rate for Payer: United Healthcare All Payer |
$29,150.00
|
|
|
GFT AORTC BDY OVATION P 23*80
|
Facility
|
IP
|
$33,125.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,937.50 |
| Max. Negotiated Rate |
$31,800.00 |
| Rate for Payer: Aetna Commercial |
$25,506.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,837.50
|
| Rate for Payer: Cash Price |
$16,562.50
|
| Rate for Payer: Cigna Commercial |
$27,493.75
|
| Rate for Payer: First Health Commercial |
$31,468.75
|
| Rate for Payer: Humana Commercial |
$28,156.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,162.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,446.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,937.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,150.00
|
| Rate for Payer: Ohio Health Group HMO |
$24,843.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,818.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,856.25
|
| Rate for Payer: PHCS Commercial |
$31,800.00
|
| Rate for Payer: United Healthcare All Payer |
$29,150.00
|
|
|
GFT AORTC BDY OVATION P 26*80
|
Facility
|
IP
|
$33,125.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,937.50 |
| Max. Negotiated Rate |
$31,800.00 |
| Rate for Payer: Aetna Commercial |
$25,506.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,837.50
|
| Rate for Payer: Cash Price |
$16,562.50
|
| Rate for Payer: Cigna Commercial |
$27,493.75
|
| Rate for Payer: First Health Commercial |
$31,468.75
|
| Rate for Payer: Humana Commercial |
$28,156.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,162.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,446.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,937.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,150.00
|
| Rate for Payer: Ohio Health Group HMO |
$24,843.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,818.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,856.25
|
| Rate for Payer: PHCS Commercial |
$31,800.00
|
| Rate for Payer: United Healthcare All Payer |
$29,150.00
|
|
|
GFT AORTC BDY OVATION P 26*80
|
Facility
|
OP
|
$33,125.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,937.50 |
| Max. Negotiated Rate |
$31,800.00 |
| Rate for Payer: Aetna Commercial |
$25,506.25
|
| Rate for Payer: Anthem Medicaid |
$11,391.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,837.50
|
| Rate for Payer: Cash Price |
$16,562.50
|
| Rate for Payer: Cigna Commercial |
$27,493.75
|
| Rate for Payer: First Health Commercial |
$31,468.75
|
| Rate for Payer: Humana Commercial |
$28,156.25
|
| Rate for Payer: Humana KY Medicaid |
$11,391.69
|
| Rate for Payer: Kentucky WC Medicaid |
$11,507.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,162.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,446.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,937.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,620.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,150.00
|
| Rate for Payer: Ohio Health Group HMO |
$24,843.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,818.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,856.25
|
| Rate for Payer: PHCS Commercial |
$31,800.00
|
| Rate for Payer: United Healthcare All Payer |
$29,150.00
|
|
|
GFT AORTC BDY OVATION P 29*80
|
Facility
|
IP
|
$33,125.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,937.50 |
| Max. Negotiated Rate |
$31,800.00 |
| Rate for Payer: Aetna Commercial |
$25,506.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,837.50
|
| Rate for Payer: Cash Price |
$16,562.50
|
| Rate for Payer: Cigna Commercial |
$27,493.75
|
| Rate for Payer: First Health Commercial |
$31,468.75
|
| Rate for Payer: Humana Commercial |
$28,156.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,162.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,446.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,937.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,150.00
|
| Rate for Payer: Ohio Health Group HMO |
$24,843.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,818.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,856.25
|
| Rate for Payer: PHCS Commercial |
$31,800.00
|
| Rate for Payer: United Healthcare All Payer |
$29,150.00
|
|
|
GFT AORTC BDY OVATION P 29*80
|
Facility
|
OP
|
$33,125.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,937.50 |
| Max. Negotiated Rate |
$31,800.00 |
| Rate for Payer: Aetna Commercial |
$25,506.25
|
| Rate for Payer: Anthem Medicaid |
$11,391.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,837.50
|
| Rate for Payer: Cash Price |
$16,562.50
|
| Rate for Payer: Cigna Commercial |
$27,493.75
|
| Rate for Payer: First Health Commercial |
$31,468.75
|
| Rate for Payer: Humana Commercial |
$28,156.25
|
| Rate for Payer: Humana KY Medicaid |
$11,391.69
|
| Rate for Payer: Kentucky WC Medicaid |
$11,507.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,162.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,446.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,937.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,620.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,150.00
|
| Rate for Payer: Ohio Health Group HMO |
$24,843.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,818.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,856.25
|
| Rate for Payer: PHCS Commercial |
$31,800.00
|
| Rate for Payer: United Healthcare All Payer |
$29,150.00
|
|
|
GFT AORTC BDY OVATION P 34*80
|
Facility
|
IP
|
$33,125.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,937.50 |
| Max. Negotiated Rate |
$31,800.00 |
| Rate for Payer: Aetna Commercial |
$25,506.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,837.50
|
| Rate for Payer: Cash Price |
$16,562.50
|
| Rate for Payer: Cigna Commercial |
$27,493.75
|
| Rate for Payer: First Health Commercial |
$31,468.75
|
| Rate for Payer: Humana Commercial |
$28,156.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,162.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,446.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,937.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,150.00
|
| Rate for Payer: Ohio Health Group HMO |
$24,843.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,818.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,856.25
|
| Rate for Payer: PHCS Commercial |
$31,800.00
|
| Rate for Payer: United Healthcare All Payer |
$29,150.00
|
|
|
GFT AORTC BDY OVATION P 34*80
|
Facility
|
OP
|
$33,125.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,937.50 |
| Max. Negotiated Rate |
$31,800.00 |
| Rate for Payer: Aetna Commercial |
$25,506.25
|
| Rate for Payer: Anthem Medicaid |
$11,391.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,837.50
|
| Rate for Payer: Cash Price |
$16,562.50
|
| Rate for Payer: Cigna Commercial |
$27,493.75
|
| Rate for Payer: First Health Commercial |
$31,468.75
|
| Rate for Payer: Humana Commercial |
$28,156.25
|
| Rate for Payer: Humana KY Medicaid |
$11,391.69
|
| Rate for Payer: Kentucky WC Medicaid |
$11,507.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,162.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,446.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,937.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,620.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,150.00
|
| Rate for Payer: Ohio Health Group HMO |
$24,843.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,818.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,856.25
|
| Rate for Payer: PHCS Commercial |
$31,800.00
|
| Rate for Payer: United Healthcare All Payer |
$29,150.00
|
|
|
GFT AORTC EXT A25-25/C75-O20 V
|
Facility
|
IP
|
$26,371.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,911.38 |
| Max. Negotiated Rate |
$25,316.40 |
| Rate for Payer: Aetna Commercial |
$20,305.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,569.58
|
| Rate for Payer: Cash Price |
$13,185.62
|
| Rate for Payer: Cigna Commercial |
$21,888.14
|
| Rate for Payer: First Health Commercial |
$25,052.69
|
| Rate for Payer: Humana Commercial |
$22,415.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,624.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,461.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,911.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,206.70
|
| Rate for Payer: Ohio Health Group HMO |
$19,778.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,097.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,942.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,196.16
|
| Rate for Payer: PHCS Commercial |
$25,316.40
|
| Rate for Payer: United Healthcare All Payer |
$23,206.70
|
|
|
GFT AORTC EXT A25-25/C75-O20 V
|
Facility
|
OP
|
$26,371.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,911.38 |
| Max. Negotiated Rate |
$25,316.40 |
| Rate for Payer: Aetna Commercial |
$20,305.86
|
| Rate for Payer: Anthem Medicaid |
$9,069.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,569.58
|
| Rate for Payer: Cash Price |
$13,185.62
|
| Rate for Payer: Cigna Commercial |
$21,888.14
|
| Rate for Payer: First Health Commercial |
$25,052.69
|
| Rate for Payer: Humana Commercial |
$22,415.56
|
| Rate for Payer: Humana KY Medicaid |
$9,069.07
|
| Rate for Payer: Kentucky WC Medicaid |
$9,161.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,624.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,461.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,911.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,251.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,206.70
|
| Rate for Payer: Ohio Health Group HMO |
$19,778.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,097.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,942.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,196.16
|
| Rate for Payer: PHCS Commercial |
$25,316.40
|
| Rate for Payer: United Healthcare All Payer |
$23,206.70
|
|
|
GFT AORTC EXT A25-25/C95-O20 V
|
Facility
|
IP
|
$23,881.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,164.38 |
| Max. Negotiated Rate |
$22,926.00 |
| Rate for Payer: Aetna Commercial |
$18,388.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,627.38
|
| Rate for Payer: Cash Price |
$11,940.62
|
| Rate for Payer: Cigna Commercial |
$19,821.44
|
| Rate for Payer: First Health Commercial |
$22,687.19
|
| Rate for Payer: Humana Commercial |
$20,299.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,582.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,624.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,164.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,015.50
|
| Rate for Payer: Ohio Health Group HMO |
$17,910.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,776.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,478.06
|
| Rate for Payer: PHCS Commercial |
$22,926.00
|
| Rate for Payer: United Healthcare All Payer |
$21,015.50
|
|
|
GFT AORTC EXT A25-25/C95-O20 V
|
Facility
|
OP
|
$23,881.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,164.38 |
| Max. Negotiated Rate |
$22,926.00 |
| Rate for Payer: Aetna Commercial |
$18,388.56
|
| Rate for Payer: Anthem Medicaid |
$8,212.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,627.38
|
| Rate for Payer: Cash Price |
$11,940.62
|
| Rate for Payer: Cigna Commercial |
$19,821.44
|
| Rate for Payer: First Health Commercial |
$22,687.19
|
| Rate for Payer: Humana Commercial |
$20,299.06
|
| Rate for Payer: Humana KY Medicaid |
$8,212.76
|
| Rate for Payer: Kentucky WC Medicaid |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,582.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,624.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,164.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,377.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,015.50
|
| Rate for Payer: Ohio Health Group HMO |
$17,910.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,776.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,478.06
|
| Rate for Payer: PHCS Commercial |
$22,926.00
|
| Rate for Payer: United Healthcare All Payer |
$21,015.50
|
|
|
GFT AORTC EXT A28-28/C95-O20 V
|
Facility
|
OP
|
$26,371.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,911.38 |
| Max. Negotiated Rate |
$25,316.40 |
| Rate for Payer: Aetna Commercial |
$20,305.86
|
| Rate for Payer: Anthem Medicaid |
$9,069.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,569.58
|
| Rate for Payer: Cash Price |
$13,185.62
|
| Rate for Payer: Cigna Commercial |
$21,888.14
|
| Rate for Payer: First Health Commercial |
$25,052.69
|
| Rate for Payer: Humana Commercial |
$22,415.56
|
| Rate for Payer: Humana KY Medicaid |
$9,069.07
|
| Rate for Payer: Kentucky WC Medicaid |
$9,161.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,624.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,461.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,911.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,251.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,206.70
|
| Rate for Payer: Ohio Health Group HMO |
$19,778.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,097.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,942.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,196.16
|
| Rate for Payer: PHCS Commercial |
$25,316.40
|
| Rate for Payer: United Healthcare All Payer |
$23,206.70
|
|
|
GFT AORTC EXT A28-28/C95-O20 V
|
Facility
|
IP
|
$26,371.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,911.38 |
| Max. Negotiated Rate |
$25,316.40 |
| Rate for Payer: Aetna Commercial |
$20,305.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,569.58
|
| Rate for Payer: Cash Price |
$13,185.62
|
| Rate for Payer: Cigna Commercial |
$21,888.14
|
| Rate for Payer: First Health Commercial |
$25,052.69
|
| Rate for Payer: Humana Commercial |
$22,415.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,624.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,461.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,911.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,206.70
|
| Rate for Payer: Ohio Health Group HMO |
$19,778.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,097.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,942.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,196.16
|
| Rate for Payer: PHCS Commercial |
$25,316.40
|
| Rate for Payer: United Healthcare All Payer |
$23,206.70
|
|
|
GFT AORTC EXT A34-34/C100-O20
|
Facility
|
IP
|
$24,743.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,423.12 |
| Max. Negotiated Rate |
$23,754.00 |
| Rate for Payer: Aetna Commercial |
$19,052.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,300.12
|
| Rate for Payer: Cash Price |
$12,371.88
|
| Rate for Payer: Cigna Commercial |
$20,537.31
|
| Rate for Payer: First Health Commercial |
$23,506.56
|
| Rate for Payer: Humana Commercial |
$21,032.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,289.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,260.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,423.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,774.50
|
| Rate for Payer: Ohio Health Group HMO |
$18,557.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,795.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,527.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,073.19
|
| Rate for Payer: PHCS Commercial |
$23,754.00
|
| Rate for Payer: United Healthcare All Payer |
$21,774.50
|
|
|
GFT AORTC EXT A34-34/C100-O20
|
Facility
|
OP
|
$24,743.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,423.12 |
| Max. Negotiated Rate |
$23,754.00 |
| Rate for Payer: Aetna Commercial |
$19,052.69
|
| Rate for Payer: Anthem Medicaid |
$8,509.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,300.12
|
| Rate for Payer: Cash Price |
$12,371.88
|
| Rate for Payer: Cigna Commercial |
$20,537.31
|
| Rate for Payer: First Health Commercial |
$23,506.56
|
| Rate for Payer: Humana Commercial |
$21,032.19
|
| Rate for Payer: Humana KY Medicaid |
$8,509.38
|
| Rate for Payer: Kentucky WC Medicaid |
$8,595.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,289.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,260.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,423.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,680.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,774.50
|
| Rate for Payer: Ohio Health Group HMO |
$18,557.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,795.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,527.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,073.19
|
| Rate for Payer: PHCS Commercial |
$23,754.00
|
| Rate for Payer: United Healthcare All Payer |
$21,774.50
|
|
|
GFT DIST EXT TALENT 26*26*50MM
|
Facility
|
IP
|
$25,625.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,687.50 |
| Max. Negotiated Rate |
$24,600.00 |
| Rate for Payer: Aetna Commercial |
$19,731.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,987.50
|
| Rate for Payer: Cash Price |
$12,812.50
|
| Rate for Payer: Cigna Commercial |
$21,268.75
|
| Rate for Payer: First Health Commercial |
$24,343.75
|
| Rate for Payer: Humana Commercial |
$21,781.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,012.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,911.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,687.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,550.00
|
| Rate for Payer: Ohio Health Group HMO |
$19,218.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,293.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,681.25
|
| Rate for Payer: PHCS Commercial |
$24,600.00
|
| Rate for Payer: United Healthcare All Payer |
$22,550.00
|
|
|
GFT DIST EXT TALENT 26*26*50MM
|
Facility
|
OP
|
$25,625.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,687.50 |
| Max. Negotiated Rate |
$24,600.00 |
| Rate for Payer: Aetna Commercial |
$19,731.25
|
| Rate for Payer: Anthem Medicaid |
$8,812.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,987.50
|
| Rate for Payer: Cash Price |
$12,812.50
|
| Rate for Payer: Cigna Commercial |
$21,268.75
|
| Rate for Payer: First Health Commercial |
$24,343.75
|
| Rate for Payer: Humana Commercial |
$21,781.25
|
| Rate for Payer: Humana KY Medicaid |
$8,812.44
|
| Rate for Payer: Kentucky WC Medicaid |
$8,902.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,012.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,911.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,687.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,989.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,550.00
|
| Rate for Payer: Ohio Health Group HMO |
$19,218.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,293.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,681.25
|
| Rate for Payer: PHCS Commercial |
$24,600.00
|
| Rate for Payer: United Healthcare All Payer |
$22,550.00
|
|
|
GFT DIST EXT TALENT 28*28*49MM
|
Facility
|
IP
|
$25,625.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,687.50 |
| Max. Negotiated Rate |
$24,600.00 |
| Rate for Payer: Aetna Commercial |
$19,731.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,987.50
|
| Rate for Payer: Cash Price |
$12,812.50
|
| Rate for Payer: Cigna Commercial |
$21,268.75
|
| Rate for Payer: First Health Commercial |
$24,343.75
|
| Rate for Payer: Humana Commercial |
$21,781.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,012.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,911.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,687.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,550.00
|
| Rate for Payer: Ohio Health Group HMO |
$19,218.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,293.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,681.25
|
| Rate for Payer: PHCS Commercial |
$24,600.00
|
| Rate for Payer: United Healthcare All Payer |
$22,550.00
|
|
|
GFT DIST EXT TALENT 28*28*49MM
|
Facility
|
OP
|
$25,625.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,687.50 |
| Max. Negotiated Rate |
$24,600.00 |
| Rate for Payer: Aetna Commercial |
$19,731.25
|
| Rate for Payer: Anthem Medicaid |
$8,812.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,987.50
|
| Rate for Payer: Cash Price |
$12,812.50
|
| Rate for Payer: Cigna Commercial |
$21,268.75
|
| Rate for Payer: First Health Commercial |
$24,343.75
|
| Rate for Payer: Humana Commercial |
$21,781.25
|
| Rate for Payer: Humana KY Medicaid |
$8,812.44
|
| Rate for Payer: Kentucky WC Medicaid |
$8,902.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,012.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,911.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,687.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,989.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,550.00
|
| Rate for Payer: Ohio Health Group HMO |
$19,218.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,293.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,681.25
|
| Rate for Payer: PHCS Commercial |
$24,600.00
|
| Rate for Payer: United Healthcare All Payer |
$22,550.00
|
|
|
GFT DIST EXT TALENT 30*30*48MM
|
Facility
|
IP
|
$25,625.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,687.50 |
| Max. Negotiated Rate |
$24,600.00 |
| Rate for Payer: Aetna Commercial |
$19,731.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,987.50
|
| Rate for Payer: Cash Price |
$12,812.50
|
| Rate for Payer: Cigna Commercial |
$21,268.75
|
| Rate for Payer: First Health Commercial |
$24,343.75
|
| Rate for Payer: Humana Commercial |
$21,781.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,012.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,911.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,687.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,550.00
|
| Rate for Payer: Ohio Health Group HMO |
$19,218.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,293.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,681.25
|
| Rate for Payer: PHCS Commercial |
$24,600.00
|
| Rate for Payer: United Healthcare All Payer |
$22,550.00
|
|
|
GFT DIST EXT TALENT 30*30*48MM
|
Facility
|
OP
|
$25,625.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,687.50 |
| Max. Negotiated Rate |
$24,600.00 |
| Rate for Payer: Aetna Commercial |
$19,731.25
|
| Rate for Payer: Anthem Medicaid |
$8,812.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,987.50
|
| Rate for Payer: Cash Price |
$12,812.50
|
| Rate for Payer: Cigna Commercial |
$21,268.75
|
| Rate for Payer: First Health Commercial |
$24,343.75
|
| Rate for Payer: Humana Commercial |
$21,781.25
|
| Rate for Payer: Humana KY Medicaid |
$8,812.44
|
| Rate for Payer: Kentucky WC Medicaid |
$8,902.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,012.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,911.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,687.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,989.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,550.00
|
| Rate for Payer: Ohio Health Group HMO |
$19,218.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,293.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,681.25
|
| Rate for Payer: PHCS Commercial |
$24,600.00
|
| Rate for Payer: United Healthcare All Payer |
$22,550.00
|
|
|
GFT DIST EXT TALENT 32*32*48MM
|
Facility
|
IP
|
$25,625.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,687.50 |
| Max. Negotiated Rate |
$24,600.00 |
| Rate for Payer: Aetna Commercial |
$19,731.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,987.50
|
| Rate for Payer: Cash Price |
$12,812.50
|
| Rate for Payer: Cigna Commercial |
$21,268.75
|
| Rate for Payer: First Health Commercial |
$24,343.75
|
| Rate for Payer: Humana Commercial |
$21,781.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,012.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,911.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,687.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,550.00
|
| Rate for Payer: Ohio Health Group HMO |
$19,218.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,293.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,681.25
|
| Rate for Payer: PHCS Commercial |
$24,600.00
|
| Rate for Payer: United Healthcare All Payer |
$22,550.00
|
|
|
GFT DIST EXT TALENT 32*32*48MM
|
Facility
|
OP
|
$25,625.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,687.50 |
| Max. Negotiated Rate |
$24,600.00 |
| Rate for Payer: Aetna Commercial |
$19,731.25
|
| Rate for Payer: Anthem Medicaid |
$8,812.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,987.50
|
| Rate for Payer: Cash Price |
$12,812.50
|
| Rate for Payer: Cigna Commercial |
$21,268.75
|
| Rate for Payer: First Health Commercial |
$24,343.75
|
| Rate for Payer: Humana Commercial |
$21,781.25
|
| Rate for Payer: Humana KY Medicaid |
$8,812.44
|
| Rate for Payer: Kentucky WC Medicaid |
$8,902.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,012.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,911.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,687.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,989.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,550.00
|
| Rate for Payer: Ohio Health Group HMO |
$19,218.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,293.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,681.25
|
| Rate for Payer: PHCS Commercial |
$24,600.00
|
| Rate for Payer: United Healthcare All Payer |
$22,550.00
|
|
|
GFT DIST EXT TALENT 34*34*48MM
|
Facility
|
IP
|
$25,625.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,687.50 |
| Max. Negotiated Rate |
$24,600.00 |
| Rate for Payer: Aetna Commercial |
$19,731.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,987.50
|
| Rate for Payer: Cash Price |
$12,812.50
|
| Rate for Payer: Cigna Commercial |
$21,268.75
|
| Rate for Payer: First Health Commercial |
$24,343.75
|
| Rate for Payer: Humana Commercial |
$21,781.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,012.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,911.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,687.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,550.00
|
| Rate for Payer: Ohio Health Group HMO |
$19,218.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,293.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,681.25
|
| Rate for Payer: PHCS Commercial |
$24,600.00
|
| Rate for Payer: United Healthcare All Payer |
$22,550.00
|
|
