|
GFT DIST TALENT 38MM*34MM*112M
|
Facility
|
OP
|
$75,100.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,530.00 |
| Max. Negotiated Rate |
$72,096.00 |
| Rate for Payer: Aetna Commercial |
$57,827.00
|
| Rate for Payer: Anthem Medicaid |
$25,826.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58,578.00
|
| Rate for Payer: Cash Price |
$37,550.00
|
| Rate for Payer: Cigna Commercial |
$62,333.00
|
| Rate for Payer: First Health Commercial |
$71,345.00
|
| Rate for Payer: Humana Commercial |
$63,835.00
|
| Rate for Payer: Humana KY Medicaid |
$25,826.89
|
| Rate for Payer: Kentucky WC Medicaid |
$26,089.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61,582.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55,423.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,530.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$26,345.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$66,088.00
|
| Rate for Payer: Ohio Health Group HMO |
$56,325.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60,080.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65,337.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51,819.00
|
| Rate for Payer: PHCS Commercial |
$72,096.00
|
| Rate for Payer: United Healthcare All Payer |
$66,088.00
|
|
|
GFT DIST TALENT 38MM*34MM*112M
|
Facility
|
IP
|
$75,100.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,530.00 |
| Max. Negotiated Rate |
$72,096.00 |
| Rate for Payer: Aetna Commercial |
$57,827.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58,578.00
|
| Rate for Payer: Cash Price |
$37,550.00
|
| Rate for Payer: Cigna Commercial |
$62,333.00
|
| Rate for Payer: First Health Commercial |
$71,345.00
|
| Rate for Payer: Humana Commercial |
$63,835.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61,582.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55,423.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,530.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$66,088.00
|
| Rate for Payer: Ohio Health Group HMO |
$56,325.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60,080.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65,337.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51,819.00
|
| Rate for Payer: PHCS Commercial |
$72,096.00
|
| Rate for Payer: United Healthcare All Payer |
$66,088.00
|
|
|
GFT DIST TALENT 40MM*36MM*112M
|
Facility
|
IP
|
$75,100.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,530.00 |
| Max. Negotiated Rate |
$72,096.00 |
| Rate for Payer: Aetna Commercial |
$57,827.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58,578.00
|
| Rate for Payer: Cash Price |
$37,550.00
|
| Rate for Payer: Cigna Commercial |
$62,333.00
|
| Rate for Payer: First Health Commercial |
$71,345.00
|
| Rate for Payer: Humana Commercial |
$63,835.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61,582.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55,423.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,530.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$66,088.00
|
| Rate for Payer: Ohio Health Group HMO |
$56,325.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60,080.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65,337.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51,819.00
|
| Rate for Payer: PHCS Commercial |
$72,096.00
|
| Rate for Payer: United Healthcare All Payer |
$66,088.00
|
|
|
GFT DIST TALENT 40MM*36MM*112M
|
Facility
|
OP
|
$75,100.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,530.00 |
| Max. Negotiated Rate |
$72,096.00 |
| Rate for Payer: Aetna Commercial |
$57,827.00
|
| Rate for Payer: Anthem Medicaid |
$25,826.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58,578.00
|
| Rate for Payer: Cash Price |
$37,550.00
|
| Rate for Payer: Cigna Commercial |
$62,333.00
|
| Rate for Payer: First Health Commercial |
$71,345.00
|
| Rate for Payer: Humana Commercial |
$63,835.00
|
| Rate for Payer: Humana KY Medicaid |
$25,826.89
|
| Rate for Payer: Kentucky WC Medicaid |
$26,089.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61,582.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55,423.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,530.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$26,345.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$66,088.00
|
| Rate for Payer: Ohio Health Group HMO |
$56,325.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60,080.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65,337.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51,819.00
|
| Rate for Payer: PHCS Commercial |
$72,096.00
|
| Rate for Payer: United Healthcare All Payer |
$66,088.00
|
|
|
GFT DIST TALENT 42MM*38MM*111M
|
Facility
|
IP
|
$76,620.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,986.00 |
| Max. Negotiated Rate |
$73,555.20 |
| Rate for Payer: Aetna Commercial |
$58,997.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59,763.60
|
| Rate for Payer: Cash Price |
$38,310.00
|
| Rate for Payer: Cigna Commercial |
$63,594.60
|
| Rate for Payer: First Health Commercial |
$72,789.00
|
| Rate for Payer: Humana Commercial |
$65,127.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62,828.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56,545.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,986.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$67,425.60
|
| Rate for Payer: Ohio Health Group HMO |
$57,465.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61,296.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66,659.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52,867.80
|
| Rate for Payer: PHCS Commercial |
$73,555.20
|
| Rate for Payer: United Healthcare All Payer |
$67,425.60
|
|
|
GFT DIST TALENT 42MM*38MM*111M
|
Facility
|
OP
|
$76,620.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,986.00 |
| Max. Negotiated Rate |
$73,555.20 |
| Rate for Payer: Aetna Commercial |
$58,997.40
|
| Rate for Payer: Anthem Medicaid |
$26,349.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59,763.60
|
| Rate for Payer: Cash Price |
$38,310.00
|
| Rate for Payer: Cigna Commercial |
$63,594.60
|
| Rate for Payer: First Health Commercial |
$72,789.00
|
| Rate for Payer: Humana Commercial |
$65,127.00
|
| Rate for Payer: Humana KY Medicaid |
$26,349.62
|
| Rate for Payer: Kentucky WC Medicaid |
$26,617.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62,828.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56,545.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,986.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$26,878.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$67,425.60
|
| Rate for Payer: Ohio Health Group HMO |
$57,465.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61,296.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66,659.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52,867.80
|
| Rate for Payer: PHCS Commercial |
$73,555.20
|
| Rate for Payer: United Healthcare All Payer |
$67,425.60
|
|
|
GFT DIST TALENT 44MM*40MM*111M
|
Facility
|
IP
|
$76,620.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,986.00 |
| Max. Negotiated Rate |
$73,555.20 |
| Rate for Payer: Aetna Commercial |
$58,997.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59,763.60
|
| Rate for Payer: Cash Price |
$38,310.00
|
| Rate for Payer: Cigna Commercial |
$63,594.60
|
| Rate for Payer: First Health Commercial |
$72,789.00
|
| Rate for Payer: Humana Commercial |
$65,127.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62,828.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56,545.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,986.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$67,425.60
|
| Rate for Payer: Ohio Health Group HMO |
$57,465.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61,296.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66,659.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52,867.80
|
| Rate for Payer: PHCS Commercial |
$73,555.20
|
| Rate for Payer: United Healthcare All Payer |
$67,425.60
|
|
|
GFT DIST TALENT 44MM*40MM*111M
|
Facility
|
OP
|
$76,620.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,986.00 |
| Max. Negotiated Rate |
$73,555.20 |
| Rate for Payer: Aetna Commercial |
$58,997.40
|
| Rate for Payer: Anthem Medicaid |
$26,349.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59,763.60
|
| Rate for Payer: Cash Price |
$38,310.00
|
| Rate for Payer: Cigna Commercial |
$63,594.60
|
| Rate for Payer: First Health Commercial |
$72,789.00
|
| Rate for Payer: Humana Commercial |
$65,127.00
|
| Rate for Payer: Humana KY Medicaid |
$26,349.62
|
| Rate for Payer: Kentucky WC Medicaid |
$26,617.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62,828.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56,545.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,986.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$26,878.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$67,425.60
|
| Rate for Payer: Ohio Health Group HMO |
$57,465.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61,296.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66,659.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52,867.80
|
| Rate for Payer: PHCS Commercial |
$73,555.20
|
| Rate for Payer: United Healthcare All Payer |
$67,425.60
|
|
|
GFT DIST TALENT 46MM*42MM*110M
|
Facility
|
OP
|
$76,620.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,986.00 |
| Max. Negotiated Rate |
$73,555.20 |
| Rate for Payer: Aetna Commercial |
$58,997.40
|
| Rate for Payer: Anthem Medicaid |
$26,349.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59,763.60
|
| Rate for Payer: Cash Price |
$38,310.00
|
| Rate for Payer: Cigna Commercial |
$63,594.60
|
| Rate for Payer: First Health Commercial |
$72,789.00
|
| Rate for Payer: Humana Commercial |
$65,127.00
|
| Rate for Payer: Humana KY Medicaid |
$26,349.62
|
| Rate for Payer: Kentucky WC Medicaid |
$26,617.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62,828.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56,545.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,986.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$26,878.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$67,425.60
|
| Rate for Payer: Ohio Health Group HMO |
$57,465.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61,296.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66,659.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52,867.80
|
| Rate for Payer: PHCS Commercial |
$73,555.20
|
| Rate for Payer: United Healthcare All Payer |
$67,425.60
|
|
|
GFT DIST TALENT 46MM*42MM*110M
|
Facility
|
IP
|
$76,620.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,986.00 |
| Max. Negotiated Rate |
$73,555.20 |
| Rate for Payer: Aetna Commercial |
$58,997.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59,763.60
|
| Rate for Payer: Cash Price |
$38,310.00
|
| Rate for Payer: Cigna Commercial |
$63,594.60
|
| Rate for Payer: First Health Commercial |
$72,789.00
|
| Rate for Payer: Humana Commercial |
$65,127.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62,828.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56,545.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,986.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$67,425.60
|
| Rate for Payer: Ohio Health Group HMO |
$57,465.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61,296.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66,659.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52,867.80
|
| Rate for Payer: PHCS Commercial |
$73,555.20
|
| Rate for Payer: United Healthcare All Payer |
$67,425.60
|
|
|
GFT DIST TALENT 46MM*44MM*110M
|
Facility
|
IP
|
$76,620.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,986.00 |
| Max. Negotiated Rate |
$73,555.20 |
| Rate for Payer: Aetna Commercial |
$58,997.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59,763.60
|
| Rate for Payer: Cash Price |
$38,310.00
|
| Rate for Payer: Cigna Commercial |
$63,594.60
|
| Rate for Payer: First Health Commercial |
$72,789.00
|
| Rate for Payer: Humana Commercial |
$65,127.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62,828.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56,545.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,986.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$67,425.60
|
| Rate for Payer: Ohio Health Group HMO |
$57,465.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61,296.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66,659.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52,867.80
|
| Rate for Payer: PHCS Commercial |
$73,555.20
|
| Rate for Payer: United Healthcare All Payer |
$67,425.60
|
|
|
GFT DIST TALENT 46MM*44MM*110M
|
Facility
|
OP
|
$76,620.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,986.00 |
| Max. Negotiated Rate |
$73,555.20 |
| Rate for Payer: Aetna Commercial |
$58,997.40
|
| Rate for Payer: Anthem Medicaid |
$26,349.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59,763.60
|
| Rate for Payer: Cash Price |
$38,310.00
|
| Rate for Payer: Cigna Commercial |
$63,594.60
|
| Rate for Payer: First Health Commercial |
$72,789.00
|
| Rate for Payer: Humana Commercial |
$65,127.00
|
| Rate for Payer: Humana KY Medicaid |
$26,349.62
|
| Rate for Payer: Kentucky WC Medicaid |
$26,617.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62,828.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56,545.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,986.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$26,878.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$67,425.60
|
| Rate for Payer: Ohio Health Group HMO |
$57,465.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61,296.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66,659.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52,867.80
|
| Rate for Payer: PHCS Commercial |
$73,555.20
|
| Rate for Payer: United Healthcare All Payer |
$67,425.60
|
|
|
GFT ENDRNT II BIFU 25*16*145MM
|
Facility
|
OP
|
$40,013.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,004.12 |
| Max. Negotiated Rate |
$38,413.20 |
| Rate for Payer: Aetna Commercial |
$30,810.59
|
| Rate for Payer: Anthem Medicaid |
$13,760.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31,210.72
|
| Rate for Payer: Cash Price |
$20,006.88
|
| Rate for Payer: Cigna Commercial |
$33,211.41
|
| Rate for Payer: First Health Commercial |
$38,013.06
|
| Rate for Payer: Humana Commercial |
$34,011.69
|
| Rate for Payer: Humana KY Medicaid |
$13,760.73
|
| Rate for Payer: Kentucky WC Medicaid |
$13,900.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32,811.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29,530.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,004.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,036.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$35,212.10
|
| Rate for Payer: Ohio Health Group HMO |
$30,010.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32,011.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$34,811.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27,609.49
|
| Rate for Payer: PHCS Commercial |
$38,413.20
|
| Rate for Payer: United Healthcare All Payer |
$35,212.10
|
|
|
GFT ENDRNT II BIFU 25*16*145MM
|
Facility
|
IP
|
$40,013.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,004.12 |
| Max. Negotiated Rate |
$38,413.20 |
| Rate for Payer: Aetna Commercial |
$30,810.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31,210.72
|
| Rate for Payer: Cash Price |
$20,006.88
|
| Rate for Payer: Cigna Commercial |
$33,211.41
|
| Rate for Payer: First Health Commercial |
$38,013.06
|
| Rate for Payer: Humana Commercial |
$34,011.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32,811.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29,530.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,004.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$35,212.10
|
| Rate for Payer: Ohio Health Group HMO |
$30,010.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32,011.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$34,811.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27,609.49
|
| Rate for Payer: PHCS Commercial |
$38,413.20
|
| Rate for Payer: United Healthcare All Payer |
$35,212.10
|
|
|
GFT EXCLDR TRK 31*14.5*15 18FR
|
Facility
|
OP
|
$74,514.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,354.44 |
| Max. Negotiated Rate |
$71,534.21 |
| Rate for Payer: Aetna Commercial |
$57,376.40
|
| Rate for Payer: Anthem Medicaid |
$25,625.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58,121.54
|
| Rate for Payer: Cash Price |
$37,257.40
|
| Rate for Payer: Cigna Commercial |
$61,847.28
|
| Rate for Payer: First Health Commercial |
$70,789.06
|
| Rate for Payer: Humana Commercial |
$63,337.58
|
| Rate for Payer: Humana KY Medicaid |
$25,625.64
|
| Rate for Payer: Kentucky WC Medicaid |
$25,886.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61,102.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,991.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,354.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$26,139.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$65,573.02
|
| Rate for Payer: Ohio Health Group HMO |
$55,886.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$59,611.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64,827.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51,415.21
|
| Rate for Payer: PHCS Commercial |
$71,534.21
|
| Rate for Payer: United Healthcare All Payer |
$65,573.02
|
|
|
GFT EXCLDR TRK 31*14.5*15 18FR
|
Facility
|
IP
|
$74,514.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,354.44 |
| Max. Negotiated Rate |
$71,534.21 |
| Rate for Payer: Aetna Commercial |
$57,376.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58,121.54
|
| Rate for Payer: Cash Price |
$37,257.40
|
| Rate for Payer: Cigna Commercial |
$61,847.28
|
| Rate for Payer: First Health Commercial |
$70,789.06
|
| Rate for Payer: Humana Commercial |
$63,337.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61,102.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,991.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,354.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$65,573.02
|
| Rate for Payer: Ohio Health Group HMO |
$55,886.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$59,611.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64,827.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51,415.21
|
| Rate for Payer: PHCS Commercial |
$71,534.21
|
| Rate for Payer: United Healthcare All Payer |
$65,573.02
|
|
|
GFT HEMASHIELD STRAIGHT 16*30
|
Facility
|
OP
|
$3,932.04
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,179.61 |
| Max. Negotiated Rate |
$3,774.76 |
| Rate for Payer: Aetna Commercial |
$3,027.67
|
| Rate for Payer: Anthem Medicaid |
$1,352.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,066.99
|
| Rate for Payer: Cash Price |
$1,966.02
|
| Rate for Payer: Cigna Commercial |
$3,263.59
|
| Rate for Payer: First Health Commercial |
$3,735.44
|
| Rate for Payer: Humana Commercial |
$3,342.23
|
| Rate for Payer: Humana KY Medicaid |
$1,352.23
|
| Rate for Payer: Kentucky WC Medicaid |
$1,365.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,224.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,901.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,179.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,379.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,460.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,949.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,145.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,420.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,713.11
|
| Rate for Payer: PHCS Commercial |
$3,774.76
|
| Rate for Payer: United Healthcare All Payer |
$3,460.20
|
|
|
GFT HEMASHIELD STRAIGHT 16*30
|
Facility
|
IP
|
$3,932.04
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,179.61 |
| Max. Negotiated Rate |
$3,774.76 |
| Rate for Payer: Aetna Commercial |
$3,027.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,066.99
|
| Rate for Payer: Cash Price |
$1,966.02
|
| Rate for Payer: Cigna Commercial |
$3,263.59
|
| Rate for Payer: First Health Commercial |
$3,735.44
|
| Rate for Payer: Humana Commercial |
$3,342.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,224.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,901.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,179.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,460.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,949.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,145.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,420.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,713.11
|
| Rate for Payer: PHCS Commercial |
$3,774.76
|
| Rate for Payer: United Healthcare All Payer |
$3,460.20
|
|
|
GFT HEMASHIELD STRAIGHT 18*30
|
Facility
|
OP
|
$3,932.04
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,179.61 |
| Max. Negotiated Rate |
$3,774.76 |
| Rate for Payer: Aetna Commercial |
$3,027.67
|
| Rate for Payer: Anthem Medicaid |
$1,352.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,066.99
|
| Rate for Payer: Cash Price |
$1,966.02
|
| Rate for Payer: Cigna Commercial |
$3,263.59
|
| Rate for Payer: First Health Commercial |
$3,735.44
|
| Rate for Payer: Humana Commercial |
$3,342.23
|
| Rate for Payer: Humana KY Medicaid |
$1,352.23
|
| Rate for Payer: Kentucky WC Medicaid |
$1,365.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,224.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,901.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,179.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,379.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,460.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,949.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,145.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,420.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,713.11
|
| Rate for Payer: PHCS Commercial |
$3,774.76
|
| Rate for Payer: United Healthcare All Payer |
$3,460.20
|
|
|
GFT HEMASHIELD STRAIGHT 18*30
|
Facility
|
IP
|
$3,932.04
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,179.61 |
| Max. Negotiated Rate |
$3,774.76 |
| Rate for Payer: Aetna Commercial |
$3,027.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,066.99
|
| Rate for Payer: Cash Price |
$1,966.02
|
| Rate for Payer: Cigna Commercial |
$3,263.59
|
| Rate for Payer: First Health Commercial |
$3,735.44
|
| Rate for Payer: Humana Commercial |
$3,342.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,224.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,901.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,179.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,460.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,949.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,145.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,420.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,713.11
|
| Rate for Payer: PHCS Commercial |
$3,774.76
|
| Rate for Payer: United Healthcare All Payer |
$3,460.20
|
|
|
GFT HEMSHLD PLAT PTCH 0.8*15.2
|
Facility
|
IP
|
$1,739.58
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$521.87 |
| Max. Negotiated Rate |
$1,670.00 |
| Rate for Payer: Aetna Commercial |
$1,339.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,356.87
|
| Rate for Payer: Cash Price |
$869.79
|
| Rate for Payer: Cigna Commercial |
$1,443.85
|
| Rate for Payer: First Health Commercial |
$1,652.60
|
| Rate for Payer: Humana Commercial |
$1,478.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,426.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,283.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,530.83
|
| Rate for Payer: Ohio Health Group HMO |
$1,304.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,391.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,513.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,200.31
|
| Rate for Payer: PHCS Commercial |
$1,670.00
|
| Rate for Payer: United Healthcare All Payer |
$1,530.83
|
|
|
GFT HEMSHLD PLAT PTCH 0.8*15.2
|
Facility
|
OP
|
$1,739.58
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$521.87 |
| Max. Negotiated Rate |
$1,670.00 |
| Rate for Payer: Aetna Commercial |
$1,339.48
|
| Rate for Payer: Anthem Medicaid |
$598.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,356.87
|
| Rate for Payer: Cash Price |
$869.79
|
| Rate for Payer: Cigna Commercial |
$1,443.85
|
| Rate for Payer: First Health Commercial |
$1,652.60
|
| Rate for Payer: Humana Commercial |
$1,478.64
|
| Rate for Payer: Humana KY Medicaid |
$598.24
|
| Rate for Payer: Kentucky WC Medicaid |
$604.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,426.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,283.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$610.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,530.83
|
| Rate for Payer: Ohio Health Group HMO |
$1,304.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,391.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,513.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,200.31
|
| Rate for Payer: PHCS Commercial |
$1,670.00
|
| Rate for Payer: United Healthcare All Payer |
$1,530.83
|
|
|
GFT ILIAC EXT OVTN IX 10*10*45
|
Facility
|
OP
|
$23,746.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,123.88 |
| Max. Negotiated Rate |
$22,796.40 |
| Rate for Payer: Aetna Commercial |
$18,284.61
|
| Rate for Payer: Anthem Medicaid |
$8,166.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,522.08
|
| Rate for Payer: Cash Price |
$11,873.12
|
| Rate for Payer: Cigna Commercial |
$19,709.39
|
| Rate for Payer: First Health Commercial |
$22,558.94
|
| Rate for Payer: Humana Commercial |
$20,184.31
|
| Rate for Payer: Humana KY Medicaid |
$8,166.34
|
| Rate for Payer: Kentucky WC Medicaid |
$8,249.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,471.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,524.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,123.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,330.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,896.70
|
| Rate for Payer: Ohio Health Group HMO |
$17,809.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,997.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,659.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,384.91
|
| Rate for Payer: PHCS Commercial |
$22,796.40
|
| Rate for Payer: United Healthcare All Payer |
$20,896.70
|
|
|
GFT ILIAC EXT OVTN IX 10*10*45
|
Facility
|
IP
|
$23,746.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,123.88 |
| Max. Negotiated Rate |
$22,796.40 |
| Rate for Payer: Aetna Commercial |
$18,284.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,522.08
|
| Rate for Payer: Cash Price |
$11,873.12
|
| Rate for Payer: Cigna Commercial |
$19,709.39
|
| Rate for Payer: First Health Commercial |
$22,558.94
|
| Rate for Payer: Humana Commercial |
$20,184.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,471.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,524.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,123.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,896.70
|
| Rate for Payer: Ohio Health Group HMO |
$17,809.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,997.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,659.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,384.91
|
| Rate for Payer: PHCS Commercial |
$22,796.40
|
| Rate for Payer: United Healthcare All Payer |
$20,896.70
|
|
|
GFT ILIAC EXT OVTN IX 12*12*45
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
