|
GFT MAIN BDY BIFR 28*110*20*30
|
Facility
|
OP
|
$73,504.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,051.20 |
| Max. Negotiated Rate |
$70,563.84 |
| Rate for Payer: Aetna Commercial |
$56,598.08
|
| Rate for Payer: Anthem Medicaid |
$25,278.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,333.12
|
| Rate for Payer: Cash Price |
$36,752.00
|
| Rate for Payer: Cigna Commercial |
$61,008.32
|
| Rate for Payer: First Health Commercial |
$69,828.80
|
| Rate for Payer: Humana Commercial |
$62,478.40
|
| Rate for Payer: Humana KY Medicaid |
$25,278.03
|
| Rate for Payer: Kentucky WC Medicaid |
$25,535.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,273.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,245.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,051.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,785.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,683.52
|
| Rate for Payer: Ohio Health Group HMO |
$55,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,803.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,948.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,717.76
|
| Rate for Payer: PHCS Commercial |
$70,563.84
|
| Rate for Payer: United Healthcare All Payer |
$64,683.52
|
|
|
GFT MAIN BDY BIFR 28*120*16*40
|
Facility
|
IP
|
$73,504.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,051.20 |
| Max. Negotiated Rate |
$70,563.84 |
| Rate for Payer: Aetna Commercial |
$56,598.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,333.12
|
| Rate for Payer: Cash Price |
$36,752.00
|
| Rate for Payer: Cigna Commercial |
$61,008.32
|
| Rate for Payer: First Health Commercial |
$69,828.80
|
| Rate for Payer: Humana Commercial |
$62,478.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,273.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,245.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,051.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,683.52
|
| Rate for Payer: Ohio Health Group HMO |
$55,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,803.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,948.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,717.76
|
| Rate for Payer: PHCS Commercial |
$70,563.84
|
| Rate for Payer: United Healthcare All Payer |
$64,683.52
|
|
|
GFT MAIN BDY BIFR 28*120*16*40
|
Facility
|
OP
|
$73,504.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,051.20 |
| Max. Negotiated Rate |
$70,563.84 |
| Rate for Payer: Aetna Commercial |
$56,598.08
|
| Rate for Payer: Anthem Medicaid |
$25,278.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,333.12
|
| Rate for Payer: Cash Price |
$36,752.00
|
| Rate for Payer: Cigna Commercial |
$61,008.32
|
| Rate for Payer: First Health Commercial |
$69,828.80
|
| Rate for Payer: Humana Commercial |
$62,478.40
|
| Rate for Payer: Humana KY Medicaid |
$25,278.03
|
| Rate for Payer: Kentucky WC Medicaid |
$25,535.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,273.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,245.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,051.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,785.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,683.52
|
| Rate for Payer: Ohio Health Group HMO |
$55,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,803.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,948.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,717.76
|
| Rate for Payer: PHCS Commercial |
$70,563.84
|
| Rate for Payer: United Healthcare All Payer |
$64,683.52
|
|
|
GFT MAIN BDY BIFR 28*120*20*40
|
Facility
|
IP
|
$73,504.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,051.20 |
| Max. Negotiated Rate |
$70,563.84 |
| Rate for Payer: Aetna Commercial |
$56,598.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,333.12
|
| Rate for Payer: Cash Price |
$36,752.00
|
| Rate for Payer: Cigna Commercial |
$61,008.32
|
| Rate for Payer: First Health Commercial |
$69,828.80
|
| Rate for Payer: Humana Commercial |
$62,478.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,273.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,245.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,051.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,683.52
|
| Rate for Payer: Ohio Health Group HMO |
$55,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,803.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,948.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,717.76
|
| Rate for Payer: PHCS Commercial |
$70,563.84
|
| Rate for Payer: United Healthcare All Payer |
$64,683.52
|
|
|
GFT MAIN BDY BIFR 28*120*20*40
|
Facility
|
OP
|
$73,504.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,051.20 |
| Max. Negotiated Rate |
$70,563.84 |
| Rate for Payer: Aetna Commercial |
$56,598.08
|
| Rate for Payer: Anthem Medicaid |
$25,278.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,333.12
|
| Rate for Payer: Cash Price |
$36,752.00
|
| Rate for Payer: Cigna Commercial |
$61,008.32
|
| Rate for Payer: First Health Commercial |
$69,828.80
|
| Rate for Payer: Humana Commercial |
$62,478.40
|
| Rate for Payer: Humana KY Medicaid |
$25,278.03
|
| Rate for Payer: Kentucky WC Medicaid |
$25,535.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,273.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,245.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,051.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,785.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,683.52
|
| Rate for Payer: Ohio Health Group HMO |
$55,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,803.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,948.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,717.76
|
| Rate for Payer: PHCS Commercial |
$70,563.84
|
| Rate for Payer: United Healthcare All Payer |
$64,683.52
|
|
|
GFT MAIN BDY BIFR 28*70*20*30
|
Facility
|
OP
|
$73,504.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,051.20 |
| Max. Negotiated Rate |
$70,563.84 |
| Rate for Payer: Aetna Commercial |
$56,598.08
|
| Rate for Payer: Anthem Medicaid |
$25,278.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,333.12
|
| Rate for Payer: Cash Price |
$36,752.00
|
| Rate for Payer: Cigna Commercial |
$61,008.32
|
| Rate for Payer: First Health Commercial |
$69,828.80
|
| Rate for Payer: Humana Commercial |
$62,478.40
|
| Rate for Payer: Humana KY Medicaid |
$25,278.03
|
| Rate for Payer: Kentucky WC Medicaid |
$25,535.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,273.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,245.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,051.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,785.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,683.52
|
| Rate for Payer: Ohio Health Group HMO |
$55,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,803.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,948.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,717.76
|
| Rate for Payer: PHCS Commercial |
$70,563.84
|
| Rate for Payer: United Healthcare All Payer |
$64,683.52
|
|
|
GFT MAIN BDY BIFR 28*70*20*30
|
Facility
|
IP
|
$73,504.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,051.20 |
| Max. Negotiated Rate |
$70,563.84 |
| Rate for Payer: Aetna Commercial |
$56,598.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,333.12
|
| Rate for Payer: Cash Price |
$36,752.00
|
| Rate for Payer: Cigna Commercial |
$61,008.32
|
| Rate for Payer: First Health Commercial |
$69,828.80
|
| Rate for Payer: Humana Commercial |
$62,478.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,273.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,245.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,051.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,683.52
|
| Rate for Payer: Ohio Health Group HMO |
$55,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,803.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,948.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,717.76
|
| Rate for Payer: PHCS Commercial |
$70,563.84
|
| Rate for Payer: United Healthcare All Payer |
$64,683.52
|
|
|
GFT MAIN BDY BIFR 28*80*20*40
|
Facility
|
IP
|
$73,504.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,051.20 |
| Max. Negotiated Rate |
$70,563.84 |
| Rate for Payer: Aetna Commercial |
$56,598.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,333.12
|
| Rate for Payer: Cash Price |
$36,752.00
|
| Rate for Payer: Cigna Commercial |
$61,008.32
|
| Rate for Payer: First Health Commercial |
$69,828.80
|
| Rate for Payer: Humana Commercial |
$62,478.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,273.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,245.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,051.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,683.52
|
| Rate for Payer: Ohio Health Group HMO |
$55,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,803.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,948.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,717.76
|
| Rate for Payer: PHCS Commercial |
$70,563.84
|
| Rate for Payer: United Healthcare All Payer |
$64,683.52
|
|
|
GFT MAIN BDY BIFR 28*80*20*40
|
Facility
|
OP
|
$73,504.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,051.20 |
| Max. Negotiated Rate |
$70,563.84 |
| Rate for Payer: Aetna Commercial |
$56,598.08
|
| Rate for Payer: Anthem Medicaid |
$25,278.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,333.12
|
| Rate for Payer: Cash Price |
$36,752.00
|
| Rate for Payer: Cigna Commercial |
$61,008.32
|
| Rate for Payer: First Health Commercial |
$69,828.80
|
| Rate for Payer: Humana Commercial |
$62,478.40
|
| Rate for Payer: Humana KY Medicaid |
$25,278.03
|
| Rate for Payer: Kentucky WC Medicaid |
$25,535.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,273.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,245.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,051.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,785.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,683.52
|
| Rate for Payer: Ohio Health Group HMO |
$55,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,803.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,948.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,717.76
|
| Rate for Payer: PHCS Commercial |
$70,563.84
|
| Rate for Payer: United Healthcare All Payer |
$64,683.52
|
|
|
GFT MAIN BDY BIFR 28*80*I16*40
|
Facility
|
OP
|
$73,504.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,051.20 |
| Max. Negotiated Rate |
$70,563.84 |
| Rate for Payer: Aetna Commercial |
$56,598.08
|
| Rate for Payer: Anthem Medicaid |
$25,278.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,333.12
|
| Rate for Payer: Cash Price |
$36,752.00
|
| Rate for Payer: Cigna Commercial |
$61,008.32
|
| Rate for Payer: First Health Commercial |
$69,828.80
|
| Rate for Payer: Humana Commercial |
$62,478.40
|
| Rate for Payer: Humana KY Medicaid |
$25,278.03
|
| Rate for Payer: Kentucky WC Medicaid |
$25,535.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,273.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,245.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,051.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,785.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,683.52
|
| Rate for Payer: Ohio Health Group HMO |
$55,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,803.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,948.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,717.76
|
| Rate for Payer: PHCS Commercial |
$70,563.84
|
| Rate for Payer: United Healthcare All Payer |
$64,683.52
|
|
|
GFT MAIN BDY BIFR 28*80*I16*40
|
Facility
|
IP
|
$73,504.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,051.20 |
| Max. Negotiated Rate |
$70,563.84 |
| Rate for Payer: Aetna Commercial |
$56,598.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,333.12
|
| Rate for Payer: Cash Price |
$36,752.00
|
| Rate for Payer: Cigna Commercial |
$61,008.32
|
| Rate for Payer: First Health Commercial |
$69,828.80
|
| Rate for Payer: Humana Commercial |
$62,478.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,273.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,245.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,051.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,683.52
|
| Rate for Payer: Ohio Health Group HMO |
$55,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,803.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,948.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,717.76
|
| Rate for Payer: PHCS Commercial |
$70,563.84
|
| Rate for Payer: United Healthcare All Payer |
$64,683.52
|
|
|
GFT MAIN BDY BIFR 28*90/116*30
|
Facility
|
OP
|
$73,504.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,051.20 |
| Max. Negotiated Rate |
$70,563.84 |
| Rate for Payer: Aetna Commercial |
$56,598.08
|
| Rate for Payer: Anthem Medicaid |
$25,278.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,333.12
|
| Rate for Payer: Cash Price |
$36,752.00
|
| Rate for Payer: Cigna Commercial |
$61,008.32
|
| Rate for Payer: First Health Commercial |
$69,828.80
|
| Rate for Payer: Humana Commercial |
$62,478.40
|
| Rate for Payer: Humana KY Medicaid |
$25,278.03
|
| Rate for Payer: Kentucky WC Medicaid |
$25,535.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,273.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,245.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,051.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,785.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,683.52
|
| Rate for Payer: Ohio Health Group HMO |
$55,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,803.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,948.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,717.76
|
| Rate for Payer: PHCS Commercial |
$70,563.84
|
| Rate for Payer: United Healthcare All Payer |
$64,683.52
|
|
|
GFT MAIN BDY BIFR 28*90/116*30
|
Facility
|
IP
|
$73,504.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,051.20 |
| Max. Negotiated Rate |
$70,563.84 |
| Rate for Payer: Aetna Commercial |
$56,598.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,333.12
|
| Rate for Payer: Cash Price |
$36,752.00
|
| Rate for Payer: Cigna Commercial |
$61,008.32
|
| Rate for Payer: First Health Commercial |
$69,828.80
|
| Rate for Payer: Humana Commercial |
$62,478.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,273.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,245.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,051.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,683.52
|
| Rate for Payer: Ohio Health Group HMO |
$55,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,803.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,948.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,717.76
|
| Rate for Payer: PHCS Commercial |
$70,563.84
|
| Rate for Payer: United Healthcare All Payer |
$64,683.52
|
|
|
GFT MAIN BDY BIFR 28*90*120*30
|
Facility
|
IP
|
$73,504.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,051.20 |
| Max. Negotiated Rate |
$70,563.84 |
| Rate for Payer: Aetna Commercial |
$56,598.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,333.12
|
| Rate for Payer: Cash Price |
$36,752.00
|
| Rate for Payer: Cigna Commercial |
$61,008.32
|
| Rate for Payer: First Health Commercial |
$69,828.80
|
| Rate for Payer: Humana Commercial |
$62,478.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,273.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,245.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,051.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,683.52
|
| Rate for Payer: Ohio Health Group HMO |
$55,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,803.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,948.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,717.76
|
| Rate for Payer: PHCS Commercial |
$70,563.84
|
| Rate for Payer: United Healthcare All Payer |
$64,683.52
|
|
|
GFT MAIN BDY BIFR 28*90*120*30
|
Facility
|
OP
|
$73,504.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,051.20 |
| Max. Negotiated Rate |
$70,563.84 |
| Rate for Payer: Aetna Commercial |
$56,598.08
|
| Rate for Payer: Anthem Medicaid |
$25,278.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,333.12
|
| Rate for Payer: Cash Price |
$36,752.00
|
| Rate for Payer: Cigna Commercial |
$61,008.32
|
| Rate for Payer: First Health Commercial |
$69,828.80
|
| Rate for Payer: Humana Commercial |
$62,478.40
|
| Rate for Payer: Humana KY Medicaid |
$25,278.03
|
| Rate for Payer: Kentucky WC Medicaid |
$25,535.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,273.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,245.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,051.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,785.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,683.52
|
| Rate for Payer: Ohio Health Group HMO |
$55,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,803.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,948.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,717.76
|
| Rate for Payer: PHCS Commercial |
$70,563.84
|
| Rate for Payer: United Healthcare All Payer |
$64,683.52
|
|
|
GFT MAIN BDY BIFUR 28*60*16*40
|
Facility
|
IP
|
$73,504.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,051.20 |
| Max. Negotiated Rate |
$70,563.84 |
| Rate for Payer: Aetna Commercial |
$56,598.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,333.12
|
| Rate for Payer: Cash Price |
$36,752.00
|
| Rate for Payer: Cigna Commercial |
$61,008.32
|
| Rate for Payer: First Health Commercial |
$69,828.80
|
| Rate for Payer: Humana Commercial |
$62,478.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,273.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,245.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,051.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,683.52
|
| Rate for Payer: Ohio Health Group HMO |
$55,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,803.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,948.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,717.76
|
| Rate for Payer: PHCS Commercial |
$70,563.84
|
| Rate for Payer: United Healthcare All Payer |
$64,683.52
|
|
|
GFT MAIN BDY BIFUR 28*60*16*40
|
Facility
|
OP
|
$73,504.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,051.20 |
| Max. Negotiated Rate |
$70,563.84 |
| Rate for Payer: Aetna Commercial |
$56,598.08
|
| Rate for Payer: Anthem Medicaid |
$25,278.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,333.12
|
| Rate for Payer: Cash Price |
$36,752.00
|
| Rate for Payer: Cigna Commercial |
$61,008.32
|
| Rate for Payer: First Health Commercial |
$69,828.80
|
| Rate for Payer: Humana Commercial |
$62,478.40
|
| Rate for Payer: Humana KY Medicaid |
$25,278.03
|
| Rate for Payer: Kentucky WC Medicaid |
$25,535.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,273.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,245.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,051.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,785.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,683.52
|
| Rate for Payer: Ohio Health Group HMO |
$55,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,803.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,948.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,717.76
|
| Rate for Payer: PHCS Commercial |
$70,563.84
|
| Rate for Payer: United Healthcare All Payer |
$64,683.52
|
|
|
GFT MAIN BDY BIFUR 28*70*16*30
|
Facility
|
OP
|
$73,504.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,051.20 |
| Max. Negotiated Rate |
$70,563.84 |
| Rate for Payer: Aetna Commercial |
$56,598.08
|
| Rate for Payer: Anthem Medicaid |
$25,278.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,333.12
|
| Rate for Payer: Cash Price |
$36,752.00
|
| Rate for Payer: Cigna Commercial |
$61,008.32
|
| Rate for Payer: First Health Commercial |
$69,828.80
|
| Rate for Payer: Humana Commercial |
$62,478.40
|
| Rate for Payer: Humana KY Medicaid |
$25,278.03
|
| Rate for Payer: Kentucky WC Medicaid |
$25,535.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,273.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,245.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,051.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,785.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,683.52
|
| Rate for Payer: Ohio Health Group HMO |
$55,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,803.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,948.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,717.76
|
| Rate for Payer: PHCS Commercial |
$70,563.84
|
| Rate for Payer: United Healthcare All Payer |
$64,683.52
|
|
|
GFT MAIN BDY BIFUR 28*70*16*30
|
Facility
|
IP
|
$73,504.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,051.20 |
| Max. Negotiated Rate |
$70,563.84 |
| Rate for Payer: Aetna Commercial |
$56,598.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,333.12
|
| Rate for Payer: Cash Price |
$36,752.00
|
| Rate for Payer: Cigna Commercial |
$61,008.32
|
| Rate for Payer: First Health Commercial |
$69,828.80
|
| Rate for Payer: Humana Commercial |
$62,478.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,273.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,245.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,051.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,683.52
|
| Rate for Payer: Ohio Health Group HMO |
$55,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,803.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,948.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,717.76
|
| Rate for Payer: PHCS Commercial |
$70,563.84
|
| Rate for Payer: United Healthcare All Payer |
$64,683.52
|
|
|
GFT MN BDY EXT 36*54 RX13654ZT
|
Facility
|
IP
|
$25,745.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,723.50 |
| Max. Negotiated Rate |
$24,715.20 |
| Rate for Payer: Aetna Commercial |
$19,823.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,081.10
|
| Rate for Payer: Cash Price |
$12,872.50
|
| Rate for Payer: Cigna Commercial |
$21,368.35
|
| Rate for Payer: First Health Commercial |
$24,457.75
|
| Rate for Payer: Humana Commercial |
$21,883.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,110.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,999.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,723.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,655.60
|
| Rate for Payer: Ohio Health Group HMO |
$19,308.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,596.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,398.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,764.05
|
| Rate for Payer: PHCS Commercial |
$24,715.20
|
| Rate for Payer: United Healthcare All Payer |
$22,655.60
|
|
|
GFT MN BDY EXT 36*54 RX13654ZT
|
Facility
|
OP
|
$25,745.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,723.50 |
| Max. Negotiated Rate |
$24,715.20 |
| Rate for Payer: Aetna Commercial |
$19,823.65
|
| Rate for Payer: Anthem Medicaid |
$8,853.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,081.10
|
| Rate for Payer: Cash Price |
$12,872.50
|
| Rate for Payer: Cigna Commercial |
$21,368.35
|
| Rate for Payer: First Health Commercial |
$24,457.75
|
| Rate for Payer: Humana Commercial |
$21,883.25
|
| Rate for Payer: Humana KY Medicaid |
$8,853.71
|
| Rate for Payer: Kentucky WC Medicaid |
$8,943.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,110.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,999.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,723.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,031.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,655.60
|
| Rate for Payer: Ohio Health Group HMO |
$19,308.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,596.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,398.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,764.05
|
| Rate for Payer: PHCS Commercial |
$24,715.20
|
| Rate for Payer: United Healthcare All Payer |
$22,655.60
|
|
|
GFT PROX 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 PROX 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 PROX 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 PROX 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
|
|
