|
GFT PROX 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 PROX 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 PROX EXT TALENT 32*32*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 PROX EXT TALENT 32*32*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 34*34*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 PROX 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
|
|
|
GFT PROX EXT TALENT 36*36*46MM
|
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 36*36*46MM
|
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 38*38*46MM
|
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 38*38*46MM
|
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 40*40*46MM
|
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 40*40*46MM
|
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 42*42*54MM
|
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 42*42*54MM
|
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 44*44*54MM
|
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 44*44*54MM
|
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 46*46*52MM
|
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 46*46*52MM
|
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 TALENT 22MM*22MM*116M
|
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 PROX TALENT 22MM*22MM*116M
|
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 PROX TALENT 24MM*24MM*116M
|
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 PROX TALENT 24MM*24MM*116M
|
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 PROX TALENT 26MM*26MM*116M
|
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 PROX TALENT 26MM*26MM*116M
|
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 PROX TALENT 28MM*28MM*116M
|
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
|
|
