|
GFT PROX TALENT 28MM*28MM*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 30MM*30MM*115M
|
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 30MM*30MM*115M
|
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 32MM*32MM*115M
|
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 32MM*32MM*115M
|
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 34MM*34MM*115M
|
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 34MM*34MM*115M
|
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 36MM*36MM*114M
|
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 36MM*36MM*114M
|
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 38MM*38MM*114M
|
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 38MM*38MM*114M
|
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 40MM*40MM*114M
|
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 40MM*40MM*114M
|
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 42MM*42MM*113M
|
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 42MM*42MM*113M
|
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 44MM*44MM*113M
|
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 44MM*44MM*113M
|
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 46MM*46MM*112M
|
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 46MM*46MM*112M
|
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 Z DISTAL ZTEG-2D-28-127-US
|
Facility
|
IP
|
$28,250.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,475.00 |
| Max. Negotiated Rate |
$27,120.00 |
| Rate for Payer: Aetna Commercial |
$21,752.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,035.00
|
| Rate for Payer: Cash Price |
$14,125.00
|
| Rate for Payer: Cigna Commercial |
$23,447.50
|
| Rate for Payer: First Health Commercial |
$26,837.50
|
| Rate for Payer: Humana Commercial |
$24,012.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,165.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,848.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,475.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$24,860.00
|
| Rate for Payer: Ohio Health Group HMO |
$21,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,577.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,492.50
|
| Rate for Payer: PHCS Commercial |
$27,120.00
|
| Rate for Payer: United Healthcare All Payer |
$24,860.00
|
|
|
GFT Z DISTAL ZTEG-2D-28-127-US
|
Facility
|
OP
|
$28,250.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,475.00 |
| Max. Negotiated Rate |
$27,120.00 |
| Rate for Payer: Aetna Commercial |
$21,752.50
|
| Rate for Payer: Anthem Medicaid |
$9,715.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,035.00
|
| Rate for Payer: Cash Price |
$14,125.00
|
| Rate for Payer: Cigna Commercial |
$23,447.50
|
| Rate for Payer: First Health Commercial |
$26,837.50
|
| Rate for Payer: Humana Commercial |
$24,012.50
|
| Rate for Payer: Humana KY Medicaid |
$9,715.17
|
| Rate for Payer: Kentucky WC Medicaid |
$9,814.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,165.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,848.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,475.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,910.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$24,860.00
|
| Rate for Payer: Ohio Health Group HMO |
$21,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,577.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,492.50
|
| Rate for Payer: PHCS Commercial |
$27,120.00
|
| Rate for Payer: United Healthcare All Payer |
$24,860.00
|
|
|
GFT Z DISTAL ZTEG-2D-28-147-US
|
Facility
|
IP
|
$28,250.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,475.00 |
| Max. Negotiated Rate |
$27,120.00 |
| Rate for Payer: Aetna Commercial |
$21,752.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,035.00
|
| Rate for Payer: Cash Price |
$14,125.00
|
| Rate for Payer: Cigna Commercial |
$23,447.50
|
| Rate for Payer: First Health Commercial |
$26,837.50
|
| Rate for Payer: Humana Commercial |
$24,012.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,165.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,848.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,475.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$24,860.00
|
| Rate for Payer: Ohio Health Group HMO |
$21,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,577.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,492.50
|
| Rate for Payer: PHCS Commercial |
$27,120.00
|
| Rate for Payer: United Healthcare All Payer |
$24,860.00
|
|
|
GFT Z DISTAL ZTEG-2D-28-147-US
|
Facility
|
OP
|
$28,250.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,475.00 |
| Max. Negotiated Rate |
$27,120.00 |
| Rate for Payer: Aetna Commercial |
$21,752.50
|
| Rate for Payer: Anthem Medicaid |
$9,715.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,035.00
|
| Rate for Payer: Cash Price |
$14,125.00
|
| Rate for Payer: Cigna Commercial |
$23,447.50
|
| Rate for Payer: First Health Commercial |
$26,837.50
|
| Rate for Payer: Humana Commercial |
$24,012.50
|
| Rate for Payer: Humana KY Medicaid |
$9,715.17
|
| Rate for Payer: Kentucky WC Medicaid |
$9,814.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,165.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,848.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,475.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,910.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$24,860.00
|
| Rate for Payer: Ohio Health Group HMO |
$21,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,577.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,492.50
|
| Rate for Payer: PHCS Commercial |
$27,120.00
|
| Rate for Payer: United Healthcare All Payer |
$24,860.00
|
|
|
GFT Z DISTAL ZTEG-2D-28-207-US
|
Facility
|
IP
|
$28,250.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,475.00 |
| Max. Negotiated Rate |
$27,120.00 |
| Rate for Payer: Aetna Commercial |
$21,752.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,035.00
|
| Rate for Payer: Cash Price |
$14,125.00
|
| Rate for Payer: Cigna Commercial |
$23,447.50
|
| Rate for Payer: First Health Commercial |
$26,837.50
|
| Rate for Payer: Humana Commercial |
$24,012.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,165.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,848.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,475.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$24,860.00
|
| Rate for Payer: Ohio Health Group HMO |
$21,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,577.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,492.50
|
| Rate for Payer: PHCS Commercial |
$27,120.00
|
| Rate for Payer: United Healthcare All Payer |
$24,860.00
|
|
|
GFT Z DISTAL ZTEG-2D-28-207-US
|
Facility
|
OP
|
$28,250.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,475.00 |
| Max. Negotiated Rate |
$27,120.00 |
| Rate for Payer: Aetna Commercial |
$21,752.50
|
| Rate for Payer: Anthem Medicaid |
$9,715.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,035.00
|
| Rate for Payer: Cash Price |
$14,125.00
|
| Rate for Payer: Cigna Commercial |
$23,447.50
|
| Rate for Payer: First Health Commercial |
$26,837.50
|
| Rate for Payer: Humana Commercial |
$24,012.50
|
| Rate for Payer: Humana KY Medicaid |
$9,715.17
|
| Rate for Payer: Kentucky WC Medicaid |
$9,814.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,165.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,848.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,475.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,910.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$24,860.00
|
| Rate for Payer: Ohio Health Group HMO |
$21,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,577.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,492.50
|
| Rate for Payer: PHCS Commercial |
$27,120.00
|
| Rate for Payer: United Healthcare All Payer |
$24,860.00
|
|
