|
GNS II POROUS P/S FEM SZ 7 RT
|
Facility
|
IP
|
$8,475.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,542.50 |
| Max. Negotiated Rate |
$8,136.00 |
| Rate for Payer: Aetna Commercial |
$6,525.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,610.50
|
| Rate for Payer: Cash Price |
$4,237.50
|
| Rate for Payer: Cigna Commercial |
$7,034.25
|
| Rate for Payer: First Health Commercial |
$8,051.25
|
| Rate for Payer: Humana Commercial |
$7,203.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,949.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,254.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,542.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,458.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,373.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,847.75
|
| Rate for Payer: PHCS Commercial |
$8,136.00
|
| Rate for Payer: United Healthcare All Payer |
$7,458.00
|
|
|
GNS II POROUS P/S FEM SZ 8 RT
|
Facility
|
OP
|
$8,475.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,542.50 |
| Max. Negotiated Rate |
$8,136.00 |
| Rate for Payer: Aetna Commercial |
$6,525.75
|
| Rate for Payer: Anthem Medicaid |
$2,914.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,610.50
|
| Rate for Payer: Cash Price |
$4,237.50
|
| Rate for Payer: Cigna Commercial |
$7,034.25
|
| Rate for Payer: First Health Commercial |
$8,051.25
|
| Rate for Payer: Humana Commercial |
$7,203.75
|
| Rate for Payer: Humana KY Medicaid |
$2,914.55
|
| Rate for Payer: Kentucky WC Medicaid |
$2,944.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,949.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,254.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,542.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,973.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,458.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,373.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,847.75
|
| Rate for Payer: PHCS Commercial |
$8,136.00
|
| Rate for Payer: United Healthcare All Payer |
$7,458.00
|
|
|
GNS II POROUS P/S FEM SZ 8 RT
|
Facility
|
IP
|
$8,475.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,542.50 |
| Max. Negotiated Rate |
$8,136.00 |
| Rate for Payer: Aetna Commercial |
$6,525.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,610.50
|
| Rate for Payer: Cash Price |
$4,237.50
|
| Rate for Payer: Cigna Commercial |
$7,034.25
|
| Rate for Payer: First Health Commercial |
$8,051.25
|
| Rate for Payer: Humana Commercial |
$7,203.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,949.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,254.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,542.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,458.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,373.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,847.75
|
| Rate for Payer: PHCS Commercial |
$8,136.00
|
| Rate for Payer: United Healthcare All Payer |
$7,458.00
|
|
|
GNS II POR TIB SZ 1 LEFT
|
Facility
|
IP
|
$9,458.67
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,837.60 |
| Max. Negotiated Rate |
$9,080.32 |
| Rate for Payer: Aetna Commercial |
$7,283.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,377.76
|
| Rate for Payer: Cash Price |
$4,729.34
|
| Rate for Payer: Cigna Commercial |
$7,850.70
|
| Rate for Payer: First Health Commercial |
$8,985.74
|
| Rate for Payer: Humana Commercial |
$8,039.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,756.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,980.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,837.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,323.63
|
| Rate for Payer: Ohio Health Group HMO |
$7,094.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,566.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,229.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,526.48
|
| Rate for Payer: PHCS Commercial |
$9,080.32
|
| Rate for Payer: United Healthcare All Payer |
$8,323.63
|
|
|
GNS II POR TIB SZ 1 LEFT
|
Facility
|
OP
|
$9,458.67
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,837.60 |
| Max. Negotiated Rate |
$9,080.32 |
| Rate for Payer: Aetna Commercial |
$7,283.18
|
| Rate for Payer: Anthem Medicaid |
$3,252.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,377.76
|
| Rate for Payer: Cash Price |
$4,729.34
|
| Rate for Payer: Cigna Commercial |
$7,850.70
|
| Rate for Payer: First Health Commercial |
$8,985.74
|
| Rate for Payer: Humana Commercial |
$8,039.87
|
| Rate for Payer: Humana KY Medicaid |
$3,252.84
|
| Rate for Payer: Kentucky WC Medicaid |
$3,285.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,756.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,980.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,837.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,318.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,323.63
|
| Rate for Payer: Ohio Health Group HMO |
$7,094.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,566.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,229.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,526.48
|
| Rate for Payer: PHCS Commercial |
$9,080.32
|
| Rate for Payer: United Healthcare All Payer |
$8,323.63
|
|
|
GNS II POR TIB SZ 1 RIGHT
|
Facility
|
OP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem Medicaid |
$2,900.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Humana KY Medicaid |
$2,900.12
|
| Rate for Payer: Kentucky WC Medicaid |
$2,929.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,958.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
|
GNS II POR TIB SZ 1 RIGHT
|
Facility
|
IP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
|
GNS II POR TIB SZ 2 LEFT
|
Facility
|
IP
|
$9,458.67
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,837.60 |
| Max. Negotiated Rate |
$9,080.32 |
| Rate for Payer: Aetna Commercial |
$7,283.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,377.76
|
| Rate for Payer: Cash Price |
$4,729.34
|
| Rate for Payer: Cigna Commercial |
$7,850.70
|
| Rate for Payer: First Health Commercial |
$8,985.74
|
| Rate for Payer: Humana Commercial |
$8,039.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,756.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,980.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,837.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,323.63
|
| Rate for Payer: Ohio Health Group HMO |
$7,094.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,566.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,229.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,526.48
|
| Rate for Payer: PHCS Commercial |
$9,080.32
|
| Rate for Payer: United Healthcare All Payer |
$8,323.63
|
|
|
GNS II POR TIB SZ 2 LEFT
|
Facility
|
OP
|
$9,458.67
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,837.60 |
| Max. Negotiated Rate |
$9,080.32 |
| Rate for Payer: Aetna Commercial |
$7,283.18
|
| Rate for Payer: Anthem Medicaid |
$3,252.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,377.76
|
| Rate for Payer: Cash Price |
$4,729.34
|
| Rate for Payer: Cigna Commercial |
$7,850.70
|
| Rate for Payer: First Health Commercial |
$8,985.74
|
| Rate for Payer: Humana Commercial |
$8,039.87
|
| Rate for Payer: Humana KY Medicaid |
$3,252.84
|
| Rate for Payer: Kentucky WC Medicaid |
$3,285.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,756.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,980.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,837.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,318.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,323.63
|
| Rate for Payer: Ohio Health Group HMO |
$7,094.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,566.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,229.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,526.48
|
| Rate for Payer: PHCS Commercial |
$9,080.32
|
| Rate for Payer: United Healthcare All Payer |
$8,323.63
|
|
|
GNS II POR TIB SZ 2 RIGHT
|
Facility
|
OP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem Medicaid |
$2,900.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Humana KY Medicaid |
$2,900.12
|
| Rate for Payer: Kentucky WC Medicaid |
$2,929.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,958.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
|
GNS II POR TIB SZ 2 RIGHT
|
Facility
|
IP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
|
GNS II POR TIB SZ 3 LEFT
|
Facility
|
IP
|
$9,458.67
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,837.60 |
| Max. Negotiated Rate |
$9,080.32 |
| Rate for Payer: Aetna Commercial |
$7,283.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,377.76
|
| Rate for Payer: Cash Price |
$4,729.34
|
| Rate for Payer: Cigna Commercial |
$7,850.70
|
| Rate for Payer: First Health Commercial |
$8,985.74
|
| Rate for Payer: Humana Commercial |
$8,039.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,756.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,980.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,837.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,323.63
|
| Rate for Payer: Ohio Health Group HMO |
$7,094.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,566.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,229.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,526.48
|
| Rate for Payer: PHCS Commercial |
$9,080.32
|
| Rate for Payer: United Healthcare All Payer |
$8,323.63
|
|
|
GNS II POR TIB SZ 3 LEFT
|
Facility
|
OP
|
$9,458.67
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,837.60 |
| Max. Negotiated Rate |
$9,080.32 |
| Rate for Payer: Aetna Commercial |
$7,283.18
|
| Rate for Payer: Anthem Medicaid |
$3,252.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,377.76
|
| Rate for Payer: Cash Price |
$4,729.34
|
| Rate for Payer: Cigna Commercial |
$7,850.70
|
| Rate for Payer: First Health Commercial |
$8,985.74
|
| Rate for Payer: Humana Commercial |
$8,039.87
|
| Rate for Payer: Humana KY Medicaid |
$3,252.84
|
| Rate for Payer: Kentucky WC Medicaid |
$3,285.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,756.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,980.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,837.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,318.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,323.63
|
| Rate for Payer: Ohio Health Group HMO |
$7,094.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,566.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,229.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,526.48
|
| Rate for Payer: PHCS Commercial |
$9,080.32
|
| Rate for Payer: United Healthcare All Payer |
$8,323.63
|
|
|
GNS II POR TIB SZ 3 RIGHT
|
Facility
|
OP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem Medicaid |
$2,900.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Humana KY Medicaid |
$2,900.12
|
| Rate for Payer: Kentucky WC Medicaid |
$2,929.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,958.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
|
GNS II POR TIB SZ 3 RIGHT
|
Facility
|
IP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
|
GNS II POR TIB SZ 4 LEFT
|
Facility
|
OP
|
$9,458.67
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,837.60 |
| Max. Negotiated Rate |
$9,080.32 |
| Rate for Payer: Aetna Commercial |
$7,283.18
|
| Rate for Payer: Anthem Medicaid |
$3,252.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,377.76
|
| Rate for Payer: Cash Price |
$4,729.34
|
| Rate for Payer: Cigna Commercial |
$7,850.70
|
| Rate for Payer: First Health Commercial |
$8,985.74
|
| Rate for Payer: Humana Commercial |
$8,039.87
|
| Rate for Payer: Humana KY Medicaid |
$3,252.84
|
| Rate for Payer: Kentucky WC Medicaid |
$3,285.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,756.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,980.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,837.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,318.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,323.63
|
| Rate for Payer: Ohio Health Group HMO |
$7,094.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,566.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,229.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,526.48
|
| Rate for Payer: PHCS Commercial |
$9,080.32
|
| Rate for Payer: United Healthcare All Payer |
$8,323.63
|
|
|
GNS II POR TIB SZ 4 LEFT
|
Facility
|
IP
|
$9,458.67
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,837.60 |
| Max. Negotiated Rate |
$9,080.32 |
| Rate for Payer: Aetna Commercial |
$7,283.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,377.76
|
| Rate for Payer: Cash Price |
$4,729.34
|
| Rate for Payer: Cigna Commercial |
$7,850.70
|
| Rate for Payer: First Health Commercial |
$8,985.74
|
| Rate for Payer: Humana Commercial |
$8,039.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,756.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,980.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,837.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,323.63
|
| Rate for Payer: Ohio Health Group HMO |
$7,094.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,566.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,229.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,526.48
|
| Rate for Payer: PHCS Commercial |
$9,080.32
|
| Rate for Payer: United Healthcare All Payer |
$8,323.63
|
|
|
GNS II POR TIB SZ 4 RIGHT
|
Facility
|
OP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem Medicaid |
$2,900.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Humana KY Medicaid |
$2,900.12
|
| Rate for Payer: Kentucky WC Medicaid |
$2,929.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,958.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
|
GNS II POR TIB SZ 4 RIGHT
|
Facility
|
IP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
|
GNS II POR TIB SZ 5 LEFT
|
Facility
|
OP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem Medicaid |
$2,900.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Humana KY Medicaid |
$2,900.12
|
| Rate for Payer: Kentucky WC Medicaid |
$2,929.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,958.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
|
GNS II POR TIB SZ 5 LEFT
|
Facility
|
IP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
|
GNS II POR TIB SZ 5 RIGHT
|
Facility
|
OP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem Medicaid |
$2,900.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Humana KY Medicaid |
$2,900.12
|
| Rate for Payer: Kentucky WC Medicaid |
$2,929.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,958.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
|
GNS II POR TIB SZ 5 RIGHT
|
Facility
|
IP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
|
GNS II POR TIB SZ 6 LEFT
|
Facility
|
IP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
|
GNS II POR TIB SZ 6 LEFT
|
Facility
|
OP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem Medicaid |
$2,900.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Humana KY Medicaid |
$2,900.12
|
| Rate for Payer: Kentucky WC Medicaid |
$2,929.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,958.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
