|
GRAFT ILIAC LMB OVTN 14*22*140
|
Facility
|
IP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GRAFT ILIAC LMB OVTN 14*22*140
|
Facility
|
OP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem Medicaid |
$6,671.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Humana KY Medicaid |
$6,671.66
|
| Rate for Payer: Kentucky WC Medicaid |
$6,739.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,805.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GRAFT ILIAC LMB OVTN 14*22*80
|
Facility
|
OP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem Medicaid |
$6,671.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Humana KY Medicaid |
$6,671.66
|
| Rate for Payer: Kentucky WC Medicaid |
$6,739.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,805.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GRAFT ILIAC LMB OVTN 14*22*80
|
Facility
|
IP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GRAFT ILIAC LMB OVTN IX 14*10*
|
Facility
|
OP
|
$21,531.60
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,799.11 |
| Max. Negotiated Rate |
$20,670.34 |
| Rate for Payer: Aetna Commercial |
$16,579.33
|
| Rate for Payer: Aetna Commercial |
$19,713.04
|
| Rate for Payer: Anthem Medicaid |
$7,404.72
|
| Rate for Payer: Anthem Medicaid |
$8,804.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,794.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,969.05
|
| Rate for Payer: Cash Price |
$10,765.80
|
| Rate for Payer: Cash Price |
$12,800.67
|
| Rate for Payer: Cigna Commercial |
$21,249.12
|
| Rate for Payer: Cigna Commercial |
$17,871.23
|
| Rate for Payer: First Health Commercial |
$24,321.28
|
| Rate for Payer: First Health Commercial |
$20,455.02
|
| Rate for Payer: Humana Commercial |
$18,301.86
|
| Rate for Payer: Humana Commercial |
$21,761.15
|
| Rate for Payer: Humana KY Medicaid |
$7,404.72
|
| Rate for Payer: Humana KY Medicaid |
$8,804.30
|
| Rate for Payer: Kentucky WC Medicaid |
$8,893.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7,480.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,655.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,993.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,893.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,890.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,680.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,459.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,553.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,980.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,947.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,529.19
|
| Rate for Payer: Ohio Health Group HMO |
$16,148.70
|
| Rate for Payer: Ohio Health Group HMO |
$19,201.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,306.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,120.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,799.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,328.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,674.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,936.42
|
| Rate for Payer: PHCS Commercial |
$24,577.30
|
| Rate for Payer: PHCS Commercial |
$20,670.34
|
| Rate for Payer: United Healthcare All Payer |
$22,529.19
|
| Rate for Payer: United Healthcare All Payer |
$18,947.81
|
|
|
GRAFT ILIAC LMB OVTN IX 14*10*
|
Facility
|
IP
|
$21,531.60
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,799.11 |
| Max. Negotiated Rate |
$20,670.34 |
| Rate for Payer: Aetna Commercial |
$16,579.33
|
| Rate for Payer: Aetna Commercial |
$19,713.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,794.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,969.05
|
| Rate for Payer: Cash Price |
$10,765.80
|
| Rate for Payer: Cash Price |
$12,800.67
|
| Rate for Payer: Cigna Commercial |
$17,871.23
|
| Rate for Payer: Cigna Commercial |
$21,249.12
|
| Rate for Payer: First Health Commercial |
$24,321.28
|
| Rate for Payer: First Health Commercial |
$20,455.02
|
| Rate for Payer: Humana Commercial |
$21,761.15
|
| Rate for Payer: Humana Commercial |
$18,301.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,655.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,993.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,890.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,893.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,680.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,459.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,947.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,529.19
|
| Rate for Payer: Ohio Health Group HMO |
$16,148.70
|
| Rate for Payer: Ohio Health Group HMO |
$19,201.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,306.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,120.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,799.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,328.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,936.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,674.80
|
| Rate for Payer: PHCS Commercial |
$20,670.34
|
| Rate for Payer: PHCS Commercial |
$24,577.30
|
| Rate for Payer: United Healthcare All Payer |
$18,947.81
|
| Rate for Payer: United Healthcare All Payer |
$22,529.19
|
|
|
GRAFT ILIAC LMB OVTN IX 14*12*
|
Facility
|
IP
|
$21,531.60
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,799.11 |
| Max. Negotiated Rate |
$20,670.34 |
| Rate for Payer: Aetna Commercial |
$16,579.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,794.65
|
| Rate for Payer: Cash Price |
$10,765.80
|
| Rate for Payer: Cigna Commercial |
$17,871.23
|
| Rate for Payer: First Health Commercial |
$20,455.02
|
| Rate for Payer: Humana Commercial |
$18,301.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,655.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,890.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,459.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,947.81
|
| Rate for Payer: Ohio Health Group HMO |
$16,148.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,306.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,799.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,674.80
|
| Rate for Payer: PHCS Commercial |
$20,670.34
|
| Rate for Payer: United Healthcare All Payer |
$18,947.81
|
|
|
GRAFT ILIAC LMB OVTN IX 14*12*
|
Facility
|
OP
|
$21,531.60
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,799.11 |
| Max. Negotiated Rate |
$20,670.34 |
| Rate for Payer: Aetna Commercial |
$16,579.33
|
| Rate for Payer: Anthem Medicaid |
$7,404.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,794.65
|
| Rate for Payer: Cash Price |
$10,765.80
|
| Rate for Payer: Cigna Commercial |
$17,871.23
|
| Rate for Payer: First Health Commercial |
$20,455.02
|
| Rate for Payer: Humana Commercial |
$18,301.86
|
| Rate for Payer: Humana KY Medicaid |
$7,404.72
|
| Rate for Payer: Kentucky WC Medicaid |
$7,480.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,655.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,890.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,459.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,553.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,947.81
|
| Rate for Payer: Ohio Health Group HMO |
$16,148.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,306.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,799.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,674.80
|
| Rate for Payer: PHCS Commercial |
$20,670.34
|
| Rate for Payer: United Healthcare All Payer |
$18,947.81
|
|
|
GRAFT ILIAC LMB OVTN IX 14*14*
|
Facility
|
IP
|
$25,601.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,328.18 |
| Max. Negotiated Rate |
$24,577.30 |
| Rate for Payer: Aetna Commercial |
$19,713.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,969.05
|
| Rate for Payer: Cash Price |
$12,800.67
|
| Rate for Payer: Cigna Commercial |
$21,249.12
|
| Rate for Payer: First Health Commercial |
$24,321.28
|
| Rate for Payer: Humana Commercial |
$21,761.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,993.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,893.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,680.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,529.19
|
| Rate for Payer: Ohio Health Group HMO |
$19,201.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,120.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,328.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,936.42
|
| Rate for Payer: PHCS Commercial |
$24,577.30
|
| Rate for Payer: United Healthcare All Payer |
$22,529.19
|
|
|
GRAFT ILIAC LMB OVTN IX 14*14*
|
Facility
|
OP
|
$25,601.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,328.18 |
| Max. Negotiated Rate |
$24,577.30 |
| Rate for Payer: Aetna Commercial |
$19,713.04
|
| Rate for Payer: Anthem Medicaid |
$8,804.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,969.05
|
| Rate for Payer: Cash Price |
$12,800.67
|
| Rate for Payer: Cigna Commercial |
$21,249.12
|
| Rate for Payer: First Health Commercial |
$24,321.28
|
| Rate for Payer: Humana Commercial |
$21,761.15
|
| Rate for Payer: Humana KY Medicaid |
$8,804.30
|
| Rate for Payer: Kentucky WC Medicaid |
$8,893.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,993.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,893.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,680.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,980.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,529.19
|
| Rate for Payer: Ohio Health Group HMO |
$19,201.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,120.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,328.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,936.42
|
| Rate for Payer: PHCS Commercial |
$24,577.30
|
| Rate for Payer: United Healthcare All Payer |
$22,529.19
|
|
|
GRAFT ILIAC LMB OVTN IX 14*16*
|
Facility
|
IP
|
$25,601.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,328.18 |
| Max. Negotiated Rate |
$24,577.30 |
| Rate for Payer: Aetna Commercial |
$19,713.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,969.05
|
| Rate for Payer: Cash Price |
$12,800.67
|
| Rate for Payer: Cigna Commercial |
$21,249.12
|
| Rate for Payer: First Health Commercial |
$24,321.28
|
| Rate for Payer: Humana Commercial |
$21,761.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,993.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,893.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,680.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,529.19
|
| Rate for Payer: Ohio Health Group HMO |
$19,201.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,120.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,328.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,936.42
|
| Rate for Payer: PHCS Commercial |
$24,577.30
|
| Rate for Payer: United Healthcare All Payer |
$22,529.19
|
|
|
GRAFT ILIAC LMB OVTN IX 14*16*
|
Facility
|
OP
|
$25,601.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,328.18 |
| Max. Negotiated Rate |
$24,577.30 |
| Rate for Payer: Aetna Commercial |
$19,713.04
|
| Rate for Payer: Anthem Medicaid |
$8,804.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,969.05
|
| Rate for Payer: Cash Price |
$12,800.67
|
| Rate for Payer: Cigna Commercial |
$21,249.12
|
| Rate for Payer: First Health Commercial |
$24,321.28
|
| Rate for Payer: Humana Commercial |
$21,761.15
|
| Rate for Payer: Humana KY Medicaid |
$8,804.30
|
| Rate for Payer: Kentucky WC Medicaid |
$8,893.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,993.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,893.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,680.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,980.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,529.19
|
| Rate for Payer: Ohio Health Group HMO |
$19,201.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,120.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,328.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,936.42
|
| Rate for Payer: PHCS Commercial |
$24,577.30
|
| Rate for Payer: United Healthcare All Payer |
$22,529.19
|
|
|
GRAFT ILIAC LMB OVTN P 14*14*1
|
Facility
|
OP
|
$25,601.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,328.18 |
| Max. Negotiated Rate |
$24,577.30 |
| Rate for Payer: Aetna Commercial |
$19,713.04
|
| Rate for Payer: Anthem Medicaid |
$8,804.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,969.05
|
| Rate for Payer: Cash Price |
$12,800.67
|
| Rate for Payer: Cigna Commercial |
$21,249.12
|
| Rate for Payer: First Health Commercial |
$24,321.28
|
| Rate for Payer: Humana Commercial |
$21,761.15
|
| Rate for Payer: Humana KY Medicaid |
$8,804.30
|
| Rate for Payer: Kentucky WC Medicaid |
$8,893.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,993.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,893.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,680.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,980.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,529.19
|
| Rate for Payer: Ohio Health Group HMO |
$19,201.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,120.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,328.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,936.42
|
| Rate for Payer: PHCS Commercial |
$24,577.30
|
| Rate for Payer: United Healthcare All Payer |
$22,529.19
|
|
|
GRAFT ILIAC LMB OVTN P 14*14*1
|
Facility
|
IP
|
$25,601.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,328.18 |
| Max. Negotiated Rate |
$24,577.30 |
| Rate for Payer: Aetna Commercial |
$19,713.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,969.05
|
| Rate for Payer: Cash Price |
$12,800.67
|
| Rate for Payer: Cigna Commercial |
$21,249.12
|
| Rate for Payer: First Health Commercial |
$24,321.28
|
| Rate for Payer: Humana Commercial |
$21,761.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,993.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,893.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,680.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,529.19
|
| Rate for Payer: Ohio Health Group HMO |
$19,201.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,120.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,328.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,936.42
|
| Rate for Payer: PHCS Commercial |
$24,577.30
|
| Rate for Payer: United Healthcare All Payer |
$22,529.19
|
|
|
GRAFT ILI LMB OVTN 14*18*100-C
|
Facility
|
OP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem Medicaid |
$6,671.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Humana KY Medicaid |
$6,671.66
|
| Rate for Payer: Kentucky WC Medicaid |
$6,739.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,805.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GRAFT ILI LMB OVTN 14*18*100-C
|
Facility
|
IP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GRAFT ILI LMB OVTN 14*18*100-J
|
Facility
|
OP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem Medicaid |
$6,671.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Humana KY Medicaid |
$6,671.66
|
| Rate for Payer: Kentucky WC Medicaid |
$6,739.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,805.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GRAFT ILI LMB OVTN 14*18*100-J
|
Facility
|
IP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS, AND/OR LEGS; 50 CC OR LESS INJECTATE
|
Facility
|
OP
|
$4,343.37
|
|
|
Service Code
|
CPT 15771
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,102.41 |
| Max. Negotiated Rate |
$4,343.37 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,102.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,343.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,188.25
|
| Rate for Payer: Humana Medicare Advantage |
$3,102.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.89
|
|
|
GRAFT INTERING 4-7X45CM
|
Facility
|
OP
|
$4,338.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$564.00 |
| Max. Negotiated Rate |
$4,164.96 |
| Rate for Payer: Aetna Commercial |
$3,340.64
|
| Rate for Payer: Anthem Medicaid |
$1,492.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,384.03
|
| Rate for Payer: Cash Price |
$2,169.25
|
| Rate for Payer: Cigna Commercial |
$3,600.96
|
| Rate for Payer: First Health Commercial |
$4,121.58
|
| Rate for Payer: Humana Commercial |
$3,687.72
|
| Rate for Payer: Humana KY Medicaid |
$1,492.01
|
| Rate for Payer: Kentucky WC Medicaid |
$1,507.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,557.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,201.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,301.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,521.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,817.88
|
| Rate for Payer: Ohio Health Group HMO |
$3,253.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$867.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$564.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,344.94
|
| Rate for Payer: PHCS Commercial |
$4,164.96
|
| Rate for Payer: United Healthcare All Payer |
$3,817.88
|
|
|
GRAFT INTERING 4-7X45CM
|
Facility
|
IP
|
$4,338.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$564.00 |
| Max. Negotiated Rate |
$4,164.96 |
| Rate for Payer: Aetna Commercial |
$3,340.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,384.03
|
| Rate for Payer: Cash Price |
$2,169.25
|
| Rate for Payer: Cigna Commercial |
$3,600.96
|
| Rate for Payer: First Health Commercial |
$4,121.58
|
| Rate for Payer: Humana Commercial |
$3,687.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,557.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,201.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,301.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,817.88
|
| Rate for Payer: Ohio Health Group HMO |
$3,253.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$867.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$564.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,344.94
|
| Rate for Payer: PHCS Commercial |
$4,164.96
|
| Rate for Payer: United Healthcare All Payer |
$3,817.88
|
|
|
GRAFT INTUITRAK BI 22-13-100BL
|
Facility
|
IP
|
$70,162.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,121.06 |
| Max. Negotiated Rate |
$67,355.52 |
| Rate for Payer: Aetna Commercial |
$54,024.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,726.36
|
| Rate for Payer: Cash Price |
$35,081.00
|
| Rate for Payer: Cigna Commercial |
$58,234.46
|
| Rate for Payer: First Health Commercial |
$66,653.90
|
| Rate for Payer: Humana Commercial |
$59,637.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57,532.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,779.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,048.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$61,742.56
|
| Rate for Payer: Ohio Health Group HMO |
$52,621.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,032.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,121.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,750.22
|
| Rate for Payer: PHCS Commercial |
$67,355.52
|
| Rate for Payer: United Healthcare All Payer |
$61,742.56
|
|
|
GRAFT INTUITRAK BI 22-13-100BL
|
Facility
|
OP
|
$70,162.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,121.06 |
| Max. Negotiated Rate |
$67,355.52 |
| Rate for Payer: Aetna Commercial |
$54,024.74
|
| Rate for Payer: Anthem Medicaid |
$24,128.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,726.36
|
| Rate for Payer: Cash Price |
$35,081.00
|
| Rate for Payer: Cigna Commercial |
$58,234.46
|
| Rate for Payer: First Health Commercial |
$66,653.90
|
| Rate for Payer: Humana Commercial |
$59,637.70
|
| Rate for Payer: Humana KY Medicaid |
$24,128.71
|
| Rate for Payer: Kentucky WC Medicaid |
$24,374.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57,532.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,779.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,048.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$24,612.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$61,742.56
|
| Rate for Payer: Ohio Health Group HMO |
$52,621.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,032.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,121.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,750.22
|
| Rate for Payer: PHCS Commercial |
$67,355.52
|
| Rate for Payer: United Healthcare All Payer |
$61,742.56
|
|
|
GRAFT INTUITRAK BI 22-13-120BL
|
Facility
|
IP
|
$70,162.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,121.06 |
| Max. Negotiated Rate |
$67,355.52 |
| Rate for Payer: Aetna Commercial |
$54,024.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,726.36
|
| Rate for Payer: Cash Price |
$35,081.00
|
| Rate for Payer: Cigna Commercial |
$58,234.46
|
| Rate for Payer: First Health Commercial |
$66,653.90
|
| Rate for Payer: Humana Commercial |
$59,637.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57,532.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,779.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,048.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$61,742.56
|
| Rate for Payer: Ohio Health Group HMO |
$52,621.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,032.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,121.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,750.22
|
| Rate for Payer: PHCS Commercial |
$67,355.52
|
| Rate for Payer: United Healthcare All Payer |
$61,742.56
|
|
|
GRAFT INTUITRAK BI 22-13-120BL
|
Facility
|
OP
|
$70,162.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,121.06 |
| Max. Negotiated Rate |
$67,355.52 |
| Rate for Payer: Aetna Commercial |
$54,024.74
|
| Rate for Payer: Anthem Medicaid |
$24,128.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,726.36
|
| Rate for Payer: Cash Price |
$35,081.00
|
| Rate for Payer: Cigna Commercial |
$58,234.46
|
| Rate for Payer: First Health Commercial |
$66,653.90
|
| Rate for Payer: Humana Commercial |
$59,637.70
|
| Rate for Payer: Humana KY Medicaid |
$24,128.71
|
| Rate for Payer: Kentucky WC Medicaid |
$24,374.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57,532.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,779.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,048.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$24,612.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$61,742.56
|
| Rate for Payer: Ohio Health Group HMO |
$52,621.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,032.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,121.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,750.22
|
| Rate for Payer: PHCS Commercial |
$67,355.52
|
| Rate for Payer: United Healthcare All Payer |
$61,742.56
|
|
