|
GRAFT Z CONVERTRS ESC-24-12-80
|
Facility
|
OP
|
$11,330.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.90 |
| Max. Negotiated Rate |
$10,876.80 |
| Rate for Payer: Aetna Commercial |
$8,724.10
|
| Rate for Payer: Anthem Medicaid |
$3,896.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,837.40
|
| Rate for Payer: Cash Price |
$5,665.00
|
| Rate for Payer: Cigna Commercial |
$9,403.90
|
| Rate for Payer: First Health Commercial |
$10,763.50
|
| Rate for Payer: Humana Commercial |
$9,630.50
|
| Rate for Payer: Humana KY Medicaid |
$3,896.39
|
| Rate for Payer: Kentucky WC Medicaid |
$3,936.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,290.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,361.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,399.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,974.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,970.40
|
| Rate for Payer: Ohio Health Group HMO |
$8,497.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,266.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,472.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.30
|
| Rate for Payer: PHCS Commercial |
$10,876.80
|
| Rate for Payer: United Healthcare All Payer |
$9,970.40
|
|
|
GRAFT Z CONVERTRS ESC-24-12-80
|
Facility
|
IP
|
$11,330.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.90 |
| Max. Negotiated Rate |
$10,876.80 |
| Rate for Payer: Aetna Commercial |
$8,724.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,837.40
|
| Rate for Payer: Cash Price |
$5,665.00
|
| Rate for Payer: Cigna Commercial |
$9,403.90
|
| Rate for Payer: First Health Commercial |
$10,763.50
|
| Rate for Payer: Humana Commercial |
$9,630.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,290.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,361.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,399.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,970.40
|
| Rate for Payer: Ohio Health Group HMO |
$8,497.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,266.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,472.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.30
|
| Rate for Payer: PHCS Commercial |
$10,876.80
|
| Rate for Payer: United Healthcare All Payer |
$9,970.40
|
|
|
GRAFT Z CONVERTRS ESC-28-12-80
|
Facility
|
IP
|
$11,330.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.90 |
| Max. Negotiated Rate |
$10,876.80 |
| Rate for Payer: Aetna Commercial |
$8,724.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,837.40
|
| Rate for Payer: Cash Price |
$5,665.00
|
| Rate for Payer: Cigna Commercial |
$9,403.90
|
| Rate for Payer: First Health Commercial |
$10,763.50
|
| Rate for Payer: Humana Commercial |
$9,630.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,290.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,361.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,399.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,970.40
|
| Rate for Payer: Ohio Health Group HMO |
$8,497.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,266.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,472.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.30
|
| Rate for Payer: PHCS Commercial |
$10,876.80
|
| Rate for Payer: United Healthcare All Payer |
$9,970.40
|
|
|
GRAFT Z CONVERTRS ESC-28-12-80
|
Facility
|
OP
|
$11,330.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.90 |
| Max. Negotiated Rate |
$10,876.80 |
| Rate for Payer: Aetna Commercial |
$8,724.10
|
| Rate for Payer: Anthem Medicaid |
$3,896.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,837.40
|
| Rate for Payer: Cash Price |
$5,665.00
|
| Rate for Payer: Cigna Commercial |
$9,403.90
|
| Rate for Payer: First Health Commercial |
$10,763.50
|
| Rate for Payer: Humana Commercial |
$9,630.50
|
| Rate for Payer: Humana KY Medicaid |
$3,896.39
|
| Rate for Payer: Kentucky WC Medicaid |
$3,936.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,290.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,361.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,399.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,974.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,970.40
|
| Rate for Payer: Ohio Health Group HMO |
$8,497.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,266.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,472.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.30
|
| Rate for Payer: PHCS Commercial |
$10,876.80
|
| Rate for Payer: United Healthcare All Payer |
$9,970.40
|
|
|
GRAFT Z CONVERTRS ESC-32-12-80
|
Facility
|
OP
|
$11,895.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,546.45 |
| Max. Negotiated Rate |
$11,419.92 |
| Rate for Payer: Aetna Commercial |
$9,159.73
|
| Rate for Payer: Anthem Medicaid |
$4,090.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,278.68
|
| Rate for Payer: Cash Price |
$5,947.88
|
| Rate for Payer: Cigna Commercial |
$9,873.47
|
| Rate for Payer: First Health Commercial |
$11,300.96
|
| Rate for Payer: Humana Commercial |
$10,111.39
|
| Rate for Payer: Humana KY Medicaid |
$4,090.95
|
| Rate for Payer: Kentucky WC Medicaid |
$4,132.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,754.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,779.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,568.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,173.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,468.26
|
| Rate for Payer: Ohio Health Group HMO |
$8,921.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,379.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,546.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,687.68
|
| Rate for Payer: PHCS Commercial |
$11,419.92
|
| Rate for Payer: United Healthcare All Payer |
$10,468.26
|
|
|
GRAFT Z CONVERTRS ESC-32-12-80
|
Facility
|
IP
|
$11,895.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,546.45 |
| Max. Negotiated Rate |
$11,419.92 |
| Rate for Payer: Aetna Commercial |
$9,159.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,278.68
|
| Rate for Payer: Cash Price |
$5,947.88
|
| Rate for Payer: Cigna Commercial |
$9,873.47
|
| Rate for Payer: First Health Commercial |
$11,300.96
|
| Rate for Payer: Humana Commercial |
$10,111.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,754.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,779.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,568.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,468.26
|
| Rate for Payer: Ohio Health Group HMO |
$8,921.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,379.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,546.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,687.68
|
| Rate for Payer: PHCS Commercial |
$11,419.92
|
| Rate for Payer: United Healthcare All Payer |
$10,468.26
|
|
|
GRAFT Z CONVRT ESC-36-12-82-ZT
|
Facility
|
OP
|
$11,895.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,546.45 |
| Max. Negotiated Rate |
$11,419.92 |
| Rate for Payer: Aetna Commercial |
$9,159.73
|
| Rate for Payer: Anthem Medicaid |
$4,090.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,278.68
|
| Rate for Payer: Cash Price |
$5,947.88
|
| Rate for Payer: Cigna Commercial |
$9,873.47
|
| Rate for Payer: First Health Commercial |
$11,300.96
|
| Rate for Payer: Humana Commercial |
$10,111.39
|
| Rate for Payer: Humana KY Medicaid |
$4,090.95
|
| Rate for Payer: Kentucky WC Medicaid |
$4,132.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,754.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,779.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,568.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,173.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,468.26
|
| Rate for Payer: Ohio Health Group HMO |
$8,921.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,379.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,546.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,687.68
|
| Rate for Payer: PHCS Commercial |
$11,419.92
|
| Rate for Payer: United Healthcare All Payer |
$10,468.26
|
|
|
GRAFT Z CONVRT ESC-36-12-82-ZT
|
Facility
|
IP
|
$11,895.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,546.45 |
| Max. Negotiated Rate |
$11,419.92 |
| Rate for Payer: Aetna Commercial |
$9,159.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,278.68
|
| Rate for Payer: Cash Price |
$5,947.88
|
| Rate for Payer: Cigna Commercial |
$9,873.47
|
| Rate for Payer: First Health Commercial |
$11,300.96
|
| Rate for Payer: Humana Commercial |
$10,111.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,754.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,779.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,568.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,468.26
|
| Rate for Payer: Ohio Health Group HMO |
$8,921.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,379.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,546.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,687.68
|
| Rate for Payer: PHCS Commercial |
$11,419.92
|
| Rate for Payer: United Healthcare All Payer |
$10,468.26
|
|
|
GRAFT ZENITH FEN DIST 12*45*76
|
Facility
|
OP
|
$18,366.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,387.58 |
| Max. Negotiated Rate |
$17,631.36 |
| Rate for Payer: Aetna Commercial |
$14,141.82
|
| Rate for Payer: Anthem Medicaid |
$6,316.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,325.48
|
| Rate for Payer: Cash Price |
$9,183.00
|
| Rate for Payer: Cigna Commercial |
$15,243.78
|
| Rate for Payer: First Health Commercial |
$17,447.70
|
| Rate for Payer: Humana Commercial |
$15,611.10
|
| Rate for Payer: Humana KY Medicaid |
$6,316.07
|
| Rate for Payer: Kentucky WC Medicaid |
$6,380.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,060.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,554.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,509.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,442.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,162.08
|
| Rate for Payer: Ohio Health Group HMO |
$13,774.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,673.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,387.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,693.46
|
| Rate for Payer: PHCS Commercial |
$17,631.36
|
| Rate for Payer: United Healthcare All Payer |
$16,162.08
|
|
|
GRAFT ZENITH FEN DIST 12*45*76
|
Facility
|
IP
|
$18,366.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,387.58 |
| Max. Negotiated Rate |
$17,631.36 |
| Rate for Payer: Aetna Commercial |
$14,141.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,325.48
|
| Rate for Payer: Cash Price |
$9,183.00
|
| Rate for Payer: Cigna Commercial |
$15,243.78
|
| Rate for Payer: First Health Commercial |
$17,447.70
|
| Rate for Payer: Humana Commercial |
$15,611.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,060.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,554.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,509.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,162.08
|
| Rate for Payer: Ohio Health Group HMO |
$13,774.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,673.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,387.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,693.46
|
| Rate for Payer: PHCS Commercial |
$17,631.36
|
| Rate for Payer: United Healthcare All Payer |
$16,162.08
|
|
|
GRAFT ZENITH FEN DISTAL 12*28*
|
Facility
|
OP
|
$18,366.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,387.58 |
| Max. Negotiated Rate |
$17,631.36 |
| Rate for Payer: Aetna Commercial |
$14,141.82
|
| Rate for Payer: Anthem Medicaid |
$6,316.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,325.48
|
| Rate for Payer: Cash Price |
$9,183.00
|
| Rate for Payer: Cigna Commercial |
$15,243.78
|
| Rate for Payer: First Health Commercial |
$17,447.70
|
| Rate for Payer: Humana Commercial |
$15,611.10
|
| Rate for Payer: Humana KY Medicaid |
$6,316.07
|
| Rate for Payer: Kentucky WC Medicaid |
$6,380.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,060.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,554.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,509.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,442.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,162.08
|
| Rate for Payer: Ohio Health Group HMO |
$13,774.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,673.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,387.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,693.46
|
| Rate for Payer: PHCS Commercial |
$17,631.36
|
| Rate for Payer: United Healthcare All Payer |
$16,162.08
|
|
|
GRAFT ZENITH FEN DISTAL 12*28*
|
Facility
|
IP
|
$18,366.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,387.58 |
| Max. Negotiated Rate |
$17,631.36 |
| Rate for Payer: Aetna Commercial |
$14,141.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,325.48
|
| Rate for Payer: Cash Price |
$9,183.00
|
| Rate for Payer: Cigna Commercial |
$15,243.78
|
| Rate for Payer: First Health Commercial |
$17,447.70
|
| Rate for Payer: Humana Commercial |
$15,611.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,060.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,554.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,509.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,162.08
|
| Rate for Payer: Ohio Health Group HMO |
$13,774.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,673.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,387.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,693.46
|
| Rate for Payer: PHCS Commercial |
$17,631.36
|
| Rate for Payer: United Healthcare All Payer |
$16,162.08
|
|
|
GRAFT ZENITH FEN PROX 2*30*109
|
Facility
|
IP
|
$71,512.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,296.56 |
| Max. Negotiated Rate |
$68,651.52 |
| Rate for Payer: Aetna Commercial |
$55,064.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55,779.36
|
| Rate for Payer: Cash Price |
$35,756.00
|
| Rate for Payer: Cigna Commercial |
$59,354.96
|
| Rate for Payer: First Health Commercial |
$67,936.40
|
| Rate for Payer: Humana Commercial |
$60,785.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58,639.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52,775.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,453.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$62,930.56
|
| Rate for Payer: Ohio Health Group HMO |
$53,634.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,302.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,296.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,168.72
|
| Rate for Payer: PHCS Commercial |
$68,651.52
|
| Rate for Payer: United Healthcare All Payer |
$62,930.56
|
|
|
GRAFT ZENITH FEN PROX 2*30*109
|
Facility
|
OP
|
$71,512.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,296.56 |
| Max. Negotiated Rate |
$68,651.52 |
| Rate for Payer: Aetna Commercial |
$55,064.24
|
| Rate for Payer: Anthem Medicaid |
$24,592.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55,779.36
|
| Rate for Payer: Cash Price |
$35,756.00
|
| Rate for Payer: Cigna Commercial |
$59,354.96
|
| Rate for Payer: First Health Commercial |
$67,936.40
|
| Rate for Payer: Humana Commercial |
$60,785.20
|
| Rate for Payer: Humana KY Medicaid |
$24,592.98
|
| Rate for Payer: Kentucky WC Medicaid |
$24,843.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58,639.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52,775.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,453.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,086.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$62,930.56
|
| Rate for Payer: Ohio Health Group HMO |
$53,634.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,302.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,296.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,168.72
|
| Rate for Payer: PHCS Commercial |
$68,651.52
|
| Rate for Payer: United Healthcare All Payer |
$62,930.56
|
|
|
GRAFT ZENITH FEN PROX 2*32*124
|
Facility
|
OP
|
$70,288.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,137.44 |
| Max. Negotiated Rate |
$67,476.48 |
| Rate for Payer: Aetna Commercial |
$54,121.76
|
| Rate for Payer: Anthem Medicaid |
$24,172.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,824.64
|
| Rate for Payer: Cash Price |
$35,144.00
|
| Rate for Payer: Cigna Commercial |
$58,339.04
|
| Rate for Payer: First Health Commercial |
$66,773.60
|
| Rate for Payer: Humana Commercial |
$59,744.80
|
| Rate for Payer: Humana KY Medicaid |
$24,172.04
|
| Rate for Payer: Kentucky WC Medicaid |
$24,418.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57,636.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,872.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,086.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$24,657.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$61,853.44
|
| Rate for Payer: Ohio Health Group HMO |
$52,716.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,057.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,137.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,789.28
|
| Rate for Payer: PHCS Commercial |
$67,476.48
|
| Rate for Payer: United Healthcare All Payer |
$61,853.44
|
|
|
GRAFT ZENITH FEN PROX 2*32*124
|
Facility
|
IP
|
$70,288.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,137.44 |
| Max. Negotiated Rate |
$67,476.48 |
| Rate for Payer: Aetna Commercial |
$54,121.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,824.64
|
| Rate for Payer: Cash Price |
$35,144.00
|
| Rate for Payer: Cigna Commercial |
$58,339.04
|
| Rate for Payer: First Health Commercial |
$66,773.60
|
| Rate for Payer: Humana Commercial |
$59,744.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57,636.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,872.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,086.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$61,853.44
|
| Rate for Payer: Ohio Health Group HMO |
$52,716.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,057.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,137.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,789.28
|
| Rate for Payer: PHCS Commercial |
$67,476.48
|
| Rate for Payer: United Healthcare All Payer |
$61,853.44
|
|
|
GRAFT Z ILIAC LEG TFLE-10-105
|
Facility
|
IP
|
$14,235.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,850.60 |
| Max. Negotiated Rate |
$13,665.98 |
| Rate for Payer: Aetna Commercial |
$10,961.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,103.61
|
| Rate for Payer: Cash Price |
$7,117.70
|
| Rate for Payer: Cigna Commercial |
$11,815.38
|
| Rate for Payer: First Health Commercial |
$13,523.63
|
| Rate for Payer: Humana Commercial |
$12,100.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,673.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,505.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,270.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,527.15
|
| Rate for Payer: Ohio Health Group HMO |
$10,676.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,847.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,850.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,412.97
|
| Rate for Payer: PHCS Commercial |
$13,665.98
|
| Rate for Payer: United Healthcare All Payer |
$12,527.15
|
|
|
GRAFT Z ILIAC LEG TFLE-10-105
|
Facility
|
OP
|
$14,235.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,850.60 |
| Max. Negotiated Rate |
$13,665.98 |
| Rate for Payer: Aetna Commercial |
$10,961.26
|
| Rate for Payer: Anthem Medicaid |
$4,895.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,103.61
|
| Rate for Payer: Cash Price |
$7,117.70
|
| Rate for Payer: Cigna Commercial |
$11,815.38
|
| Rate for Payer: First Health Commercial |
$13,523.63
|
| Rate for Payer: Humana Commercial |
$12,100.09
|
| Rate for Payer: Humana KY Medicaid |
$4,895.55
|
| Rate for Payer: Kentucky WC Medicaid |
$4,945.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,673.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,505.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,270.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,993.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,527.15
|
| Rate for Payer: Ohio Health Group HMO |
$10,676.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,847.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,850.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,412.97
|
| Rate for Payer: PHCS Commercial |
$13,665.98
|
| Rate for Payer: United Healthcare All Payer |
$12,527.15
|
|
|
GRAFT Z ILIAC LEG TFLE-10-122
|
Facility
|
OP
|
$14,235.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,850.60 |
| Max. Negotiated Rate |
$13,665.98 |
| Rate for Payer: Aetna Commercial |
$10,961.26
|
| Rate for Payer: Anthem Medicaid |
$4,895.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,103.61
|
| Rate for Payer: Cash Price |
$7,117.70
|
| Rate for Payer: Cigna Commercial |
$11,815.38
|
| Rate for Payer: First Health Commercial |
$13,523.63
|
| Rate for Payer: Humana Commercial |
$12,100.09
|
| Rate for Payer: Humana KY Medicaid |
$4,895.55
|
| Rate for Payer: Kentucky WC Medicaid |
$4,945.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,673.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,505.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,270.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,993.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,527.15
|
| Rate for Payer: Ohio Health Group HMO |
$10,676.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,847.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,850.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,412.97
|
| Rate for Payer: PHCS Commercial |
$13,665.98
|
| Rate for Payer: United Healthcare All Payer |
$12,527.15
|
|
|
GRAFT Z ILIAC LEG TFLE-10-122
|
Facility
|
IP
|
$14,235.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,850.60 |
| Max. Negotiated Rate |
$13,665.98 |
| Rate for Payer: Aetna Commercial |
$10,961.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,103.61
|
| Rate for Payer: Cash Price |
$7,117.70
|
| Rate for Payer: Cigna Commercial |
$11,815.38
|
| Rate for Payer: First Health Commercial |
$13,523.63
|
| Rate for Payer: Humana Commercial |
$12,100.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,673.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,505.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,270.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,527.15
|
| Rate for Payer: Ohio Health Group HMO |
$10,676.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,847.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,850.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,412.97
|
| Rate for Payer: PHCS Commercial |
$13,665.98
|
| Rate for Payer: United Healthcare All Payer |
$12,527.15
|
|
|
GRAFT Z ILIAC LEG TFLE-10-37
|
Facility
|
OP
|
$14,235.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,850.60 |
| Max. Negotiated Rate |
$13,665.98 |
| Rate for Payer: Aetna Commercial |
$10,961.26
|
| Rate for Payer: Anthem Medicaid |
$4,895.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,103.61
|
| Rate for Payer: Cash Price |
$7,117.70
|
| Rate for Payer: Cigna Commercial |
$11,815.38
|
| Rate for Payer: First Health Commercial |
$13,523.63
|
| Rate for Payer: Humana Commercial |
$12,100.09
|
| Rate for Payer: Humana KY Medicaid |
$4,895.55
|
| Rate for Payer: Kentucky WC Medicaid |
$4,945.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,673.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,505.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,270.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,993.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,527.15
|
| Rate for Payer: Ohio Health Group HMO |
$10,676.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,847.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,850.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,412.97
|
| Rate for Payer: PHCS Commercial |
$13,665.98
|
| Rate for Payer: United Healthcare All Payer |
$12,527.15
|
|
|
GRAFT Z ILIAC LEG TFLE-10-37
|
Facility
|
IP
|
$14,235.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,850.60 |
| Max. Negotiated Rate |
$13,665.98 |
| Rate for Payer: Aetna Commercial |
$10,961.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,103.61
|
| Rate for Payer: Cash Price |
$7,117.70
|
| Rate for Payer: Cigna Commercial |
$11,815.38
|
| Rate for Payer: First Health Commercial |
$13,523.63
|
| Rate for Payer: Humana Commercial |
$12,100.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,673.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,505.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,270.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,527.15
|
| Rate for Payer: Ohio Health Group HMO |
$10,676.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,847.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,850.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,412.97
|
| Rate for Payer: PHCS Commercial |
$13,665.98
|
| Rate for Payer: United Healthcare All Payer |
$12,527.15
|
|
|
GRAFT Z ILIAC LEG TFLE-10-54
|
Facility
|
IP
|
$14,235.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,850.60 |
| Max. Negotiated Rate |
$13,665.98 |
| Rate for Payer: Aetna Commercial |
$10,961.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,103.61
|
| Rate for Payer: Cash Price |
$7,117.70
|
| Rate for Payer: Cigna Commercial |
$11,815.38
|
| Rate for Payer: First Health Commercial |
$13,523.63
|
| Rate for Payer: Humana Commercial |
$12,100.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,673.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,505.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,270.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,527.15
|
| Rate for Payer: Ohio Health Group HMO |
$10,676.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,847.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,850.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,412.97
|
| Rate for Payer: PHCS Commercial |
$13,665.98
|
| Rate for Payer: United Healthcare All Payer |
$12,527.15
|
|
|
GRAFT Z ILIAC LEG TFLE-10-54
|
Facility
|
OP
|
$14,235.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,850.60 |
| Max. Negotiated Rate |
$13,665.98 |
| Rate for Payer: Aetna Commercial |
$10,961.26
|
| Rate for Payer: Anthem Medicaid |
$4,895.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,103.61
|
| Rate for Payer: Cash Price |
$7,117.70
|
| Rate for Payer: Cigna Commercial |
$11,815.38
|
| Rate for Payer: First Health Commercial |
$13,523.63
|
| Rate for Payer: Humana Commercial |
$12,100.09
|
| Rate for Payer: Humana KY Medicaid |
$4,895.55
|
| Rate for Payer: Kentucky WC Medicaid |
$4,945.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,673.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,505.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,270.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,993.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,527.15
|
| Rate for Payer: Ohio Health Group HMO |
$10,676.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,847.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,850.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,412.97
|
| Rate for Payer: PHCS Commercial |
$13,665.98
|
| Rate for Payer: United Healthcare All Payer |
$12,527.15
|
|
|
GRAFT Z ILIAC LEG TFLE-10-71
|
Facility
|
IP
|
$14,235.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,850.60 |
| Max. Negotiated Rate |
$13,665.98 |
| Rate for Payer: Aetna Commercial |
$10,961.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,103.61
|
| Rate for Payer: Cash Price |
$7,117.70
|
| Rate for Payer: Cigna Commercial |
$11,815.38
|
| Rate for Payer: First Health Commercial |
$13,523.63
|
| Rate for Payer: Humana Commercial |
$12,100.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,673.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,505.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,270.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,527.15
|
| Rate for Payer: Ohio Health Group HMO |
$10,676.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,847.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,850.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,412.97
|
| Rate for Payer: PHCS Commercial |
$13,665.98
|
| Rate for Payer: United Healthcare All Payer |
$12,527.15
|
|
