|
GRAFT Z ILIAC LEG TFLE-16-54
|
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-16-54
|
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-16-71
|
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
|
|
|
GRAFT Z ILIAC LEG TFLE-16-71
|
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-16-88
|
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-16-88
|
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-18-37
|
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-18-37
|
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-18-54
|
Facility
|
IP
|
$13,753.60
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,787.97 |
| Max. Negotiated Rate |
$13,203.46 |
| Rate for Payer: Aetna Commercial |
$10,590.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,727.81
|
| Rate for Payer: Cash Price |
$6,876.80
|
| Rate for Payer: Cigna Commercial |
$11,415.49
|
| Rate for Payer: First Health Commercial |
$13,065.92
|
| Rate for Payer: Humana Commercial |
$11,690.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,277.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,150.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,126.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,103.17
|
| Rate for Payer: Ohio Health Group HMO |
$10,315.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,750.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,787.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,263.62
|
| Rate for Payer: PHCS Commercial |
$13,203.46
|
| Rate for Payer: United Healthcare All Payer |
$12,103.17
|
|
|
GRAFT Z ILIAC LEG TFLE-18-54
|
Facility
|
OP
|
$13,753.60
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,787.97 |
| Max. Negotiated Rate |
$13,203.46 |
| Rate for Payer: Aetna Commercial |
$10,590.27
|
| Rate for Payer: Anthem Medicaid |
$4,729.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,727.81
|
| Rate for Payer: Cash Price |
$6,876.80
|
| Rate for Payer: Cigna Commercial |
$11,415.49
|
| Rate for Payer: First Health Commercial |
$13,065.92
|
| Rate for Payer: Humana Commercial |
$11,690.56
|
| Rate for Payer: Humana KY Medicaid |
$4,729.86
|
| Rate for Payer: Kentucky WC Medicaid |
$4,778.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,277.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,150.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,126.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,824.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,103.17
|
| Rate for Payer: Ohio Health Group HMO |
$10,315.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,750.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,787.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,263.62
|
| Rate for Payer: PHCS Commercial |
$13,203.46
|
| Rate for Payer: United Healthcare All Payer |
$12,103.17
|
|
|
GRAFT Z ILIAC LEG TFLE-18-71
|
Facility
|
IP
|
$13,753.60
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,787.97 |
| Max. Negotiated Rate |
$13,203.46 |
| Rate for Payer: Aetna Commercial |
$10,590.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,727.81
|
| Rate for Payer: Cash Price |
$6,876.80
|
| Rate for Payer: Cigna Commercial |
$11,415.49
|
| Rate for Payer: First Health Commercial |
$13,065.92
|
| Rate for Payer: Humana Commercial |
$11,690.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,277.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,150.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,126.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,103.17
|
| Rate for Payer: Ohio Health Group HMO |
$10,315.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,750.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,787.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,263.62
|
| Rate for Payer: PHCS Commercial |
$13,203.46
|
| Rate for Payer: United Healthcare All Payer |
$12,103.17
|
|
|
GRAFT Z ILIAC LEG TFLE-18-71
|
Facility
|
OP
|
$13,753.60
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,787.97 |
| Max. Negotiated Rate |
$13,203.46 |
| Rate for Payer: Aetna Commercial |
$10,590.27
|
| Rate for Payer: Anthem Medicaid |
$4,729.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,727.81
|
| Rate for Payer: Cash Price |
$6,876.80
|
| Rate for Payer: Cigna Commercial |
$11,415.49
|
| Rate for Payer: First Health Commercial |
$13,065.92
|
| Rate for Payer: Humana Commercial |
$11,690.56
|
| Rate for Payer: Humana KY Medicaid |
$4,729.86
|
| Rate for Payer: Kentucky WC Medicaid |
$4,778.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,277.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,150.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,126.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,824.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,103.17
|
| Rate for Payer: Ohio Health Group HMO |
$10,315.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,750.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,787.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,263.62
|
| Rate for Payer: PHCS Commercial |
$13,203.46
|
| Rate for Payer: United Healthcare All Payer |
$12,103.17
|
|
|
GRAFT Z ILIAC LEG TFLE-18-88
|
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-18-88
|
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-20-37
|
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-20-37
|
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-20-54
|
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-20-54
|
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-20-71
|
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-20-71
|
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
|
|
|
GRAFT Z ILIAC LEG TFLE-20-88
|
Facility
|
IP
|
$13,753.60
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,787.97 |
| Max. Negotiated Rate |
$13,203.46 |
| Rate for Payer: Aetna Commercial |
$10,590.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,727.81
|
| Rate for Payer: Cash Price |
$6,876.80
|
| Rate for Payer: Cigna Commercial |
$11,415.49
|
| Rate for Payer: First Health Commercial |
$13,065.92
|
| Rate for Payer: Humana Commercial |
$11,690.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,277.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,150.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,126.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,103.17
|
| Rate for Payer: Ohio Health Group HMO |
$10,315.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,750.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,787.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,263.62
|
| Rate for Payer: PHCS Commercial |
$13,203.46
|
| Rate for Payer: United Healthcare All Payer |
$12,103.17
|
|
|
GRAFT Z ILIAC LEG TFLE-20-88
|
Facility
|
OP
|
$13,753.60
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,787.97 |
| Max. Negotiated Rate |
$13,203.46 |
| Rate for Payer: Aetna Commercial |
$10,590.27
|
| Rate for Payer: Anthem Medicaid |
$4,729.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,727.81
|
| Rate for Payer: Cash Price |
$6,876.80
|
| Rate for Payer: Cigna Commercial |
$11,415.49
|
| Rate for Payer: First Health Commercial |
$13,065.92
|
| Rate for Payer: Humana Commercial |
$11,690.56
|
| Rate for Payer: Humana KY Medicaid |
$4,729.86
|
| Rate for Payer: Kentucky WC Medicaid |
$4,778.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,277.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,150.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,126.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,824.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,103.17
|
| Rate for Payer: Ohio Health Group HMO |
$10,315.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,750.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,787.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,263.62
|
| Rate for Payer: PHCS Commercial |
$13,203.46
|
| Rate for Payer: United Healthcare All Payer |
$12,103.17
|
|
|
GRAFT Z ILIAC LEG TFLE-22-37
|
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-22-37
|
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-22-54
|
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
|
|
