|
GRAFT Z MAIN BODY TFFB-22-111
|
Facility
|
OP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem Medicaid |
$11,958.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Humana KY Medicaid |
$11,958.71
|
| Rate for Payer: Kentucky WC Medicaid |
$12,080.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,198.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-22-111
|
Facility
|
IP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-22-125
|
Facility
|
OP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem Medicaid |
$11,958.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Humana KY Medicaid |
$11,958.71
|
| Rate for Payer: Kentucky WC Medicaid |
$12,080.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,198.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-22-125
|
Facility
|
IP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-22-140
|
Facility
|
IP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-22-140
|
Facility
|
OP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem Medicaid |
$11,958.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Humana KY Medicaid |
$11,958.71
|
| Rate for Payer: Kentucky WC Medicaid |
$12,080.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,198.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-22-82
|
Facility
|
OP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem Medicaid |
$11,958.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Humana KY Medicaid |
$11,958.71
|
| Rate for Payer: Kentucky WC Medicaid |
$12,080.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,198.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-22-82
|
Facility
|
IP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-22-96
|
Facility
|
IP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-22-96
|
Facility
|
OP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem Medicaid |
$11,958.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Humana KY Medicaid |
$11,958.71
|
| Rate for Payer: Kentucky WC Medicaid |
$12,080.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,198.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-24-111
|
Facility
|
IP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-24-111
|
Facility
|
OP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem Medicaid |
$11,958.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Humana KY Medicaid |
$11,958.71
|
| Rate for Payer: Kentucky WC Medicaid |
$12,080.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,198.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-24-125
|
Facility
|
OP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem Medicaid |
$11,958.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Humana KY Medicaid |
$11,958.71
|
| Rate for Payer: Kentucky WC Medicaid |
$12,080.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,198.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-24-125
|
Facility
|
IP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-24-140
|
Facility
|
IP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-24-140
|
Facility
|
OP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem Medicaid |
$11,958.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Humana KY Medicaid |
$11,958.71
|
| Rate for Payer: Kentucky WC Medicaid |
$12,080.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,198.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-24-82
|
Facility
|
IP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-24-82
|
Facility
|
OP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem Medicaid |
$11,958.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Humana KY Medicaid |
$11,958.71
|
| Rate for Payer: Kentucky WC Medicaid |
$12,080.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,198.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-24-96
|
Facility
|
OP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem Medicaid |
$11,958.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Humana KY Medicaid |
$11,958.71
|
| Rate for Payer: Kentucky WC Medicaid |
$12,080.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,198.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-24-96
|
Facility
|
IP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-26-111
|
Facility
|
OP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem Medicaid |
$11,958.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Humana KY Medicaid |
$11,958.71
|
| Rate for Payer: Kentucky WC Medicaid |
$12,080.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,198.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-26-111
|
Facility
|
IP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-26-125
|
Facility
|
IP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-26-125
|
Facility
|
OP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem Medicaid |
$11,958.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Humana KY Medicaid |
$11,958.71
|
| Rate for Payer: Kentucky WC Medicaid |
$12,080.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,198.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
|
GRAFT Z MAIN BODY TFFB-26-140
|
Facility
|
IP
|
$34,773.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.59 |
| Max. Negotiated Rate |
$33,382.85 |
| Rate for Payer: Aetna Commercial |
$26,775.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,123.56
|
| Rate for Payer: Cash Price |
$17,386.90
|
| Rate for Payer: Cigna Commercial |
$28,862.25
|
| Rate for Payer: First Health Commercial |
$33,035.11
|
| Rate for Payer: Humana Commercial |
$29,557.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,514.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,663.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,432.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,600.94
|
| Rate for Payer: Ohio Health Group HMO |
$26,080.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,954.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,520.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,779.88
|
| Rate for Payer: PHCS Commercial |
$33,382.85
|
| Rate for Payer: United Healthcare All Payer |
$30,600.94
|
|
