|
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
|
|
|
GRAFT Z MAIN BODY TFFB-26-82
|
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-26-82
|
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-26-82-Z
|
Facility
|
IP
|
$40,586.68
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,276.27 |
| Max. Negotiated Rate |
$38,963.21 |
| Rate for Payer: Aetna Commercial |
$31,251.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31,657.61
|
| Rate for Payer: Cash Price |
$20,293.34
|
| Rate for Payer: Cigna Commercial |
$33,686.94
|
| Rate for Payer: First Health Commercial |
$38,557.35
|
| Rate for Payer: Humana Commercial |
$34,498.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$33,281.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29,952.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,176.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$35,716.28
|
| Rate for Payer: Ohio Health Group HMO |
$30,440.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,117.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,276.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,581.87
|
| Rate for Payer: PHCS Commercial |
$38,963.21
|
| Rate for Payer: United Healthcare All Payer |
$35,716.28
|
|
|
GRAFT Z MAIN BODY TFFB-26-82-Z
|
Facility
|
OP
|
$40,586.68
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,276.27 |
| Max. Negotiated Rate |
$38,963.21 |
| Rate for Payer: Aetna Commercial |
$31,251.74
|
| Rate for Payer: Anthem Medicaid |
$13,957.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31,657.61
|
| Rate for Payer: Cash Price |
$20,293.34
|
| Rate for Payer: Cigna Commercial |
$33,686.94
|
| Rate for Payer: First Health Commercial |
$38,557.35
|
| Rate for Payer: Humana Commercial |
$34,498.68
|
| Rate for Payer: Humana KY Medicaid |
$13,957.76
|
| Rate for Payer: Kentucky WC Medicaid |
$14,099.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$33,281.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29,952.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,176.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,237.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$35,716.28
|
| Rate for Payer: Ohio Health Group HMO |
$30,440.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,117.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,276.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,581.87
|
| Rate for Payer: PHCS Commercial |
$38,963.21
|
| Rate for Payer: United Healthcare All Payer |
$35,716.28
|
|
|
GRAFT Z MAIN BODY TFFB-26-96
|
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-26-96
|
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-26-96-Z
|
Facility
|
OP
|
$65,856.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,561.33 |
| Max. Negotiated Rate |
$63,222.14 |
| Rate for Payer: Aetna Commercial |
$50,709.43
|
| Rate for Payer: Anthem Medicaid |
$22,648.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51,367.99
|
| Rate for Payer: Cash Price |
$32,928.20
|
| Rate for Payer: Cigna Commercial |
$54,660.81
|
| Rate for Payer: First Health Commercial |
$62,563.58
|
| Rate for Payer: Humana Commercial |
$55,977.94
|
| Rate for Payer: Humana KY Medicaid |
$22,648.02
|
| Rate for Payer: Kentucky WC Medicaid |
$22,878.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54,002.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48,602.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19,756.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$23,102.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$57,953.63
|
| Rate for Payer: Ohio Health Group HMO |
$49,392.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,171.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,561.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20,415.48
|
| Rate for Payer: PHCS Commercial |
$63,222.14
|
| Rate for Payer: United Healthcare All Payer |
$57,953.63
|
|
|
GRAFT Z MAIN BODY TFFB-26-96-Z
|
Facility
|
IP
|
$65,856.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,561.33 |
| Max. Negotiated Rate |
$63,222.14 |
| Rate for Payer: Aetna Commercial |
$50,709.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51,367.99
|
| Rate for Payer: Cash Price |
$32,928.20
|
| Rate for Payer: Cigna Commercial |
$54,660.81
|
| Rate for Payer: First Health Commercial |
$62,563.58
|
| Rate for Payer: Humana Commercial |
$55,977.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54,002.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48,602.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19,756.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$57,953.63
|
| Rate for Payer: Ohio Health Group HMO |
$49,392.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,171.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,561.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20,415.48
|
| Rate for Payer: PHCS Commercial |
$63,222.14
|
| Rate for Payer: United Healthcare All Payer |
$57,953.63
|
|
|
GRAFT Z MAIN BODY TFFB-28-111
|
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-28-111
|
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-28-125
|
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-28-125
|
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-28-140
|
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-28-140
|
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-28-82
|
Facility
|
OP
|
$33,456.15
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,349.30 |
| Max. Negotiated Rate |
$32,117.90 |
| Rate for Payer: Aetna Commercial |
$25,761.24
|
| Rate for Payer: Anthem Medicaid |
$11,505.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,095.80
|
| Rate for Payer: Cash Price |
$16,728.08
|
| Rate for Payer: Cigna Commercial |
$27,768.60
|
| Rate for Payer: First Health Commercial |
$31,783.34
|
| Rate for Payer: Humana Commercial |
$28,437.73
|
| Rate for Payer: Humana KY Medicaid |
$11,505.57
|
| Rate for Payer: Kentucky WC Medicaid |
$11,622.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,434.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,690.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,036.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,736.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,441.41
|
| Rate for Payer: Ohio Health Group HMO |
$25,092.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,691.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,349.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,371.41
|
| Rate for Payer: PHCS Commercial |
$32,117.90
|
| Rate for Payer: United Healthcare All Payer |
$29,441.41
|
|
|
GRAFT Z MAIN BODY TFFB-28-82
|
Facility
|
IP
|
$33,456.15
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,349.30 |
| Max. Negotiated Rate |
$32,117.90 |
| Rate for Payer: Aetna Commercial |
$25,761.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,095.80
|
| Rate for Payer: Cash Price |
$16,728.08
|
| Rate for Payer: Cigna Commercial |
$27,768.60
|
| Rate for Payer: First Health Commercial |
$31,783.34
|
| Rate for Payer: Humana Commercial |
$28,437.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,434.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,690.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,036.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,441.41
|
| Rate for Payer: Ohio Health Group HMO |
$25,092.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,691.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,349.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,371.41
|
| Rate for Payer: PHCS Commercial |
$32,117.90
|
| Rate for Payer: United Healthcare All Payer |
$29,441.41
|
|
|
GRAFT Z MAIN BODY TFFB-28-82-Z
|
Facility
|
OP
|
$65,856.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,561.33 |
| Max. Negotiated Rate |
$63,222.14 |
| Rate for Payer: Aetna Commercial |
$50,709.43
|
| Rate for Payer: Anthem Medicaid |
$22,648.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51,367.99
|
| Rate for Payer: Cash Price |
$32,928.20
|
| Rate for Payer: Cigna Commercial |
$54,660.81
|
| Rate for Payer: First Health Commercial |
$62,563.58
|
| Rate for Payer: Humana Commercial |
$55,977.94
|
| Rate for Payer: Humana KY Medicaid |
$22,648.02
|
| Rate for Payer: Kentucky WC Medicaid |
$22,878.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54,002.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48,602.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19,756.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$23,102.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$57,953.63
|
| Rate for Payer: Ohio Health Group HMO |
$49,392.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,171.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,561.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20,415.48
|
| Rate for Payer: PHCS Commercial |
$63,222.14
|
| Rate for Payer: United Healthcare All Payer |
$57,953.63
|
|
|
GRAFT Z MAIN BODY TFFB-28-82-Z
|
Facility
|
IP
|
$65,856.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,561.33 |
| Max. Negotiated Rate |
$63,222.14 |
| Rate for Payer: Aetna Commercial |
$50,709.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51,367.99
|
| Rate for Payer: Cash Price |
$32,928.20
|
| Rate for Payer: Cigna Commercial |
$54,660.81
|
| Rate for Payer: First Health Commercial |
$62,563.58
|
| Rate for Payer: Humana Commercial |
$55,977.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54,002.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48,602.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19,756.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$57,953.63
|
| Rate for Payer: Ohio Health Group HMO |
$49,392.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,171.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,561.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20,415.48
|
| Rate for Payer: PHCS Commercial |
$63,222.14
|
| Rate for Payer: United Healthcare All Payer |
$57,953.63
|
|
|
GRAFT Z MAIN BODY TFFB-28-96
|
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-28-96
|
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-28-96-Z
|
Facility
|
IP
|
$37,551.45
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,881.69 |
| Max. Negotiated Rate |
$36,049.39 |
| Rate for Payer: Aetna Commercial |
$28,914.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29,290.13
|
| Rate for Payer: Cash Price |
$18,775.72
|
| Rate for Payer: Cigna Commercial |
$31,167.70
|
| Rate for Payer: First Health Commercial |
$35,673.88
|
| Rate for Payer: Humana Commercial |
$31,918.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30,792.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27,712.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,265.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$33,045.28
|
| Rate for Payer: Ohio Health Group HMO |
$28,163.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,510.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,881.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,640.95
|
| Rate for Payer: PHCS Commercial |
$36,049.39
|
| Rate for Payer: United Healthcare All Payer |
$33,045.28
|
|
|
GRAFT Z MAIN BODY TFFB-28-96-Z
|
Facility
|
OP
|
$37,551.45
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,881.69 |
| Max. Negotiated Rate |
$36,049.39 |
| Rate for Payer: Aetna Commercial |
$28,914.62
|
| Rate for Payer: Anthem Medicaid |
$12,913.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29,290.13
|
| Rate for Payer: Cash Price |
$18,775.72
|
| Rate for Payer: Cigna Commercial |
$31,167.70
|
| Rate for Payer: First Health Commercial |
$35,673.88
|
| Rate for Payer: Humana Commercial |
$31,918.73
|
| Rate for Payer: Humana KY Medicaid |
$12,913.94
|
| Rate for Payer: Kentucky WC Medicaid |
$13,045.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30,792.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27,712.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,265.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,173.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$33,045.28
|
| Rate for Payer: Ohio Health Group HMO |
$28,163.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,510.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,881.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,640.95
|
| Rate for Payer: PHCS Commercial |
$36,049.39
|
| Rate for Payer: United Healthcare All Payer |
$33,045.28
|
|
|
GRAFT Z MAIN BODY TFFB-30-111
|
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-30-111
|
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
|
|
