|
GRAFT Z MAIN BODY TFFB-30-125
|
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-30-125
|
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-30-140
|
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-30-140
|
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-30-82
|
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-30-82
|
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-30-96
|
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-30-96
|
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-30-96-Z
|
Facility
|
IP
|
$66,576.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,654.93 |
| Max. Negotiated Rate |
$63,913.34 |
| Rate for Payer: Aetna Commercial |
$51,263.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51,929.59
|
| Rate for Payer: Cash Price |
$33,288.20
|
| Rate for Payer: Cigna Commercial |
$55,258.41
|
| Rate for Payer: First Health Commercial |
$63,247.58
|
| Rate for Payer: Humana Commercial |
$56,589.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54,592.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49,133.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19,972.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$58,587.23
|
| Rate for Payer: Ohio Health Group HMO |
$49,932.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,315.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,654.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20,638.68
|
| Rate for Payer: PHCS Commercial |
$63,913.34
|
| Rate for Payer: United Healthcare All Payer |
$58,587.23
|
|
|
GRAFT Z MAIN BODY TFFB-30-96-Z
|
Facility
|
OP
|
$66,576.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,654.93 |
| Max. Negotiated Rate |
$63,913.34 |
| Rate for Payer: Aetna Commercial |
$51,263.83
|
| Rate for Payer: Anthem Medicaid |
$22,895.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51,929.59
|
| Rate for Payer: Cash Price |
$33,288.20
|
| Rate for Payer: Cigna Commercial |
$55,258.41
|
| Rate for Payer: First Health Commercial |
$63,247.58
|
| Rate for Payer: Humana Commercial |
$56,589.94
|
| Rate for Payer: Humana KY Medicaid |
$22,895.62
|
| Rate for Payer: Kentucky WC Medicaid |
$23,128.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54,592.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49,133.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19,972.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$23,355.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$58,587.23
|
| Rate for Payer: Ohio Health Group HMO |
$49,932.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,315.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,654.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20,638.68
|
| Rate for Payer: PHCS Commercial |
$63,913.34
|
| Rate for Payer: United Healthcare All Payer |
$58,587.23
|
|
|
GRAFT Z MAIN BODY TFFB-32-111
|
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-32-111
|
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-32-111-
|
Facility
|
IP
|
$67,688.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,799.54 |
| Max. Negotiated Rate |
$64,981.25 |
| Rate for Payer: Aetna Commercial |
$52,120.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52,797.26
|
| Rate for Payer: Cash Price |
$33,844.40
|
| Rate for Payer: Cigna Commercial |
$56,181.70
|
| Rate for Payer: First Health Commercial |
$64,304.36
|
| Rate for Payer: Humana Commercial |
$57,535.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55,504.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49,954.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,306.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$59,566.14
|
| Rate for Payer: Ohio Health Group HMO |
$50,766.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,537.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,799.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20,983.53
|
| Rate for Payer: PHCS Commercial |
$64,981.25
|
| Rate for Payer: United Healthcare All Payer |
$59,566.14
|
|
|
GRAFT Z MAIN BODY TFFB-32-111-
|
Facility
|
OP
|
$67,688.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,799.54 |
| Max. Negotiated Rate |
$64,981.25 |
| Rate for Payer: Aetna Commercial |
$52,120.38
|
| Rate for Payer: Anthem Medicaid |
$23,278.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52,797.26
|
| Rate for Payer: Cash Price |
$33,844.40
|
| Rate for Payer: Cigna Commercial |
$56,181.70
|
| Rate for Payer: First Health Commercial |
$64,304.36
|
| Rate for Payer: Humana Commercial |
$57,535.48
|
| Rate for Payer: Humana KY Medicaid |
$23,278.18
|
| Rate for Payer: Kentucky WC Medicaid |
$23,515.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55,504.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49,954.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,306.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$23,745.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$59,566.14
|
| Rate for Payer: Ohio Health Group HMO |
$50,766.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,537.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,799.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20,983.53
|
| Rate for Payer: PHCS Commercial |
$64,981.25
|
| Rate for Payer: United Healthcare All Payer |
$59,566.14
|
|
|
GRAFT Z MAIN BODY TFFB-32-125
|
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-32-125
|
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-32-140
|
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-32-140
|
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-32-82
|
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-32-82
|
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-32-82-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-32-82-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-32-96
|
Facility
|
OP
|
$35,671.70
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,637.32 |
| Max. Negotiated Rate |
$34,244.83 |
| Rate for Payer: Aetna Commercial |
$27,467.21
|
| Rate for Payer: Anthem Medicaid |
$12,267.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,823.93
|
| Rate for Payer: Cash Price |
$17,835.85
|
| Rate for Payer: Cigna Commercial |
$29,607.51
|
| Rate for Payer: First Health Commercial |
$33,888.12
|
| Rate for Payer: Humana Commercial |
$30,320.94
|
| Rate for Payer: Humana KY Medicaid |
$12,267.50
|
| Rate for Payer: Kentucky WC Medicaid |
$12,392.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,250.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,325.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,701.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,513.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,391.10
|
| Rate for Payer: Ohio Health Group HMO |
$26,753.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,134.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,637.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,058.23
|
| Rate for Payer: PHCS Commercial |
$34,244.83
|
| Rate for Payer: United Healthcare All Payer |
$31,391.10
|
|
|
GRAFT Z MAIN BODY TFFB-32-96
|
Facility
|
IP
|
$35,671.70
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,637.32 |
| Max. Negotiated Rate |
$34,244.83 |
| Rate for Payer: Aetna Commercial |
$27,467.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,823.93
|
| Rate for Payer: Cash Price |
$17,835.85
|
| Rate for Payer: Cigna Commercial |
$29,607.51
|
| Rate for Payer: First Health Commercial |
$33,888.12
|
| Rate for Payer: Humana Commercial |
$30,320.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,250.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,325.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,701.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,391.10
|
| Rate for Payer: Ohio Health Group HMO |
$26,753.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,134.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,637.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,058.23
|
| Rate for Payer: PHCS Commercial |
$34,244.83
|
| Rate for Payer: United Healthcare All Payer |
$31,391.10
|
|
|
GRAFT Z MAIN BODY TFFB-32-96-Z
|
Facility
|
IP
|
$39,544.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,140.77 |
| Max. Negotiated Rate |
$37,962.58 |
| Rate for Payer: Aetna Commercial |
$30,449.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30,844.59
|
| Rate for Payer: Cash Price |
$19,772.18
|
| Rate for Payer: Cigna Commercial |
$32,821.81
|
| Rate for Payer: First Health Commercial |
$37,567.13
|
| Rate for Payer: Humana Commercial |
$33,612.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32,426.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29,183.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,863.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$34,799.03
|
| Rate for Payer: Ohio Health Group HMO |
$29,658.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,908.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,140.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,258.75
|
| Rate for Payer: PHCS Commercial |
$37,962.58
|
| Rate for Payer: United Healthcare All Payer |
$34,799.03
|
|
