|
GRAFT ILIAC LMB OVTN 14*18*120
|
Facility
|
OP
|
$20,000.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,000.00 |
| Max. Negotiated Rate |
$19,200.00 |
| Rate for Payer: Aetna Commercial |
$15,400.00
|
| Rate for Payer: Anthem Medicaid |
$6,878.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,600.00
|
| Rate for Payer: Cash Price |
$10,000.00
|
| Rate for Payer: Cigna Commercial |
$16,600.00
|
| Rate for Payer: First Health Commercial |
$19,000.00
|
| Rate for Payer: Humana Commercial |
$17,000.00
|
| Rate for Payer: Humana KY Medicaid |
$6,878.00
|
| Rate for Payer: Kentucky WC Medicaid |
$6,948.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,400.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,760.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,000.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,016.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,600.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,400.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,800.00
|
| Rate for Payer: PHCS Commercial |
$19,200.00
|
| Rate for Payer: United Healthcare All Payer |
$17,600.00
|
|
|
GRAFT ILIAC LMB OVTN 14*18*140
|
Facility
|
OP
|
$20,000.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,000.00 |
| Max. Negotiated Rate |
$19,200.00 |
| Rate for Payer: Aetna Commercial |
$15,400.00
|
| Rate for Payer: Anthem Medicaid |
$6,878.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,600.00
|
| Rate for Payer: Cash Price |
$10,000.00
|
| Rate for Payer: Cigna Commercial |
$16,600.00
|
| Rate for Payer: First Health Commercial |
$19,000.00
|
| Rate for Payer: Humana Commercial |
$17,000.00
|
| Rate for Payer: Humana KY Medicaid |
$6,878.00
|
| Rate for Payer: Kentucky WC Medicaid |
$6,948.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,400.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,760.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,000.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,016.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,600.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,400.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,800.00
|
| Rate for Payer: PHCS Commercial |
$19,200.00
|
| Rate for Payer: United Healthcare All Payer |
$17,600.00
|
|
|
GRAFT ILIAC LMB OVTN 14*18*140
|
Facility
|
IP
|
$20,000.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,000.00 |
| Max. Negotiated Rate |
$19,200.00 |
| Rate for Payer: Aetna Commercial |
$15,400.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,600.00
|
| Rate for Payer: Cash Price |
$10,000.00
|
| Rate for Payer: Cigna Commercial |
$16,600.00
|
| Rate for Payer: First Health Commercial |
$19,000.00
|
| Rate for Payer: Humana Commercial |
$17,000.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,400.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,760.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,000.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,600.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,400.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,800.00
|
| Rate for Payer: PHCS Commercial |
$19,200.00
|
| Rate for Payer: United Healthcare All Payer |
$17,600.00
|
|
|
GRAFT ILIAC LMB OVTN 14*18*80
|
Facility
|
IP
|
$20,000.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,000.00 |
| Max. Negotiated Rate |
$19,200.00 |
| Rate for Payer: Aetna Commercial |
$15,400.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,600.00
|
| Rate for Payer: Cash Price |
$10,000.00
|
| Rate for Payer: Cigna Commercial |
$16,600.00
|
| Rate for Payer: First Health Commercial |
$19,000.00
|
| Rate for Payer: Humana Commercial |
$17,000.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,400.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,760.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,000.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,600.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,400.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,800.00
|
| Rate for Payer: PHCS Commercial |
$19,200.00
|
| Rate for Payer: United Healthcare All Payer |
$17,600.00
|
|
|
GRAFT ILIAC LMB OVTN 14*18*80
|
Facility
|
OP
|
$20,000.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,000.00 |
| Max. Negotiated Rate |
$19,200.00 |
| Rate for Payer: Aetna Commercial |
$15,400.00
|
| Rate for Payer: Anthem Medicaid |
$6,878.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,600.00
|
| Rate for Payer: Cash Price |
$10,000.00
|
| Rate for Payer: Cigna Commercial |
$16,600.00
|
| Rate for Payer: First Health Commercial |
$19,000.00
|
| Rate for Payer: Humana Commercial |
$17,000.00
|
| Rate for Payer: Humana KY Medicaid |
$6,878.00
|
| Rate for Payer: Kentucky WC Medicaid |
$6,948.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,400.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,760.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,000.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,016.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,600.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,400.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,800.00
|
| Rate for Payer: PHCS Commercial |
$19,200.00
|
| Rate for Payer: United Healthcare All Payer |
$17,600.00
|
|
|
GRAFT ILIAC LMB OVTN 14*22*100
|
Facility
|
IP
|
$20,000.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,000.00 |
| Max. Negotiated Rate |
$19,200.00 |
| Rate for Payer: Aetna Commercial |
$15,400.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,600.00
|
| Rate for Payer: Cash Price |
$10,000.00
|
| Rate for Payer: Cigna Commercial |
$16,600.00
|
| Rate for Payer: First Health Commercial |
$19,000.00
|
| Rate for Payer: Humana Commercial |
$17,000.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,400.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,760.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,000.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,600.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,400.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,800.00
|
| Rate for Payer: PHCS Commercial |
$19,200.00
|
| Rate for Payer: United Healthcare All Payer |
$17,600.00
|
|
|
GRAFT ILIAC LMB OVTN 14*22*100
|
Facility
|
OP
|
$20,000.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,000.00 |
| Max. Negotiated Rate |
$19,200.00 |
| Rate for Payer: Aetna Commercial |
$15,400.00
|
| Rate for Payer: Anthem Medicaid |
$6,878.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,600.00
|
| Rate for Payer: Cash Price |
$10,000.00
|
| Rate for Payer: Cigna Commercial |
$16,600.00
|
| Rate for Payer: First Health Commercial |
$19,000.00
|
| Rate for Payer: Humana Commercial |
$17,000.00
|
| Rate for Payer: Humana KY Medicaid |
$6,878.00
|
| Rate for Payer: Kentucky WC Medicaid |
$6,948.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,400.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,760.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,000.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,016.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,600.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,400.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,800.00
|
| Rate for Payer: PHCS Commercial |
$19,200.00
|
| Rate for Payer: United Healthcare All Payer |
$17,600.00
|
|
|
GRAFT ILIAC LMB OVTN 14*22*120
|
Facility
|
OP
|
$20,000.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,000.00 |
| Max. Negotiated Rate |
$19,200.00 |
| Rate for Payer: Aetna Commercial |
$15,400.00
|
| Rate for Payer: Anthem Medicaid |
$6,878.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,600.00
|
| Rate for Payer: Cash Price |
$10,000.00
|
| Rate for Payer: Cigna Commercial |
$16,600.00
|
| Rate for Payer: First Health Commercial |
$19,000.00
|
| Rate for Payer: Humana Commercial |
$17,000.00
|
| Rate for Payer: Humana KY Medicaid |
$6,878.00
|
| Rate for Payer: Kentucky WC Medicaid |
$6,948.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,400.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,760.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,000.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,016.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,600.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,400.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,800.00
|
| Rate for Payer: PHCS Commercial |
$19,200.00
|
| Rate for Payer: United Healthcare All Payer |
$17,600.00
|
|
|
GRAFT ILIAC LMB OVTN 14*22*120
|
Facility
|
IP
|
$20,000.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,000.00 |
| Max. Negotiated Rate |
$19,200.00 |
| Rate for Payer: Aetna Commercial |
$15,400.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,600.00
|
| Rate for Payer: Cash Price |
$10,000.00
|
| Rate for Payer: Cigna Commercial |
$16,600.00
|
| Rate for Payer: First Health Commercial |
$19,000.00
|
| Rate for Payer: Humana Commercial |
$17,000.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,400.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,760.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,000.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,600.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,400.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,800.00
|
| Rate for Payer: PHCS Commercial |
$19,200.00
|
| Rate for Payer: United Healthcare All Payer |
$17,600.00
|
|
|
GRAFT ILIAC LMB OVTN 14*22*140
|
Facility
|
OP
|
$20,000.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,000.00 |
| Max. Negotiated Rate |
$19,200.00 |
| Rate for Payer: Aetna Commercial |
$15,400.00
|
| Rate for Payer: Anthem Medicaid |
$6,878.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,600.00
|
| Rate for Payer: Cash Price |
$10,000.00
|
| Rate for Payer: Cigna Commercial |
$16,600.00
|
| Rate for Payer: First Health Commercial |
$19,000.00
|
| Rate for Payer: Humana Commercial |
$17,000.00
|
| Rate for Payer: Humana KY Medicaid |
$6,878.00
|
| Rate for Payer: Kentucky WC Medicaid |
$6,948.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,400.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,760.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,000.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,016.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,600.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,400.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,800.00
|
| Rate for Payer: PHCS Commercial |
$19,200.00
|
| Rate for Payer: United Healthcare All Payer |
$17,600.00
|
|
|
GRAFT ILIAC LMB OVTN 14*22*140
|
Facility
|
IP
|
$20,000.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,000.00 |
| Max. Negotiated Rate |
$19,200.00 |
| Rate for Payer: Aetna Commercial |
$15,400.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,600.00
|
| Rate for Payer: Cash Price |
$10,000.00
|
| Rate for Payer: Cigna Commercial |
$16,600.00
|
| Rate for Payer: First Health Commercial |
$19,000.00
|
| Rate for Payer: Humana Commercial |
$17,000.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,400.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,760.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,000.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,600.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,400.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,800.00
|
| Rate for Payer: PHCS Commercial |
$19,200.00
|
| Rate for Payer: United Healthcare All Payer |
$17,600.00
|
|
|
GRAFT ILIAC LMB OVTN 14*22*80
|
Facility
|
IP
|
$20,000.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,000.00 |
| Max. Negotiated Rate |
$19,200.00 |
| Rate for Payer: Aetna Commercial |
$15,400.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,600.00
|
| Rate for Payer: Cash Price |
$10,000.00
|
| Rate for Payer: Cigna Commercial |
$16,600.00
|
| Rate for Payer: First Health Commercial |
$19,000.00
|
| Rate for Payer: Humana Commercial |
$17,000.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,400.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,760.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,000.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,600.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,400.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,800.00
|
| Rate for Payer: PHCS Commercial |
$19,200.00
|
| Rate for Payer: United Healthcare All Payer |
$17,600.00
|
|
|
GRAFT ILIAC LMB OVTN 14*22*80
|
Facility
|
OP
|
$20,000.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,000.00 |
| Max. Negotiated Rate |
$19,200.00 |
| Rate for Payer: Aetna Commercial |
$15,400.00
|
| Rate for Payer: Anthem Medicaid |
$6,878.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,600.00
|
| Rate for Payer: Cash Price |
$10,000.00
|
| Rate for Payer: Cigna Commercial |
$16,600.00
|
| Rate for Payer: First Health Commercial |
$19,000.00
|
| Rate for Payer: Humana Commercial |
$17,000.00
|
| Rate for Payer: Humana KY Medicaid |
$6,878.00
|
| Rate for Payer: Kentucky WC Medicaid |
$6,948.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,400.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,760.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,000.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,016.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,600.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,400.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,800.00
|
| Rate for Payer: PHCS Commercial |
$19,200.00
|
| Rate for Payer: United Healthcare All Payer |
$17,600.00
|
|
|
GRAFT ILIAC LMB OVTN IX 14*10*
|
Facility
|
OP
|
$26,371.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,911.38 |
| Max. Negotiated Rate |
$25,316.40 |
| Rate for Payer: Aetna Commercial |
$20,305.86
|
| Rate for Payer: Anthem Medicaid |
$9,069.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,569.58
|
| Rate for Payer: Cash Price |
$13,185.62
|
| Rate for Payer: Cigna Commercial |
$21,888.14
|
| Rate for Payer: First Health Commercial |
$25,052.69
|
| Rate for Payer: Humana Commercial |
$22,415.56
|
| Rate for Payer: Humana KY Medicaid |
$9,069.07
|
| Rate for Payer: Kentucky WC Medicaid |
$9,161.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,624.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,461.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,911.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,251.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,206.70
|
| Rate for Payer: Ohio Health Group HMO |
$19,778.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,097.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,942.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,196.16
|
| Rate for Payer: PHCS Commercial |
$25,316.40
|
| Rate for Payer: United Healthcare All Payer |
$23,206.70
|
|
|
GRAFT ILIAC LMB OVTN IX 14*10*
|
Facility
|
IP
|
$26,371.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,911.38 |
| Max. Negotiated Rate |
$25,316.40 |
| Rate for Payer: Aetna Commercial |
$20,305.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,569.58
|
| Rate for Payer: Cash Price |
$13,185.62
|
| Rate for Payer: Cigna Commercial |
$21,888.14
|
| Rate for Payer: First Health Commercial |
$25,052.69
|
| Rate for Payer: Humana Commercial |
$22,415.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,624.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,461.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,911.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,206.70
|
| Rate for Payer: Ohio Health Group HMO |
$19,778.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,097.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,942.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,196.16
|
| Rate for Payer: PHCS Commercial |
$25,316.40
|
| Rate for Payer: United Healthcare All Payer |
$23,206.70
|
|
|
GRAFT ILIAC LMB OVTN IX 14*12*
|
Facility
|
OP
|
$22,190.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,657.00 |
| Max. Negotiated Rate |
$21,302.40 |
| Rate for Payer: Aetna Commercial |
$17,086.30
|
| Rate for Payer: Anthem Medicaid |
$7,631.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,308.20
|
| Rate for Payer: Cash Price |
$11,095.00
|
| Rate for Payer: Cigna Commercial |
$18,417.70
|
| Rate for Payer: First Health Commercial |
$21,080.50
|
| Rate for Payer: Humana Commercial |
$18,861.50
|
| Rate for Payer: Humana KY Medicaid |
$7,631.14
|
| Rate for Payer: Kentucky WC Medicaid |
$7,708.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,195.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,376.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,657.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,784.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,527.20
|
| Rate for Payer: Ohio Health Group HMO |
$16,642.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,752.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,305.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,311.10
|
| Rate for Payer: PHCS Commercial |
$21,302.40
|
| Rate for Payer: United Healthcare All Payer |
$19,527.20
|
|
|
GRAFT ILIAC LMB OVTN IX 14*12*
|
Facility
|
IP
|
$22,190.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,657.00 |
| Max. Negotiated Rate |
$21,302.40 |
| Rate for Payer: Aetna Commercial |
$17,086.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,308.20
|
| Rate for Payer: Cash Price |
$11,095.00
|
| Rate for Payer: Cigna Commercial |
$18,417.70
|
| Rate for Payer: First Health Commercial |
$21,080.50
|
| Rate for Payer: Humana Commercial |
$18,861.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,195.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,376.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,657.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,527.20
|
| Rate for Payer: Ohio Health Group HMO |
$16,642.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,752.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,305.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,311.10
|
| Rate for Payer: PHCS Commercial |
$21,302.40
|
| Rate for Payer: United Healthcare All Payer |
$19,527.20
|
|
|
GRAFT ILIAC LMB OVTN IX 14*14*
|
Facility
|
OP
|
$26,371.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,911.38 |
| Max. Negotiated Rate |
$25,316.40 |
| Rate for Payer: Aetna Commercial |
$20,305.86
|
| Rate for Payer: Anthem Medicaid |
$9,069.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,569.58
|
| Rate for Payer: Cash Price |
$13,185.62
|
| Rate for Payer: Cigna Commercial |
$21,888.14
|
| Rate for Payer: First Health Commercial |
$25,052.69
|
| Rate for Payer: Humana Commercial |
$22,415.56
|
| Rate for Payer: Humana KY Medicaid |
$9,069.07
|
| Rate for Payer: Kentucky WC Medicaid |
$9,161.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,624.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,461.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,911.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,251.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,206.70
|
| Rate for Payer: Ohio Health Group HMO |
$19,778.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,097.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,942.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,196.16
|
| Rate for Payer: PHCS Commercial |
$25,316.40
|
| Rate for Payer: United Healthcare All Payer |
$23,206.70
|
|
|
GRAFT ILIAC LMB OVTN IX 14*14*
|
Facility
|
IP
|
$26,371.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,911.38 |
| Max. Negotiated Rate |
$25,316.40 |
| Rate for Payer: Aetna Commercial |
$20,305.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,569.58
|
| Rate for Payer: Cash Price |
$13,185.62
|
| Rate for Payer: Cigna Commercial |
$21,888.14
|
| Rate for Payer: First Health Commercial |
$25,052.69
|
| Rate for Payer: Humana Commercial |
$22,415.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,624.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,461.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,911.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,206.70
|
| Rate for Payer: Ohio Health Group HMO |
$19,778.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,097.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,942.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,196.16
|
| Rate for Payer: PHCS Commercial |
$25,316.40
|
| Rate for Payer: United Healthcare All Payer |
$23,206.70
|
|
|
GRAFT ILIAC LMB OVTN IX 14*16*
|
Facility
|
IP
|
$26,371.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,911.38 |
| Max. Negotiated Rate |
$25,316.40 |
| Rate for Payer: Aetna Commercial |
$20,305.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,569.58
|
| Rate for Payer: Cash Price |
$13,185.62
|
| Rate for Payer: Cigna Commercial |
$21,888.14
|
| Rate for Payer: First Health Commercial |
$25,052.69
|
| Rate for Payer: Humana Commercial |
$22,415.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,624.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,461.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,911.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,206.70
|
| Rate for Payer: Ohio Health Group HMO |
$19,778.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,097.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,942.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,196.16
|
| Rate for Payer: PHCS Commercial |
$25,316.40
|
| Rate for Payer: United Healthcare All Payer |
$23,206.70
|
|
|
GRAFT ILIAC LMB OVTN IX 14*16*
|
Facility
|
OP
|
$26,371.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,911.38 |
| Max. Negotiated Rate |
$25,316.40 |
| Rate for Payer: Aetna Commercial |
$20,305.86
|
| Rate for Payer: Anthem Medicaid |
$9,069.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,569.58
|
| Rate for Payer: Cash Price |
$13,185.62
|
| Rate for Payer: Cigna Commercial |
$21,888.14
|
| Rate for Payer: First Health Commercial |
$25,052.69
|
| Rate for Payer: Humana Commercial |
$22,415.56
|
| Rate for Payer: Humana KY Medicaid |
$9,069.07
|
| Rate for Payer: Kentucky WC Medicaid |
$9,161.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,624.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,461.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,911.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,251.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,206.70
|
| Rate for Payer: Ohio Health Group HMO |
$19,778.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,097.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,942.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,196.16
|
| Rate for Payer: PHCS Commercial |
$25,316.40
|
| Rate for Payer: United Healthcare All Payer |
$23,206.70
|
|
|
GRAFT ILIAC LMB OVTN P 14*14*1
|
Facility
|
IP
|
$26,371.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,911.38 |
| Max. Negotiated Rate |
$25,316.40 |
| Rate for Payer: Aetna Commercial |
$20,305.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,569.58
|
| Rate for Payer: Cash Price |
$13,185.62
|
| Rate for Payer: Cigna Commercial |
$21,888.14
|
| Rate for Payer: First Health Commercial |
$25,052.69
|
| Rate for Payer: Humana Commercial |
$22,415.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,624.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,461.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,911.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,206.70
|
| Rate for Payer: Ohio Health Group HMO |
$19,778.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,097.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,942.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,196.16
|
| Rate for Payer: PHCS Commercial |
$25,316.40
|
| Rate for Payer: United Healthcare All Payer |
$23,206.70
|
|
|
GRAFT ILIAC LMB OVTN P 14*14*1
|
Facility
|
OP
|
$26,371.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,911.38 |
| Max. Negotiated Rate |
$25,316.40 |
| Rate for Payer: Aetna Commercial |
$20,305.86
|
| Rate for Payer: Anthem Medicaid |
$9,069.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,569.58
|
| Rate for Payer: Cash Price |
$13,185.62
|
| Rate for Payer: Cigna Commercial |
$21,888.14
|
| Rate for Payer: First Health Commercial |
$25,052.69
|
| Rate for Payer: Humana Commercial |
$22,415.56
|
| Rate for Payer: Humana KY Medicaid |
$9,069.07
|
| Rate for Payer: Kentucky WC Medicaid |
$9,161.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,624.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,461.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,911.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,251.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,206.70
|
| Rate for Payer: Ohio Health Group HMO |
$19,778.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,097.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,942.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,196.16
|
| Rate for Payer: PHCS Commercial |
$25,316.40
|
| Rate for Payer: United Healthcare All Payer |
$23,206.70
|
|
|
GRAFT ILI LMB OVTN 14*18*100-C
|
Facility
|
IP
|
$20,000.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,000.00 |
| Max. Negotiated Rate |
$19,200.00 |
| Rate for Payer: Aetna Commercial |
$15,400.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,600.00
|
| Rate for Payer: Cash Price |
$10,000.00
|
| Rate for Payer: Cigna Commercial |
$16,600.00
|
| Rate for Payer: First Health Commercial |
$19,000.00
|
| Rate for Payer: Humana Commercial |
$17,000.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,400.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,760.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,000.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,600.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,400.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,800.00
|
| Rate for Payer: PHCS Commercial |
$19,200.00
|
| Rate for Payer: United Healthcare All Payer |
$17,600.00
|
|
|
GRAFT ILI LMB OVTN 14*18*100-C
|
Facility
|
OP
|
$20,000.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,000.00 |
| Max. Negotiated Rate |
$19,200.00 |
| Rate for Payer: Aetna Commercial |
$15,400.00
|
| Rate for Payer: Anthem Medicaid |
$6,878.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,600.00
|
| Rate for Payer: Cash Price |
$10,000.00
|
| Rate for Payer: Cigna Commercial |
$16,600.00
|
| Rate for Payer: First Health Commercial |
$19,000.00
|
| Rate for Payer: Humana Commercial |
$17,000.00
|
| Rate for Payer: Humana KY Medicaid |
$6,878.00
|
| Rate for Payer: Kentucky WC Medicaid |
$6,948.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,400.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,760.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,000.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,016.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,600.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,400.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,800.00
|
| Rate for Payer: PHCS Commercial |
$19,200.00
|
| Rate for Payer: United Healthcare All Payer |
$17,600.00
|
|
