|
GRAFT ZENITH FEN PROX 2*32*124
|
Facility
|
IP
|
$72,554.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21,766.20 |
| Max. Negotiated Rate |
$69,651.84 |
| Rate for Payer: Aetna Commercial |
$55,866.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56,592.12
|
| Rate for Payer: Cash Price |
$36,277.00
|
| Rate for Payer: Cigna Commercial |
$60,219.82
|
| Rate for Payer: First Health Commercial |
$68,926.30
|
| Rate for Payer: Humana Commercial |
$61,670.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59,494.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53,544.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,766.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$63,847.52
|
| Rate for Payer: Ohio Health Group HMO |
$54,415.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,043.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,121.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,062.26
|
| Rate for Payer: PHCS Commercial |
$69,651.84
|
| Rate for Payer: United Healthcare All Payer |
$63,847.52
|
|
|
GRAFT ZENITH FEN PROX 2*32*124
|
Facility
|
OP
|
$72,554.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21,766.20 |
| Max. Negotiated Rate |
$69,651.84 |
| Rate for Payer: Aetna Commercial |
$55,866.58
|
| Rate for Payer: Anthem Medicaid |
$24,951.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56,592.12
|
| Rate for Payer: Cash Price |
$36,277.00
|
| Rate for Payer: Cigna Commercial |
$60,219.82
|
| Rate for Payer: First Health Commercial |
$68,926.30
|
| Rate for Payer: Humana Commercial |
$61,670.90
|
| Rate for Payer: Humana KY Medicaid |
$24,951.32
|
| Rate for Payer: Kentucky WC Medicaid |
$25,205.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59,494.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53,544.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,766.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,451.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$63,847.52
|
| Rate for Payer: Ohio Health Group HMO |
$54,415.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,043.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,121.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,062.26
|
| Rate for Payer: PHCS Commercial |
$69,651.84
|
| Rate for Payer: United Healthcare All Payer |
$63,847.52
|
|
|
GRAFT Z ILIAC LEG TFLE-10-105
|
Facility
|
IP
|
$14,495.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,348.60 |
| Max. Negotiated Rate |
$13,915.51 |
| Rate for Payer: Aetna Commercial |
$11,161.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,306.35
|
| Rate for Payer: Cash Price |
$7,247.66
|
| Rate for Payer: Cigna Commercial |
$12,031.12
|
| Rate for Payer: First Health Commercial |
$13,770.55
|
| Rate for Payer: Humana Commercial |
$12,321.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,886.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,697.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,348.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,755.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,871.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,596.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,610.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,001.77
|
| Rate for Payer: PHCS Commercial |
$13,915.51
|
| Rate for Payer: United Healthcare All Payer |
$12,755.88
|
|
|
GRAFT Z ILIAC LEG TFLE-10-105
|
Facility
|
OP
|
$14,495.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,348.60 |
| Max. Negotiated Rate |
$13,915.51 |
| Rate for Payer: Aetna Commercial |
$11,161.40
|
| Rate for Payer: Anthem Medicaid |
$4,984.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,306.35
|
| Rate for Payer: Cash Price |
$7,247.66
|
| Rate for Payer: Cigna Commercial |
$12,031.12
|
| Rate for Payer: First Health Commercial |
$13,770.55
|
| Rate for Payer: Humana Commercial |
$12,321.02
|
| Rate for Payer: Humana KY Medicaid |
$4,984.94
|
| Rate for Payer: Kentucky WC Medicaid |
$5,035.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,886.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,697.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,348.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,084.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,755.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,871.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,596.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,610.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,001.77
|
| Rate for Payer: PHCS Commercial |
$13,915.51
|
| Rate for Payer: United Healthcare All Payer |
$12,755.88
|
|
|
GRAFT Z ILIAC LEG TFLE-10-122
|
Facility
|
OP
|
$14,495.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,348.60 |
| Max. Negotiated Rate |
$13,915.51 |
| Rate for Payer: Aetna Commercial |
$11,161.40
|
| Rate for Payer: Anthem Medicaid |
$4,984.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,306.35
|
| Rate for Payer: Cash Price |
$7,247.66
|
| Rate for Payer: Cigna Commercial |
$12,031.12
|
| Rate for Payer: First Health Commercial |
$13,770.55
|
| Rate for Payer: Humana Commercial |
$12,321.02
|
| Rate for Payer: Humana KY Medicaid |
$4,984.94
|
| Rate for Payer: Kentucky WC Medicaid |
$5,035.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,886.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,697.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,348.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,084.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,755.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,871.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,596.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,610.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,001.77
|
| Rate for Payer: PHCS Commercial |
$13,915.51
|
| Rate for Payer: United Healthcare All Payer |
$12,755.88
|
|
|
GRAFT Z ILIAC LEG TFLE-10-122
|
Facility
|
IP
|
$14,495.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,348.60 |
| Max. Negotiated Rate |
$13,915.51 |
| Rate for Payer: Aetna Commercial |
$11,161.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,306.35
|
| Rate for Payer: Cash Price |
$7,247.66
|
| Rate for Payer: Cigna Commercial |
$12,031.12
|
| Rate for Payer: First Health Commercial |
$13,770.55
|
| Rate for Payer: Humana Commercial |
$12,321.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,886.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,697.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,348.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,755.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,871.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,596.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,610.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,001.77
|
| Rate for Payer: PHCS Commercial |
$13,915.51
|
| Rate for Payer: United Healthcare All Payer |
$12,755.88
|
|
|
GRAFT Z ILIAC LEG TFLE-10-37
|
Facility
|
IP
|
$14,495.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,348.60 |
| Max. Negotiated Rate |
$13,915.51 |
| Rate for Payer: Aetna Commercial |
$11,161.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,306.35
|
| Rate for Payer: Cash Price |
$7,247.66
|
| Rate for Payer: Cigna Commercial |
$12,031.12
|
| Rate for Payer: First Health Commercial |
$13,770.55
|
| Rate for Payer: Humana Commercial |
$12,321.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,886.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,697.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,348.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,755.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,871.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,596.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,610.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,001.77
|
| Rate for Payer: PHCS Commercial |
$13,915.51
|
| Rate for Payer: United Healthcare All Payer |
$12,755.88
|
|
|
GRAFT Z ILIAC LEG TFLE-10-37
|
Facility
|
OP
|
$14,495.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,348.60 |
| Max. Negotiated Rate |
$13,915.51 |
| Rate for Payer: Aetna Commercial |
$11,161.40
|
| Rate for Payer: Anthem Medicaid |
$4,984.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,306.35
|
| Rate for Payer: Cash Price |
$7,247.66
|
| Rate for Payer: Cigna Commercial |
$12,031.12
|
| Rate for Payer: First Health Commercial |
$13,770.55
|
| Rate for Payer: Humana Commercial |
$12,321.02
|
| Rate for Payer: Humana KY Medicaid |
$4,984.94
|
| Rate for Payer: Kentucky WC Medicaid |
$5,035.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,886.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,697.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,348.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,084.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,755.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,871.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,596.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,610.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,001.77
|
| Rate for Payer: PHCS Commercial |
$13,915.51
|
| Rate for Payer: United Healthcare All Payer |
$12,755.88
|
|
|
GRAFT Z ILIAC LEG TFLE-10-54
|
Facility
|
OP
|
$14,495.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,348.60 |
| Max. Negotiated Rate |
$13,915.51 |
| Rate for Payer: Aetna Commercial |
$11,161.40
|
| Rate for Payer: Anthem Medicaid |
$4,984.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,306.35
|
| Rate for Payer: Cash Price |
$7,247.66
|
| Rate for Payer: Cigna Commercial |
$12,031.12
|
| Rate for Payer: First Health Commercial |
$13,770.55
|
| Rate for Payer: Humana Commercial |
$12,321.02
|
| Rate for Payer: Humana KY Medicaid |
$4,984.94
|
| Rate for Payer: Kentucky WC Medicaid |
$5,035.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,886.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,697.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,348.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,084.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,755.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,871.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,596.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,610.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,001.77
|
| Rate for Payer: PHCS Commercial |
$13,915.51
|
| Rate for Payer: United Healthcare All Payer |
$12,755.88
|
|
|
GRAFT Z ILIAC LEG TFLE-10-54
|
Facility
|
IP
|
$14,495.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,348.60 |
| Max. Negotiated Rate |
$13,915.51 |
| Rate for Payer: Aetna Commercial |
$11,161.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,306.35
|
| Rate for Payer: Cash Price |
$7,247.66
|
| Rate for Payer: Cigna Commercial |
$12,031.12
|
| Rate for Payer: First Health Commercial |
$13,770.55
|
| Rate for Payer: Humana Commercial |
$12,321.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,886.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,697.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,348.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,755.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,871.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,596.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,610.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,001.77
|
| Rate for Payer: PHCS Commercial |
$13,915.51
|
| Rate for Payer: United Healthcare All Payer |
$12,755.88
|
|
|
GRAFT Z ILIAC LEG TFLE-10-71
|
Facility
|
IP
|
$14,495.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,348.60 |
| Max. Negotiated Rate |
$13,915.51 |
| Rate for Payer: Aetna Commercial |
$11,161.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,306.35
|
| Rate for Payer: Cash Price |
$7,247.66
|
| Rate for Payer: Cigna Commercial |
$12,031.12
|
| Rate for Payer: First Health Commercial |
$13,770.55
|
| Rate for Payer: Humana Commercial |
$12,321.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,886.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,697.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,348.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,755.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,871.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,596.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,610.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,001.77
|
| Rate for Payer: PHCS Commercial |
$13,915.51
|
| Rate for Payer: United Healthcare All Payer |
$12,755.88
|
|
|
GRAFT Z ILIAC LEG TFLE-10-71
|
Facility
|
OP
|
$14,495.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,348.60 |
| Max. Negotiated Rate |
$13,915.51 |
| Rate for Payer: Aetna Commercial |
$11,161.40
|
| Rate for Payer: Anthem Medicaid |
$4,984.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,306.35
|
| Rate for Payer: Cash Price |
$7,247.66
|
| Rate for Payer: Cigna Commercial |
$12,031.12
|
| Rate for Payer: First Health Commercial |
$13,770.55
|
| Rate for Payer: Humana Commercial |
$12,321.02
|
| Rate for Payer: Humana KY Medicaid |
$4,984.94
|
| Rate for Payer: Kentucky WC Medicaid |
$5,035.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,886.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,697.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,348.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,084.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,755.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,871.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,596.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,610.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,001.77
|
| Rate for Payer: PHCS Commercial |
$13,915.51
|
| Rate for Payer: United Healthcare All Payer |
$12,755.88
|
|
|
GRAFT Z ILIAC LEG TFLE-10-88
|
Facility
|
OP
|
$14,495.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,348.60 |
| Max. Negotiated Rate |
$13,915.51 |
| Rate for Payer: Aetna Commercial |
$11,161.40
|
| Rate for Payer: Anthem Medicaid |
$4,984.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,306.35
|
| Rate for Payer: Cash Price |
$7,247.66
|
| Rate for Payer: Cigna Commercial |
$12,031.12
|
| Rate for Payer: First Health Commercial |
$13,770.55
|
| Rate for Payer: Humana Commercial |
$12,321.02
|
| Rate for Payer: Humana KY Medicaid |
$4,984.94
|
| Rate for Payer: Kentucky WC Medicaid |
$5,035.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,886.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,697.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,348.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,084.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,755.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,871.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,596.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,610.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,001.77
|
| Rate for Payer: PHCS Commercial |
$13,915.51
|
| Rate for Payer: United Healthcare All Payer |
$12,755.88
|
|
|
GRAFT Z ILIAC LEG TFLE-10-88
|
Facility
|
IP
|
$14,495.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,348.60 |
| Max. Negotiated Rate |
$13,915.51 |
| Rate for Payer: Aetna Commercial |
$11,161.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,306.35
|
| Rate for Payer: Cash Price |
$7,247.66
|
| Rate for Payer: Cigna Commercial |
$12,031.12
|
| Rate for Payer: First Health Commercial |
$13,770.55
|
| Rate for Payer: Humana Commercial |
$12,321.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,886.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,697.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,348.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,755.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,871.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,596.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,610.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,001.77
|
| Rate for Payer: PHCS Commercial |
$13,915.51
|
| Rate for Payer: United Healthcare All Payer |
$12,755.88
|
|
|
GRAFT Z ILIAC LEG TFLE-12-105
|
Facility
|
OP
|
$14,495.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,348.60 |
| Max. Negotiated Rate |
$13,915.51 |
| Rate for Payer: Aetna Commercial |
$11,161.40
|
| Rate for Payer: Anthem Medicaid |
$4,984.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,306.35
|
| Rate for Payer: Cash Price |
$7,247.66
|
| Rate for Payer: Cigna Commercial |
$12,031.12
|
| Rate for Payer: First Health Commercial |
$13,770.55
|
| Rate for Payer: Humana Commercial |
$12,321.02
|
| Rate for Payer: Humana KY Medicaid |
$4,984.94
|
| Rate for Payer: Kentucky WC Medicaid |
$5,035.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,886.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,697.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,348.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,084.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,755.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,871.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,596.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,610.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,001.77
|
| Rate for Payer: PHCS Commercial |
$13,915.51
|
| Rate for Payer: United Healthcare All Payer |
$12,755.88
|
|
|
GRAFT Z ILIAC LEG TFLE-12-105
|
Facility
|
IP
|
$14,495.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,348.60 |
| Max. Negotiated Rate |
$13,915.51 |
| Rate for Payer: Aetna Commercial |
$11,161.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,306.35
|
| Rate for Payer: Cash Price |
$7,247.66
|
| Rate for Payer: Cigna Commercial |
$12,031.12
|
| Rate for Payer: First Health Commercial |
$13,770.55
|
| Rate for Payer: Humana Commercial |
$12,321.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,886.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,697.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,348.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,755.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,871.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,596.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,610.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,001.77
|
| Rate for Payer: PHCS Commercial |
$13,915.51
|
| Rate for Payer: United Healthcare All Payer |
$12,755.88
|
|
|
GRAFT Z ILIAC LEG TFLE-12-122
|
Facility
|
IP
|
$14,010.88
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,203.26 |
| Max. Negotiated Rate |
$13,450.44 |
| Rate for Payer: Aetna Commercial |
$10,788.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,928.49
|
| Rate for Payer: Cash Price |
$7,005.44
|
| Rate for Payer: Cigna Commercial |
$11,629.03
|
| Rate for Payer: First Health Commercial |
$13,310.34
|
| Rate for Payer: Humana Commercial |
$11,909.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,488.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,340.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,203.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,329.57
|
| Rate for Payer: Ohio Health Group HMO |
$10,508.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,208.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,189.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,667.51
|
| Rate for Payer: PHCS Commercial |
$13,450.44
|
| Rate for Payer: United Healthcare All Payer |
$12,329.57
|
|
|
GRAFT Z ILIAC LEG TFLE-12-122
|
Facility
|
OP
|
$14,010.88
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,203.26 |
| Max. Negotiated Rate |
$13,450.44 |
| Rate for Payer: Aetna Commercial |
$10,788.38
|
| Rate for Payer: Anthem Medicaid |
$4,818.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,928.49
|
| Rate for Payer: Cash Price |
$7,005.44
|
| Rate for Payer: Cigna Commercial |
$11,629.03
|
| Rate for Payer: First Health Commercial |
$13,310.34
|
| Rate for Payer: Humana Commercial |
$11,909.25
|
| Rate for Payer: Humana KY Medicaid |
$4,818.34
|
| Rate for Payer: Kentucky WC Medicaid |
$4,867.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,488.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,340.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,203.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,915.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,329.57
|
| Rate for Payer: Ohio Health Group HMO |
$10,508.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,208.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,189.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,667.51
|
| Rate for Payer: PHCS Commercial |
$13,450.44
|
| Rate for Payer: United Healthcare All Payer |
$12,329.57
|
|
|
GRAFT Z ILIAC LEG TFLE-12-37
|
Facility
|
IP
|
$14,495.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,348.60 |
| Max. Negotiated Rate |
$13,915.51 |
| Rate for Payer: Aetna Commercial |
$11,161.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,306.35
|
| Rate for Payer: Cash Price |
$7,247.66
|
| Rate for Payer: Cigna Commercial |
$12,031.12
|
| Rate for Payer: First Health Commercial |
$13,770.55
|
| Rate for Payer: Humana Commercial |
$12,321.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,886.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,697.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,348.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,755.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,871.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,596.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,610.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,001.77
|
| Rate for Payer: PHCS Commercial |
$13,915.51
|
| Rate for Payer: United Healthcare All Payer |
$12,755.88
|
|
|
GRAFT Z ILIAC LEG TFLE-12-37
|
Facility
|
OP
|
$14,495.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,348.60 |
| Max. Negotiated Rate |
$13,915.51 |
| Rate for Payer: Aetna Commercial |
$11,161.40
|
| Rate for Payer: Anthem Medicaid |
$4,984.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,306.35
|
| Rate for Payer: Cash Price |
$7,247.66
|
| Rate for Payer: Cigna Commercial |
$12,031.12
|
| Rate for Payer: First Health Commercial |
$13,770.55
|
| Rate for Payer: Humana Commercial |
$12,321.02
|
| Rate for Payer: Humana KY Medicaid |
$4,984.94
|
| Rate for Payer: Kentucky WC Medicaid |
$5,035.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,886.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,697.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,348.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,084.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,755.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,871.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,596.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,610.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,001.77
|
| Rate for Payer: PHCS Commercial |
$13,915.51
|
| Rate for Payer: United Healthcare All Payer |
$12,755.88
|
|
|
GRAFT Z ILIAC LEG TFLE-12-54
|
Facility
|
IP
|
$14,495.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,348.60 |
| Max. Negotiated Rate |
$13,915.51 |
| Rate for Payer: Aetna Commercial |
$11,161.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,306.35
|
| Rate for Payer: Cash Price |
$7,247.66
|
| Rate for Payer: Cigna Commercial |
$12,031.12
|
| Rate for Payer: First Health Commercial |
$13,770.55
|
| Rate for Payer: Humana Commercial |
$12,321.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,886.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,697.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,348.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,755.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,871.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,596.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,610.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,001.77
|
| Rate for Payer: PHCS Commercial |
$13,915.51
|
| Rate for Payer: United Healthcare All Payer |
$12,755.88
|
|
|
GRAFT Z ILIAC LEG TFLE-12-54
|
Facility
|
OP
|
$14,495.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,348.60 |
| Max. Negotiated Rate |
$13,915.51 |
| Rate for Payer: Aetna Commercial |
$11,161.40
|
| Rate for Payer: Anthem Medicaid |
$4,984.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,306.35
|
| Rate for Payer: Cash Price |
$7,247.66
|
| Rate for Payer: Cigna Commercial |
$12,031.12
|
| Rate for Payer: First Health Commercial |
$13,770.55
|
| Rate for Payer: Humana Commercial |
$12,321.02
|
| Rate for Payer: Humana KY Medicaid |
$4,984.94
|
| Rate for Payer: Kentucky WC Medicaid |
$5,035.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,886.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,697.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,348.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,084.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,755.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,871.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,596.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,610.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,001.77
|
| Rate for Payer: PHCS Commercial |
$13,915.51
|
| Rate for Payer: United Healthcare All Payer |
$12,755.88
|
|
|
GRAFT Z ILIAC LEG TFLE-12-71
|
Facility
|
IP
|
$14,495.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,348.60 |
| Max. Negotiated Rate |
$13,915.51 |
| Rate for Payer: Aetna Commercial |
$11,161.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,306.35
|
| Rate for Payer: Cash Price |
$7,247.66
|
| Rate for Payer: Cigna Commercial |
$12,031.12
|
| Rate for Payer: First Health Commercial |
$13,770.55
|
| Rate for Payer: Humana Commercial |
$12,321.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,886.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,697.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,348.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,755.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,871.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,596.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,610.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,001.77
|
| Rate for Payer: PHCS Commercial |
$13,915.51
|
| Rate for Payer: United Healthcare All Payer |
$12,755.88
|
|
|
GRAFT Z ILIAC LEG TFLE-12-71
|
Facility
|
OP
|
$14,495.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,348.60 |
| Max. Negotiated Rate |
$13,915.51 |
| Rate for Payer: Aetna Commercial |
$11,161.40
|
| Rate for Payer: Anthem Medicaid |
$4,984.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,306.35
|
| Rate for Payer: Cash Price |
$7,247.66
|
| Rate for Payer: Cigna Commercial |
$12,031.12
|
| Rate for Payer: First Health Commercial |
$13,770.55
|
| Rate for Payer: Humana Commercial |
$12,321.02
|
| Rate for Payer: Humana KY Medicaid |
$4,984.94
|
| Rate for Payer: Kentucky WC Medicaid |
$5,035.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,886.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,697.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,348.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,084.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,755.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,871.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,596.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,610.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,001.77
|
| Rate for Payer: PHCS Commercial |
$13,915.51
|
| Rate for Payer: United Healthcare All Payer |
$12,755.88
|
|
|
GRAFT Z ILIAC LEG TFLE-12-88
|
Facility
|
IP
|
$36,717.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,015.25 |
| Max. Negotiated Rate |
$35,248.80 |
| Rate for Payer: Aetna Commercial |
$28,272.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28,639.65
|
| Rate for Payer: Cash Price |
$18,358.75
|
| Rate for Payer: Cigna Commercial |
$30,475.53
|
| Rate for Payer: First Health Commercial |
$34,881.62
|
| Rate for Payer: Humana Commercial |
$31,209.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30,108.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27,097.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,015.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$32,311.40
|
| Rate for Payer: Ohio Health Group HMO |
$27,538.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29,374.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31,944.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25,335.08
|
| Rate for Payer: PHCS Commercial |
$35,248.80
|
| Rate for Payer: United Healthcare All Payer |
$32,311.40
|
|
