|
GRAFT Z ILIAC LEG ZSLE-16-39-Z
|
Facility
|
IP
|
$21,605.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,481.50 |
| Max. Negotiated Rate |
$20,740.80 |
| Rate for Payer: Aetna Commercial |
$16,635.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,851.90
|
| Rate for Payer: Cash Price |
$10,802.50
|
| Rate for Payer: Cigna Commercial |
$17,932.15
|
| Rate for Payer: First Health Commercial |
$20,524.75
|
| Rate for Payer: Humana Commercial |
$18,364.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,716.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,944.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,481.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,012.40
|
| Rate for Payer: Ohio Health Group HMO |
$16,203.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,284.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,796.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,907.45
|
| Rate for Payer: PHCS Commercial |
$20,740.80
|
| Rate for Payer: United Healthcare All Payer |
$19,012.40
|
|
|
GRAFT Z ILIAC LEG ZSLE-16-39-Z
|
Facility
|
OP
|
$21,605.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,481.50 |
| Max. Negotiated Rate |
$20,740.80 |
| Rate for Payer: Aetna Commercial |
$16,635.85
|
| Rate for Payer: Anthem Medicaid |
$7,429.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,851.90
|
| Rate for Payer: Cash Price |
$10,802.50
|
| Rate for Payer: Cigna Commercial |
$17,932.15
|
| Rate for Payer: First Health Commercial |
$20,524.75
|
| Rate for Payer: Humana Commercial |
$18,364.25
|
| Rate for Payer: Humana KY Medicaid |
$7,429.96
|
| Rate for Payer: Kentucky WC Medicaid |
$7,505.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,716.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,944.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,481.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,579.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,012.40
|
| Rate for Payer: Ohio Health Group HMO |
$16,203.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,284.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,796.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,907.45
|
| Rate for Payer: PHCS Commercial |
$20,740.80
|
| Rate for Payer: United Healthcare All Payer |
$19,012.40
|
|
|
GRAFT Z ILIAC LEG ZSLE-16-56-Z
|
Facility
|
IP
|
$21,121.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,336.38 |
| Max. Negotiated Rate |
$20,276.40 |
| Rate for Payer: Aetna Commercial |
$16,263.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,474.58
|
| Rate for Payer: Cash Price |
$10,560.62
|
| Rate for Payer: Cigna Commercial |
$17,530.64
|
| Rate for Payer: First Health Commercial |
$20,065.19
|
| Rate for Payer: Humana Commercial |
$17,953.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,319.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,587.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,336.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,586.70
|
| Rate for Payer: Ohio Health Group HMO |
$15,840.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,897.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,375.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,573.66
|
| Rate for Payer: PHCS Commercial |
$20,276.40
|
| Rate for Payer: United Healthcare All Payer |
$18,586.70
|
|
|
GRAFT Z ILIAC LEG ZSLE-16-56-Z
|
Facility
|
OP
|
$21,121.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,336.38 |
| Max. Negotiated Rate |
$20,276.40 |
| Rate for Payer: Aetna Commercial |
$16,263.36
|
| Rate for Payer: Anthem Medicaid |
$7,263.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,474.58
|
| Rate for Payer: Cash Price |
$10,560.62
|
| Rate for Payer: Cigna Commercial |
$17,530.64
|
| Rate for Payer: First Health Commercial |
$20,065.19
|
| Rate for Payer: Humana Commercial |
$17,953.06
|
| Rate for Payer: Humana KY Medicaid |
$7,263.60
|
| Rate for Payer: Kentucky WC Medicaid |
$7,337.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,319.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,587.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,336.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,409.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,586.70
|
| Rate for Payer: Ohio Health Group HMO |
$15,840.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,897.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,375.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,573.66
|
| Rate for Payer: PHCS Commercial |
$20,276.40
|
| Rate for Payer: United Healthcare All Payer |
$18,586.70
|
|
|
GRAFT Z ILIAC LEG ZSLE-16-74-Z
|
Facility
|
OP
|
$22,437.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,731.25 |
| Max. Negotiated Rate |
$21,540.00 |
| Rate for Payer: Aetna Commercial |
$17,276.88
|
| Rate for Payer: Anthem Medicaid |
$7,716.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,501.25
|
| Rate for Payer: Cash Price |
$11,218.75
|
| Rate for Payer: Cigna Commercial |
$18,623.12
|
| Rate for Payer: First Health Commercial |
$21,315.62
|
| Rate for Payer: Humana Commercial |
$19,071.88
|
| Rate for Payer: Humana KY Medicaid |
$7,716.26
|
| Rate for Payer: Kentucky WC Medicaid |
$7,794.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,398.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,558.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,731.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,871.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,745.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,828.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,520.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,481.88
|
| Rate for Payer: PHCS Commercial |
$21,540.00
|
| Rate for Payer: United Healthcare All Payer |
$19,745.00
|
|
|
GRAFT Z ILIAC LEG ZSLE-16-74-Z
|
Facility
|
IP
|
$22,437.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,731.25 |
| Max. Negotiated Rate |
$21,540.00 |
| Rate for Payer: Aetna Commercial |
$17,276.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,501.25
|
| Rate for Payer: Cash Price |
$11,218.75
|
| Rate for Payer: Cigna Commercial |
$18,623.12
|
| Rate for Payer: First Health Commercial |
$21,315.62
|
| Rate for Payer: Humana Commercial |
$19,071.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,398.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,558.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,731.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,745.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,828.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,520.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,481.88
|
| Rate for Payer: PHCS Commercial |
$21,540.00
|
| Rate for Payer: United Healthcare All Payer |
$19,745.00
|
|
|
GRAFT Z ILIAC LEG ZSLE-16-90-Z
|
Facility
|
IP
|
$20,431.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,129.38 |
| Max. Negotiated Rate |
$19,614.00 |
| Rate for Payer: Aetna Commercial |
$15,732.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,936.38
|
| Rate for Payer: Cash Price |
$10,215.62
|
| Rate for Payer: Cigna Commercial |
$16,957.94
|
| Rate for Payer: First Health Commercial |
$19,409.69
|
| Rate for Payer: Humana Commercial |
$17,366.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,753.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,078.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,129.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,979.50
|
| Rate for Payer: Ohio Health Group HMO |
$15,323.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,345.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,775.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,097.56
|
| Rate for Payer: PHCS Commercial |
$19,614.00
|
| Rate for Payer: United Healthcare All Payer |
$17,979.50
|
|
|
GRAFT Z ILIAC LEG ZSLE-16-90-Z
|
Facility
|
OP
|
$20,431.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,129.38 |
| Max. Negotiated Rate |
$19,614.00 |
| Rate for Payer: Aetna Commercial |
$15,732.06
|
| Rate for Payer: Anthem Medicaid |
$7,026.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,936.38
|
| Rate for Payer: Cash Price |
$10,215.62
|
| Rate for Payer: Cigna Commercial |
$16,957.94
|
| Rate for Payer: First Health Commercial |
$19,409.69
|
| Rate for Payer: Humana Commercial |
$17,366.56
|
| Rate for Payer: Humana KY Medicaid |
$7,026.31
|
| Rate for Payer: Kentucky WC Medicaid |
$7,097.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,753.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,078.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,129.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,167.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,979.50
|
| Rate for Payer: Ohio Health Group HMO |
$15,323.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,345.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,775.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,097.56
|
| Rate for Payer: PHCS Commercial |
$19,614.00
|
| Rate for Payer: United Healthcare All Payer |
$17,979.50
|
|
|
GRAFT Z ILIAC LEG ZSLE-20-39-Z
|
Facility
|
IP
|
$18,748.60
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,624.58 |
| Max. Negotiated Rate |
$17,998.66 |
| Rate for Payer: Aetna Commercial |
$14,436.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,623.91
|
| Rate for Payer: Cash Price |
$9,374.30
|
| Rate for Payer: Cigna Commercial |
$15,561.34
|
| Rate for Payer: First Health Commercial |
$17,811.17
|
| Rate for Payer: Humana Commercial |
$15,936.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,373.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,836.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,624.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,498.77
|
| Rate for Payer: Ohio Health Group HMO |
$14,061.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,998.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,311.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,936.53
|
| Rate for Payer: PHCS Commercial |
$17,998.66
|
| Rate for Payer: United Healthcare All Payer |
$16,498.77
|
|
|
GRAFT Z ILIAC LEG ZSLE-20-39-Z
|
Facility
|
OP
|
$18,748.60
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,624.58 |
| Max. Negotiated Rate |
$17,998.66 |
| Rate for Payer: Aetna Commercial |
$14,436.42
|
| Rate for Payer: Anthem Medicaid |
$6,447.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,623.91
|
| Rate for Payer: Cash Price |
$9,374.30
|
| Rate for Payer: Cigna Commercial |
$15,561.34
|
| Rate for Payer: First Health Commercial |
$17,811.17
|
| Rate for Payer: Humana Commercial |
$15,936.31
|
| Rate for Payer: Humana KY Medicaid |
$6,447.64
|
| Rate for Payer: Kentucky WC Medicaid |
$6,513.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,373.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,836.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,624.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,577.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,498.77
|
| Rate for Payer: Ohio Health Group HMO |
$14,061.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,998.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,311.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,936.53
|
| Rate for Payer: PHCS Commercial |
$17,998.66
|
| Rate for Payer: United Healthcare All Payer |
$16,498.77
|
|
|
GRAFT Z ILIAC LEG ZSLE-20-56-Z
|
Facility
|
OP
|
$21,605.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,481.50 |
| Max. Negotiated Rate |
$20,740.80 |
| Rate for Payer: Aetna Commercial |
$16,635.85
|
| Rate for Payer: Anthem Medicaid |
$7,429.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,851.90
|
| Rate for Payer: Cash Price |
$10,802.50
|
| Rate for Payer: Cigna Commercial |
$17,932.15
|
| Rate for Payer: First Health Commercial |
$20,524.75
|
| Rate for Payer: Humana Commercial |
$18,364.25
|
| Rate for Payer: Humana KY Medicaid |
$7,429.96
|
| Rate for Payer: Kentucky WC Medicaid |
$7,505.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,716.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,944.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,481.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,579.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,012.40
|
| Rate for Payer: Ohio Health Group HMO |
$16,203.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,284.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,796.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,907.45
|
| Rate for Payer: PHCS Commercial |
$20,740.80
|
| Rate for Payer: United Healthcare All Payer |
$19,012.40
|
|
|
GRAFT Z ILIAC LEG ZSLE-20-56-Z
|
Facility
|
IP
|
$21,605.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,481.50 |
| Max. Negotiated Rate |
$20,740.80 |
| Rate for Payer: Aetna Commercial |
$16,635.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,851.90
|
| Rate for Payer: Cash Price |
$10,802.50
|
| Rate for Payer: Cigna Commercial |
$17,932.15
|
| Rate for Payer: First Health Commercial |
$20,524.75
|
| Rate for Payer: Humana Commercial |
$18,364.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,716.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,944.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,481.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,012.40
|
| Rate for Payer: Ohio Health Group HMO |
$16,203.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,284.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,796.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,907.45
|
| Rate for Payer: PHCS Commercial |
$20,740.80
|
| Rate for Payer: United Healthcare All Payer |
$19,012.40
|
|
|
GRAFT Z ILIAC LEG ZSLE-20-74-Z
|
Facility
|
OP
|
$21,121.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,336.38 |
| Max. Negotiated Rate |
$20,276.40 |
| Rate for Payer: Aetna Commercial |
$16,263.36
|
| Rate for Payer: Anthem Medicaid |
$7,263.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,474.58
|
| Rate for Payer: Cash Price |
$10,560.62
|
| Rate for Payer: Cigna Commercial |
$17,530.64
|
| Rate for Payer: First Health Commercial |
$20,065.19
|
| Rate for Payer: Humana Commercial |
$17,953.06
|
| Rate for Payer: Humana KY Medicaid |
$7,263.60
|
| Rate for Payer: Kentucky WC Medicaid |
$7,337.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,319.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,587.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,336.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,409.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,586.70
|
| Rate for Payer: Ohio Health Group HMO |
$15,840.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,897.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,375.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,573.66
|
| Rate for Payer: PHCS Commercial |
$20,276.40
|
| Rate for Payer: United Healthcare All Payer |
$18,586.70
|
|
|
GRAFT Z ILIAC LEG ZSLE-20-74-Z
|
Facility
|
IP
|
$21,121.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,336.38 |
| Max. Negotiated Rate |
$20,276.40 |
| Rate for Payer: Aetna Commercial |
$16,263.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,474.58
|
| Rate for Payer: Cash Price |
$10,560.62
|
| Rate for Payer: Cigna Commercial |
$17,530.64
|
| Rate for Payer: First Health Commercial |
$20,065.19
|
| Rate for Payer: Humana Commercial |
$17,953.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,319.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,587.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,336.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,586.70
|
| Rate for Payer: Ohio Health Group HMO |
$15,840.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,897.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,375.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,573.66
|
| Rate for Payer: PHCS Commercial |
$20,276.40
|
| Rate for Payer: United Healthcare All Payer |
$18,586.70
|
|
|
GRAFT Z ILIAC LEG ZSLE-20-90-Z
|
Facility
|
OP
|
$20,431.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,129.38 |
| Max. Negotiated Rate |
$19,614.00 |
| Rate for Payer: Aetna Commercial |
$15,732.06
|
| Rate for Payer: Anthem Medicaid |
$7,026.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,936.38
|
| Rate for Payer: Cash Price |
$10,215.62
|
| Rate for Payer: Cigna Commercial |
$16,957.94
|
| Rate for Payer: First Health Commercial |
$19,409.69
|
| Rate for Payer: Humana Commercial |
$17,366.56
|
| Rate for Payer: Humana KY Medicaid |
$7,026.31
|
| Rate for Payer: Kentucky WC Medicaid |
$7,097.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,753.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,078.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,129.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,167.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,979.50
|
| Rate for Payer: Ohio Health Group HMO |
$15,323.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,345.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,775.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,097.56
|
| Rate for Payer: PHCS Commercial |
$19,614.00
|
| Rate for Payer: United Healthcare All Payer |
$17,979.50
|
|
|
GRAFT Z ILIAC LEG ZSLE-20-90-Z
|
Facility
|
IP
|
$20,431.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,129.38 |
| Max. Negotiated Rate |
$19,614.00 |
| Rate for Payer: Aetna Commercial |
$15,732.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,936.38
|
| Rate for Payer: Cash Price |
$10,215.62
|
| Rate for Payer: Cigna Commercial |
$16,957.94
|
| Rate for Payer: First Health Commercial |
$19,409.69
|
| Rate for Payer: Humana Commercial |
$17,366.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,753.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,078.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,129.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,979.50
|
| Rate for Payer: Ohio Health Group HMO |
$15,323.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,345.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,775.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,097.56
|
| Rate for Payer: PHCS Commercial |
$19,614.00
|
| Rate for Payer: United Healthcare All Payer |
$17,979.50
|
|
|
GRAFT Z ILIAC LEG ZSLE-24-39-Z
|
Facility
|
IP
|
$18,330.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,499.15 |
| Max. Negotiated Rate |
$17,597.28 |
| Rate for Payer: Aetna Commercial |
$14,114.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,297.79
|
| Rate for Payer: Cash Price |
$9,165.25
|
| Rate for Payer: Cigna Commercial |
$15,214.32
|
| Rate for Payer: First Health Commercial |
$17,413.97
|
| Rate for Payer: Humana Commercial |
$15,580.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,031.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,527.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,499.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,130.84
|
| Rate for Payer: Ohio Health Group HMO |
$13,747.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,664.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,947.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,648.05
|
| Rate for Payer: PHCS Commercial |
$17,597.28
|
| Rate for Payer: United Healthcare All Payer |
$16,130.84
|
|
|
GRAFT Z ILIAC LEG ZSLE-24-39-Z
|
Facility
|
OP
|
$18,330.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,499.15 |
| Max. Negotiated Rate |
$17,597.28 |
| Rate for Payer: Aetna Commercial |
$14,114.49
|
| Rate for Payer: Anthem Medicaid |
$6,303.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,297.79
|
| Rate for Payer: Cash Price |
$9,165.25
|
| Rate for Payer: Cigna Commercial |
$15,214.32
|
| Rate for Payer: First Health Commercial |
$17,413.97
|
| Rate for Payer: Humana Commercial |
$15,580.92
|
| Rate for Payer: Humana KY Medicaid |
$6,303.86
|
| Rate for Payer: Kentucky WC Medicaid |
$6,368.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,031.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,527.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,499.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,430.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,130.84
|
| Rate for Payer: Ohio Health Group HMO |
$13,747.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,664.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,947.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,648.05
|
| Rate for Payer: PHCS Commercial |
$17,597.28
|
| Rate for Payer: United Healthcare All Payer |
$16,130.84
|
|
|
GRAFT Z ILIAC LEG ZSLE-24-56-Z
|
Facility
|
OP
|
$21,121.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,336.38 |
| Max. Negotiated Rate |
$20,276.40 |
| Rate for Payer: Aetna Commercial |
$16,263.36
|
| Rate for Payer: Anthem Medicaid |
$7,263.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,474.58
|
| Rate for Payer: Cash Price |
$10,560.62
|
| Rate for Payer: Cigna Commercial |
$17,530.64
|
| Rate for Payer: First Health Commercial |
$20,065.19
|
| Rate for Payer: Humana Commercial |
$17,953.06
|
| Rate for Payer: Humana KY Medicaid |
$7,263.60
|
| Rate for Payer: Kentucky WC Medicaid |
$7,337.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,319.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,587.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,336.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,409.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,586.70
|
| Rate for Payer: Ohio Health Group HMO |
$15,840.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,897.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,375.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,573.66
|
| Rate for Payer: PHCS Commercial |
$20,276.40
|
| Rate for Payer: United Healthcare All Payer |
$18,586.70
|
|
|
GRAFT Z ILIAC LEG ZSLE-24-56-Z
|
Facility
|
IP
|
$21,121.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,336.38 |
| Max. Negotiated Rate |
$20,276.40 |
| Rate for Payer: Aetna Commercial |
$16,263.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,474.58
|
| Rate for Payer: Cash Price |
$10,560.62
|
| Rate for Payer: Cigna Commercial |
$17,530.64
|
| Rate for Payer: First Health Commercial |
$20,065.19
|
| Rate for Payer: Humana Commercial |
$17,953.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,319.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,587.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,336.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,586.70
|
| Rate for Payer: Ohio Health Group HMO |
$15,840.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,897.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,375.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,573.66
|
| Rate for Payer: PHCS Commercial |
$20,276.40
|
| Rate for Payer: United Healthcare All Payer |
$18,586.70
|
|
|
GRAFT Z ILIAC LEG ZSLE-24-74-Z
|
Facility
|
OP
|
$19,179.06
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,753.72 |
| Max. Negotiated Rate |
$18,411.90 |
| Rate for Payer: Aetna Commercial |
$14,767.88
|
| Rate for Payer: Anthem Medicaid |
$6,595.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,959.67
|
| Rate for Payer: Cash Price |
$9,589.53
|
| Rate for Payer: Cigna Commercial |
$15,918.62
|
| Rate for Payer: First Health Commercial |
$18,220.11
|
| Rate for Payer: Humana Commercial |
$16,302.20
|
| Rate for Payer: Humana KY Medicaid |
$6,595.68
|
| Rate for Payer: Kentucky WC Medicaid |
$6,662.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,726.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,154.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,753.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,728.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,877.57
|
| Rate for Payer: Ohio Health Group HMO |
$14,384.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,343.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,685.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,233.55
|
| Rate for Payer: PHCS Commercial |
$18,411.90
|
| Rate for Payer: United Healthcare All Payer |
$16,877.57
|
|
|
GRAFT Z ILIAC LEG ZSLE-24-74-Z
|
Facility
|
IP
|
$19,179.06
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,753.72 |
| Max. Negotiated Rate |
$18,411.90 |
| Rate for Payer: Aetna Commercial |
$14,767.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,959.67
|
| Rate for Payer: Cash Price |
$9,589.53
|
| Rate for Payer: Cigna Commercial |
$15,918.62
|
| Rate for Payer: First Health Commercial |
$18,220.11
|
| Rate for Payer: Humana Commercial |
$16,302.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,726.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,154.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,753.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,877.57
|
| Rate for Payer: Ohio Health Group HMO |
$14,384.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,343.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,685.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,233.55
|
| Rate for Payer: PHCS Commercial |
$18,411.90
|
| Rate for Payer: United Healthcare All Payer |
$16,877.57
|
|
|
GRAFT Z MAIN BDY EXT ESBE3239Z
|
Facility
|
OP
|
$11,063.87
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,319.16 |
| Max. Negotiated Rate |
$10,621.32 |
| Rate for Payer: Aetna Commercial |
$8,519.18
|
| Rate for Payer: Anthem Medicaid |
$3,804.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,629.82
|
| Rate for Payer: Cash Price |
$5,531.94
|
| Rate for Payer: Cigna Commercial |
$9,183.01
|
| Rate for Payer: First Health Commercial |
$10,510.68
|
| Rate for Payer: Humana Commercial |
$9,404.29
|
| Rate for Payer: Humana KY Medicaid |
$3,804.86
|
| Rate for Payer: Kentucky WC Medicaid |
$3,843.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,072.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,165.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,319.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,881.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,736.21
|
| Rate for Payer: Ohio Health Group HMO |
$8,297.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,851.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,625.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,634.07
|
| Rate for Payer: PHCS Commercial |
$10,621.32
|
| Rate for Payer: United Healthcare All Payer |
$9,736.21
|
|
|
GRAFT Z MAIN BDY EXT ESBE3239Z
|
Facility
|
IP
|
$11,063.87
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,319.16 |
| Max. Negotiated Rate |
$10,621.32 |
| Rate for Payer: Aetna Commercial |
$8,519.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,629.82
|
| Rate for Payer: Cash Price |
$5,531.94
|
| Rate for Payer: Cigna Commercial |
$9,183.01
|
| Rate for Payer: First Health Commercial |
$10,510.68
|
| Rate for Payer: Humana Commercial |
$9,404.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,072.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,165.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,319.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,736.21
|
| Rate for Payer: Ohio Health Group HMO |
$8,297.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,851.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,625.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,634.07
|
| Rate for Payer: PHCS Commercial |
$10,621.32
|
| Rate for Payer: United Healthcare All Payer |
$9,736.21
|
|
|
GRAFT Z MAIN BDY TFFB-22-82-ZT
|
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
|
|
