|
GRAFT Z MAIN BODY TFFB-28-140
|
Facility
|
IP
|
$35,795.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,738.50 |
| Max. Negotiated Rate |
$34,363.20 |
| Rate for Payer: Aetna Commercial |
$27,562.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,920.10
|
| Rate for Payer: Cash Price |
$17,897.50
|
| Rate for Payer: Cigna Commercial |
$29,709.85
|
| Rate for Payer: First Health Commercial |
$34,005.25
|
| Rate for Payer: Humana Commercial |
$30,425.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,351.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,416.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,738.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,499.60
|
| Rate for Payer: Ohio Health Group HMO |
$26,846.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28,636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31,141.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,698.55
|
| Rate for Payer: PHCS Commercial |
$34,363.20
|
| Rate for Payer: United Healthcare All Payer |
$31,499.60
|
|
|
GRAFT Z MAIN BODY TFFB-28-82
|
Facility
|
IP
|
$34,441.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,332.38 |
| Max. Negotiated Rate |
$33,063.60 |
| Rate for Payer: Aetna Commercial |
$26,519.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,864.17
|
| Rate for Payer: Cash Price |
$17,220.62
|
| Rate for Payer: Cigna Commercial |
$28,586.24
|
| Rate for Payer: First Health Commercial |
$32,719.19
|
| Rate for Payer: Humana Commercial |
$29,275.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,241.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,417.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,332.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,308.30
|
| Rate for Payer: Ohio Health Group HMO |
$25,830.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27,553.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29,963.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,764.46
|
| Rate for Payer: PHCS Commercial |
$33,063.60
|
| Rate for Payer: United Healthcare All Payer |
$30,308.30
|
|
|
GRAFT Z MAIN BODY TFFB-28-82
|
Facility
|
OP
|
$34,441.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,332.38 |
| Max. Negotiated Rate |
$33,063.60 |
| Rate for Payer: Aetna Commercial |
$26,519.76
|
| Rate for Payer: Anthem Medicaid |
$11,844.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,864.17
|
| Rate for Payer: Cash Price |
$17,220.62
|
| Rate for Payer: Cigna Commercial |
$28,586.24
|
| Rate for Payer: First Health Commercial |
$32,719.19
|
| Rate for Payer: Humana Commercial |
$29,275.06
|
| Rate for Payer: Humana KY Medicaid |
$11,844.35
|
| Rate for Payer: Kentucky WC Medicaid |
$11,964.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28,241.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,417.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,332.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,081.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$30,308.30
|
| Rate for Payer: Ohio Health Group HMO |
$25,830.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27,553.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29,963.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,764.46
|
| Rate for Payer: PHCS Commercial |
$33,063.60
|
| Rate for Payer: United Healthcare All Payer |
$30,308.30
|
|
|
GRAFT Z MAIN BODY TFFB-28-82-Z
|
Facility
|
OP
|
$67,876.20
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$20,362.86 |
| Max. Negotiated Rate |
$65,161.15 |
| Rate for Payer: Aetna Commercial |
$52,264.67
|
| Rate for Payer: Anthem Medicaid |
$23,342.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52,943.44
|
| Rate for Payer: Cash Price |
$33,938.10
|
| Rate for Payer: Cigna Commercial |
$56,337.25
|
| Rate for Payer: First Health Commercial |
$64,482.39
|
| Rate for Payer: Humana Commercial |
$57,694.77
|
| Rate for Payer: Humana KY Medicaid |
$23,342.63
|
| Rate for Payer: Kentucky WC Medicaid |
$23,580.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55,658.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50,092.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,362.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$23,810.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$59,731.06
|
| Rate for Payer: Ohio Health Group HMO |
$50,907.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$54,300.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59,052.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46,834.58
|
| Rate for Payer: PHCS Commercial |
$65,161.15
|
| Rate for Payer: United Healthcare All Payer |
$59,731.06
|
|
|
GRAFT Z MAIN BODY TFFB-28-82-Z
|
Facility
|
IP
|
$67,876.20
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$20,362.86 |
| Max. Negotiated Rate |
$65,161.15 |
| Rate for Payer: Aetna Commercial |
$52,264.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52,943.44
|
| Rate for Payer: Cash Price |
$33,938.10
|
| Rate for Payer: Cigna Commercial |
$56,337.25
|
| Rate for Payer: First Health Commercial |
$64,482.39
|
| Rate for Payer: Humana Commercial |
$57,694.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55,658.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50,092.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,362.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$59,731.06
|
| Rate for Payer: Ohio Health Group HMO |
$50,907.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$54,300.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59,052.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46,834.58
|
| Rate for Payer: PHCS Commercial |
$65,161.15
|
| Rate for Payer: United Healthcare All Payer |
$59,731.06
|
|
|
GRAFT Z MAIN BODY TFFB-28-96
|
Facility
|
OP
|
$35,795.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,738.50 |
| Max. Negotiated Rate |
$34,363.20 |
| Rate for Payer: Aetna Commercial |
$27,562.15
|
| Rate for Payer: Anthem Medicaid |
$12,309.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,920.10
|
| Rate for Payer: Cash Price |
$17,897.50
|
| Rate for Payer: Cigna Commercial |
$29,709.85
|
| Rate for Payer: First Health Commercial |
$34,005.25
|
| Rate for Payer: Humana Commercial |
$30,425.75
|
| Rate for Payer: Humana KY Medicaid |
$12,309.90
|
| Rate for Payer: Kentucky WC Medicaid |
$12,435.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,351.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,416.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,738.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,556.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,499.60
|
| Rate for Payer: Ohio Health Group HMO |
$26,846.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28,636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31,141.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,698.55
|
| Rate for Payer: PHCS Commercial |
$34,363.20
|
| Rate for Payer: United Healthcare All Payer |
$31,499.60
|
|
|
GRAFT Z MAIN BODY TFFB-28-96
|
Facility
|
IP
|
$35,795.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,738.50 |
| Max. Negotiated Rate |
$34,363.20 |
| Rate for Payer: Aetna Commercial |
$27,562.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,920.10
|
| Rate for Payer: Cash Price |
$17,897.50
|
| Rate for Payer: Cigna Commercial |
$29,709.85
|
| Rate for Payer: First Health Commercial |
$34,005.25
|
| Rate for Payer: Humana Commercial |
$30,425.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,351.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,416.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,738.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,499.60
|
| Rate for Payer: Ohio Health Group HMO |
$26,846.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28,636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31,141.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,698.55
|
| Rate for Payer: PHCS Commercial |
$34,363.20
|
| Rate for Payer: United Healthcare All Payer |
$31,499.60
|
|
|
GRAFT Z MAIN BODY TFFB-28-96-Z
|
Facility
|
OP
|
$71,425.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21,427.62 |
| Max. Negotiated Rate |
$68,568.38 |
| Rate for Payer: Aetna Commercial |
$54,997.56
|
| Rate for Payer: Anthem Medicaid |
$24,563.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55,711.81
|
| Rate for Payer: Cash Price |
$35,712.70
|
| Rate for Payer: Cigna Commercial |
$59,283.08
|
| Rate for Payer: First Health Commercial |
$67,854.13
|
| Rate for Payer: Humana Commercial |
$60,711.59
|
| Rate for Payer: Humana KY Medicaid |
$24,563.20
|
| Rate for Payer: Kentucky WC Medicaid |
$24,813.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58,568.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52,711.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,427.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,056.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$62,854.35
|
| Rate for Payer: Ohio Health Group HMO |
$53,569.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57,140.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62,140.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49,283.53
|
| Rate for Payer: PHCS Commercial |
$68,568.38
|
| Rate for Payer: United Healthcare All Payer |
$62,854.35
|
|
|
GRAFT Z MAIN BODY TFFB-28-96-Z
|
Facility
|
IP
|
$71,425.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21,427.62 |
| Max. Negotiated Rate |
$68,568.38 |
| Rate for Payer: Aetna Commercial |
$54,997.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55,711.81
|
| Rate for Payer: Cash Price |
$35,712.70
|
| Rate for Payer: Cigna Commercial |
$59,283.08
|
| Rate for Payer: First Health Commercial |
$67,854.13
|
| Rate for Payer: Humana Commercial |
$60,711.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58,568.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52,711.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,427.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$62,854.35
|
| Rate for Payer: Ohio Health Group HMO |
$53,569.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57,140.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62,140.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49,283.53
|
| Rate for Payer: PHCS Commercial |
$68,568.38
|
| Rate for Payer: United Healthcare All Payer |
$62,854.35
|
|
|
GRAFT Z MAIN BODY TFFB-30-111
|
Facility
|
OP
|
$35,795.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,738.50 |
| Max. Negotiated Rate |
$34,363.20 |
| Rate for Payer: Aetna Commercial |
$27,562.15
|
| Rate for Payer: Anthem Medicaid |
$12,309.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,920.10
|
| Rate for Payer: Cash Price |
$17,897.50
|
| Rate for Payer: Cigna Commercial |
$29,709.85
|
| Rate for Payer: First Health Commercial |
$34,005.25
|
| Rate for Payer: Humana Commercial |
$30,425.75
|
| Rate for Payer: Humana KY Medicaid |
$12,309.90
|
| Rate for Payer: Kentucky WC Medicaid |
$12,435.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,351.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,416.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,738.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,556.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,499.60
|
| Rate for Payer: Ohio Health Group HMO |
$26,846.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28,636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31,141.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,698.55
|
| Rate for Payer: PHCS Commercial |
$34,363.20
|
| Rate for Payer: United Healthcare All Payer |
$31,499.60
|
|
|
GRAFT Z MAIN BODY TFFB-30-111
|
Facility
|
IP
|
$35,795.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,738.50 |
| Max. Negotiated Rate |
$34,363.20 |
| Rate for Payer: Aetna Commercial |
$27,562.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,920.10
|
| Rate for Payer: Cash Price |
$17,897.50
|
| Rate for Payer: Cigna Commercial |
$29,709.85
|
| Rate for Payer: First Health Commercial |
$34,005.25
|
| Rate for Payer: Humana Commercial |
$30,425.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,351.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,416.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,738.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,499.60
|
| Rate for Payer: Ohio Health Group HMO |
$26,846.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28,636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31,141.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,698.55
|
| Rate for Payer: PHCS Commercial |
$34,363.20
|
| Rate for Payer: United Healthcare All Payer |
$31,499.60
|
|
|
GRAFT Z MAIN BODY TFFB-30-125
|
Facility
|
OP
|
$35,795.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,738.50 |
| Max. Negotiated Rate |
$34,363.20 |
| Rate for Payer: Aetna Commercial |
$27,562.15
|
| Rate for Payer: Anthem Medicaid |
$12,309.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,920.10
|
| Rate for Payer: Cash Price |
$17,897.50
|
| Rate for Payer: Cigna Commercial |
$29,709.85
|
| Rate for Payer: First Health Commercial |
$34,005.25
|
| Rate for Payer: Humana Commercial |
$30,425.75
|
| Rate for Payer: Humana KY Medicaid |
$12,309.90
|
| Rate for Payer: Kentucky WC Medicaid |
$12,435.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,351.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,416.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,738.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,556.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,499.60
|
| Rate for Payer: Ohio Health Group HMO |
$26,846.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28,636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31,141.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,698.55
|
| Rate for Payer: PHCS Commercial |
$34,363.20
|
| Rate for Payer: United Healthcare All Payer |
$31,499.60
|
|
|
GRAFT Z MAIN BODY TFFB-30-125
|
Facility
|
IP
|
$35,795.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,738.50 |
| Max. Negotiated Rate |
$34,363.20 |
| Rate for Payer: Aetna Commercial |
$27,562.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,920.10
|
| Rate for Payer: Cash Price |
$17,897.50
|
| Rate for Payer: Cigna Commercial |
$29,709.85
|
| Rate for Payer: First Health Commercial |
$34,005.25
|
| Rate for Payer: Humana Commercial |
$30,425.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,351.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,416.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,738.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,499.60
|
| Rate for Payer: Ohio Health Group HMO |
$26,846.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28,636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31,141.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,698.55
|
| Rate for Payer: PHCS Commercial |
$34,363.20
|
| Rate for Payer: United Healthcare All Payer |
$31,499.60
|
|
|
GRAFT Z MAIN BODY TFFB-30-140
|
Facility
|
OP
|
$35,795.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,738.50 |
| Max. Negotiated Rate |
$34,363.20 |
| Rate for Payer: Aetna Commercial |
$27,562.15
|
| Rate for Payer: Anthem Medicaid |
$12,309.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,920.10
|
| Rate for Payer: Cash Price |
$17,897.50
|
| Rate for Payer: Cigna Commercial |
$29,709.85
|
| Rate for Payer: First Health Commercial |
$34,005.25
|
| Rate for Payer: Humana Commercial |
$30,425.75
|
| Rate for Payer: Humana KY Medicaid |
$12,309.90
|
| Rate for Payer: Kentucky WC Medicaid |
$12,435.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,351.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,416.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,738.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,556.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,499.60
|
| Rate for Payer: Ohio Health Group HMO |
$26,846.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28,636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31,141.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,698.55
|
| Rate for Payer: PHCS Commercial |
$34,363.20
|
| Rate for Payer: United Healthcare All Payer |
$31,499.60
|
|
|
GRAFT Z MAIN BODY TFFB-30-140
|
Facility
|
IP
|
$35,795.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,738.50 |
| Max. Negotiated Rate |
$34,363.20 |
| Rate for Payer: Aetna Commercial |
$27,562.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,920.10
|
| Rate for Payer: Cash Price |
$17,897.50
|
| Rate for Payer: Cigna Commercial |
$29,709.85
|
| Rate for Payer: First Health Commercial |
$34,005.25
|
| Rate for Payer: Humana Commercial |
$30,425.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,351.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,416.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,738.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,499.60
|
| Rate for Payer: Ohio Health Group HMO |
$26,846.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28,636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31,141.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,698.55
|
| Rate for Payer: PHCS Commercial |
$34,363.20
|
| Rate for Payer: United Healthcare All Payer |
$31,499.60
|
|
|
GRAFT Z MAIN BODY TFFB-30-82
|
Facility
|
IP
|
$35,795.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,738.50 |
| Max. Negotiated Rate |
$34,363.20 |
| Rate for Payer: Aetna Commercial |
$27,562.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,920.10
|
| Rate for Payer: Cash Price |
$17,897.50
|
| Rate for Payer: Cigna Commercial |
$29,709.85
|
| Rate for Payer: First Health Commercial |
$34,005.25
|
| Rate for Payer: Humana Commercial |
$30,425.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,351.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,416.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,738.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,499.60
|
| Rate for Payer: Ohio Health Group HMO |
$26,846.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28,636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31,141.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,698.55
|
| Rate for Payer: PHCS Commercial |
$34,363.20
|
| Rate for Payer: United Healthcare All Payer |
$31,499.60
|
|
|
GRAFT Z MAIN BODY TFFB-30-82
|
Facility
|
OP
|
$35,795.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,738.50 |
| Max. Negotiated Rate |
$34,363.20 |
| Rate for Payer: Aetna Commercial |
$27,562.15
|
| Rate for Payer: Anthem Medicaid |
$12,309.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,920.10
|
| Rate for Payer: Cash Price |
$17,897.50
|
| Rate for Payer: Cigna Commercial |
$29,709.85
|
| Rate for Payer: First Health Commercial |
$34,005.25
|
| Rate for Payer: Humana Commercial |
$30,425.75
|
| Rate for Payer: Humana KY Medicaid |
$12,309.90
|
| Rate for Payer: Kentucky WC Medicaid |
$12,435.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,351.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,416.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,738.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,556.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,499.60
|
| Rate for Payer: Ohio Health Group HMO |
$26,846.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28,636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31,141.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,698.55
|
| Rate for Payer: PHCS Commercial |
$34,363.20
|
| Rate for Payer: United Healthcare All Payer |
$31,499.60
|
|
|
GRAFT Z MAIN BODY TFFB-30-96
|
Facility
|
IP
|
$35,795.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,738.50 |
| Max. Negotiated Rate |
$34,363.20 |
| Rate for Payer: Aetna Commercial |
$27,562.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,920.10
|
| Rate for Payer: Cash Price |
$17,897.50
|
| Rate for Payer: Cigna Commercial |
$29,709.85
|
| Rate for Payer: First Health Commercial |
$34,005.25
|
| Rate for Payer: Humana Commercial |
$30,425.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,351.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,416.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,738.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,499.60
|
| Rate for Payer: Ohio Health Group HMO |
$26,846.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28,636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31,141.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,698.55
|
| Rate for Payer: PHCS Commercial |
$34,363.20
|
| Rate for Payer: United Healthcare All Payer |
$31,499.60
|
|
|
GRAFT Z MAIN BODY TFFB-30-96
|
Facility
|
OP
|
$35,795.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,738.50 |
| Max. Negotiated Rate |
$34,363.20 |
| Rate for Payer: Aetna Commercial |
$27,562.15
|
| Rate for Payer: Anthem Medicaid |
$12,309.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,920.10
|
| Rate for Payer: Cash Price |
$17,897.50
|
| Rate for Payer: Cigna Commercial |
$29,709.85
|
| Rate for Payer: First Health Commercial |
$34,005.25
|
| Rate for Payer: Humana Commercial |
$30,425.75
|
| Rate for Payer: Humana KY Medicaid |
$12,309.90
|
| Rate for Payer: Kentucky WC Medicaid |
$12,435.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,351.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,416.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,738.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,556.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,499.60
|
| Rate for Payer: Ohio Health Group HMO |
$26,846.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28,636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31,141.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,698.55
|
| Rate for Payer: PHCS Commercial |
$34,363.20
|
| Rate for Payer: United Healthcare All Payer |
$31,499.60
|
|
|
GRAFT Z MAIN BODY TFFB-30-96-Z
|
Facility
|
IP
|
$68,636.20
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$20,590.86 |
| Max. Negotiated Rate |
$65,890.75 |
| Rate for Payer: Aetna Commercial |
$52,849.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53,536.24
|
| Rate for Payer: Cash Price |
$34,318.10
|
| Rate for Payer: Cigna Commercial |
$56,968.05
|
| Rate for Payer: First Health Commercial |
$65,204.39
|
| Rate for Payer: Humana Commercial |
$58,340.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56,281.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50,653.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,590.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$60,399.86
|
| Rate for Payer: Ohio Health Group HMO |
$51,477.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$54,908.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59,713.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47,358.98
|
| Rate for Payer: PHCS Commercial |
$65,890.75
|
| Rate for Payer: United Healthcare All Payer |
$60,399.86
|
|
|
GRAFT Z MAIN BODY TFFB-30-96-Z
|
Facility
|
OP
|
$68,636.20
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$20,590.86 |
| Max. Negotiated Rate |
$65,890.75 |
| Rate for Payer: Aetna Commercial |
$52,849.87
|
| Rate for Payer: Anthem Medicaid |
$23,603.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53,536.24
|
| Rate for Payer: Cash Price |
$34,318.10
|
| Rate for Payer: Cigna Commercial |
$56,968.05
|
| Rate for Payer: First Health Commercial |
$65,204.39
|
| Rate for Payer: Humana Commercial |
$58,340.77
|
| Rate for Payer: Humana KY Medicaid |
$23,603.99
|
| Rate for Payer: Kentucky WC Medicaid |
$23,844.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56,281.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50,653.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,590.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$24,077.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$60,399.86
|
| Rate for Payer: Ohio Health Group HMO |
$51,477.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$54,908.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59,713.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47,358.98
|
| Rate for Payer: PHCS Commercial |
$65,890.75
|
| Rate for Payer: United Healthcare All Payer |
$60,399.86
|
|
|
GRAFT Z MAIN BODY TFFB-32-111
|
Facility
|
IP
|
$35,795.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,738.50 |
| Max. Negotiated Rate |
$34,363.20 |
| Rate for Payer: Aetna Commercial |
$27,562.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,920.10
|
| Rate for Payer: Cash Price |
$17,897.50
|
| Rate for Payer: Cigna Commercial |
$29,709.85
|
| Rate for Payer: First Health Commercial |
$34,005.25
|
| Rate for Payer: Humana Commercial |
$30,425.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,351.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,416.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,738.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,499.60
|
| Rate for Payer: Ohio Health Group HMO |
$26,846.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28,636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31,141.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,698.55
|
| Rate for Payer: PHCS Commercial |
$34,363.20
|
| Rate for Payer: United Healthcare All Payer |
$31,499.60
|
|
|
GRAFT Z MAIN BODY TFFB-32-111
|
Facility
|
OP
|
$35,795.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,738.50 |
| Max. Negotiated Rate |
$34,363.20 |
| Rate for Payer: Aetna Commercial |
$27,562.15
|
| Rate for Payer: Anthem Medicaid |
$12,309.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,920.10
|
| Rate for Payer: Cash Price |
$17,897.50
|
| Rate for Payer: Cigna Commercial |
$29,709.85
|
| Rate for Payer: First Health Commercial |
$34,005.25
|
| Rate for Payer: Humana Commercial |
$30,425.75
|
| Rate for Payer: Humana KY Medicaid |
$12,309.90
|
| Rate for Payer: Kentucky WC Medicaid |
$12,435.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,351.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,416.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,738.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,556.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,499.60
|
| Rate for Payer: Ohio Health Group HMO |
$26,846.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28,636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31,141.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,698.55
|
| Rate for Payer: PHCS Commercial |
$34,363.20
|
| Rate for Payer: United Healthcare All Payer |
$31,499.60
|
|
|
GRAFT Z MAIN BODY TFFB-32-111-
|
Facility
|
IP
|
$69,810.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$20,943.12 |
| Max. Negotiated Rate |
$67,017.98 |
| Rate for Payer: Aetna Commercial |
$53,754.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,452.11
|
| Rate for Payer: Cash Price |
$34,905.20
|
| Rate for Payer: Cigna Commercial |
$57,942.63
|
| Rate for Payer: First Health Commercial |
$66,319.88
|
| Rate for Payer: Humana Commercial |
$59,338.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57,244.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,520.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,943.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$61,433.15
|
| Rate for Payer: Ohio Health Group HMO |
$52,357.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55,848.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60,735.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$48,169.18
|
| Rate for Payer: PHCS Commercial |
$67,017.98
|
| Rate for Payer: United Healthcare All Payer |
$61,433.15
|
|
|
GRAFT Z MAIN BODY TFFB-32-111-
|
Facility
|
OP
|
$69,810.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$20,943.12 |
| Max. Negotiated Rate |
$67,017.98 |
| Rate for Payer: Aetna Commercial |
$53,754.01
|
| Rate for Payer: Anthem Medicaid |
$24,007.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,452.11
|
| Rate for Payer: Cash Price |
$34,905.20
|
| Rate for Payer: Cigna Commercial |
$57,942.63
|
| Rate for Payer: First Health Commercial |
$66,319.88
|
| Rate for Payer: Humana Commercial |
$59,338.84
|
| Rate for Payer: Humana KY Medicaid |
$24,007.80
|
| Rate for Payer: Kentucky WC Medicaid |
$24,252.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57,244.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,520.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,943.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$24,489.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$61,433.15
|
| Rate for Payer: Ohio Health Group HMO |
$52,357.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55,848.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60,735.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$48,169.18
|
| Rate for Payer: PHCS Commercial |
$67,017.98
|
| Rate for Payer: United Healthcare All Payer |
$61,433.15
|
|
