|
GRAFT Z MAIN BODY TFFB-32-125
|
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-32-125
|
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-32-140
|
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-32-140
|
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-32-82
|
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-32-82
|
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-32-82-Z
|
Facility
|
OP
|
$41,767.14
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,530.14 |
| Max. Negotiated Rate |
$40,096.45 |
| Rate for Payer: Aetna Commercial |
$32,160.70
|
| Rate for Payer: Anthem Medicaid |
$14,363.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$32,578.37
|
| Rate for Payer: Cash Price |
$20,883.57
|
| Rate for Payer: Cigna Commercial |
$34,666.73
|
| Rate for Payer: First Health Commercial |
$39,678.78
|
| Rate for Payer: Humana Commercial |
$35,502.07
|
| Rate for Payer: Humana KY Medicaid |
$14,363.72
|
| Rate for Payer: Kentucky WC Medicaid |
$14,509.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34,249.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$30,824.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,530.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,651.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$36,755.08
|
| Rate for Payer: Ohio Health Group HMO |
$31,325.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33,413.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36,337.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28,819.33
|
| Rate for Payer: PHCS Commercial |
$40,096.45
|
| Rate for Payer: United Healthcare All Payer |
$36,755.08
|
|
|
GRAFT Z MAIN BODY TFFB-32-82-Z
|
Facility
|
IP
|
$41,767.14
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,530.14 |
| Max. Negotiated Rate |
$40,096.45 |
| Rate for Payer: Aetna Commercial |
$32,160.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$32,578.37
|
| Rate for Payer: Cash Price |
$20,883.57
|
| Rate for Payer: Cigna Commercial |
$34,666.73
|
| Rate for Payer: First Health Commercial |
$39,678.78
|
| Rate for Payer: Humana Commercial |
$35,502.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34,249.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$30,824.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,530.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$36,755.08
|
| Rate for Payer: Ohio Health Group HMO |
$31,325.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33,413.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36,337.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28,819.33
|
| Rate for Payer: PHCS Commercial |
$40,096.45
|
| Rate for Payer: United Healthcare All Payer |
$36,755.08
|
|
|
GRAFT Z MAIN BODY TFFB-32-96
|
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
|
|
|
GRAFT Z MAIN BODY TFFB-32-96
|
Facility
|
OP
|
$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 Medicaid |
$12,627.15
|
| 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: Humana KY Medicaid |
$12,627.15
|
| Rate for Payer: Kentucky WC Medicaid |
$12,755.66
|
| 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: Molina Healthcare Medicaid |
$12,880.50
|
| 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
|
|
|
GRAFT Z MAIN BODY TFFB-32-96-Z
|
Facility
|
OP
|
$40,696.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,208.88 |
| Max. Negotiated Rate |
$39,068.40 |
| Rate for Payer: Aetna Commercial |
$31,336.11
|
| Rate for Payer: Anthem Medicaid |
$13,995.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31,743.08
|
| Rate for Payer: Cash Price |
$20,348.12
|
| Rate for Payer: Cigna Commercial |
$33,777.89
|
| Rate for Payer: First Health Commercial |
$38,661.44
|
| Rate for Payer: Humana Commercial |
$34,591.81
|
| Rate for Payer: Humana KY Medicaid |
$13,995.44
|
| Rate for Payer: Kentucky WC Medicaid |
$14,137.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$33,370.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$30,033.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,208.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,276.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$35,812.70
|
| Rate for Payer: Ohio Health Group HMO |
$30,522.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32,557.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35,405.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28,080.41
|
| Rate for Payer: PHCS Commercial |
$39,068.40
|
| Rate for Payer: United Healthcare All Payer |
$35,812.70
|
|
|
GRAFT Z MAIN BODY TFFB-32-96-Z
|
Facility
|
IP
|
$40,696.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,208.88 |
| Max. Negotiated Rate |
$39,068.40 |
| Rate for Payer: Aetna Commercial |
$31,336.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31,743.08
|
| Rate for Payer: Cash Price |
$20,348.12
|
| Rate for Payer: Cigna Commercial |
$33,777.89
|
| Rate for Payer: First Health Commercial |
$38,661.44
|
| Rate for Payer: Humana Commercial |
$34,591.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$33,370.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$30,033.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,208.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$35,812.70
|
| Rate for Payer: Ohio Health Group HMO |
$30,522.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32,557.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35,405.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28,080.41
|
| Rate for Payer: PHCS Commercial |
$39,068.40
|
| Rate for Payer: United Healthcare All Payer |
$35,812.70
|
|
|
GRAFT Z MAIN BODY TFFB-36-113
|
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-36-113
|
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-36-131
|
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-36-131
|
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-36-149
|
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-36-149
|
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-36-95-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-36-95-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 OCCLUDERS ESP-16-20
|
Facility
|
IP
|
$9,887.55
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,966.26 |
| Max. Negotiated Rate |
$9,492.05 |
| Rate for Payer: Aetna Commercial |
$7,613.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,712.29
|
| Rate for Payer: Cash Price |
$4,943.77
|
| Rate for Payer: Cigna Commercial |
$8,206.67
|
| Rate for Payer: First Health Commercial |
$9,393.17
|
| Rate for Payer: Humana Commercial |
$8,404.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,107.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,297.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,966.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,701.04
|
| Rate for Payer: Ohio Health Group HMO |
$7,415.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,910.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,602.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,822.41
|
| Rate for Payer: PHCS Commercial |
$9,492.05
|
| Rate for Payer: United Healthcare All Payer |
$8,701.04
|
|
|
GRAFT Z OCCLUDERS ESP-16-20
|
Facility
|
OP
|
$9,887.55
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,966.26 |
| Max. Negotiated Rate |
$9,492.05 |
| Rate for Payer: Aetna Commercial |
$7,613.41
|
| Rate for Payer: Anthem Medicaid |
$3,400.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,712.29
|
| Rate for Payer: Cash Price |
$4,943.77
|
| Rate for Payer: Cigna Commercial |
$8,206.67
|
| Rate for Payer: First Health Commercial |
$9,393.17
|
| Rate for Payer: Humana Commercial |
$8,404.42
|
| Rate for Payer: Humana KY Medicaid |
$3,400.33
|
| Rate for Payer: Kentucky WC Medicaid |
$3,434.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,107.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,297.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,966.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,468.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,701.04
|
| Rate for Payer: Ohio Health Group HMO |
$7,415.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,910.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,602.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,822.41
|
| Rate for Payer: PHCS Commercial |
$9,492.05
|
| Rate for Payer: United Healthcare All Payer |
$8,701.04
|
|
|
GRAFT Z OCCLUDERS ESP-24-20
|
Facility
|
IP
|
$4,550.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,365.00 |
| Max. Negotiated Rate |
$4,368.00 |
| Rate for Payer: Aetna Commercial |
$3,503.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,549.00
|
| Rate for Payer: Cash Price |
$2,275.00
|
| Rate for Payer: Cigna Commercial |
$3,776.50
|
| Rate for Payer: First Health Commercial |
$4,322.50
|
| Rate for Payer: Humana Commercial |
$3,867.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,731.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,357.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,365.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,004.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,412.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,958.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,139.50
|
| Rate for Payer: PHCS Commercial |
$4,368.00
|
| Rate for Payer: United Healthcare All Payer |
$4,004.00
|
|
|
GRAFT Z OCCLUDERS ESP-24-20
|
Facility
|
OP
|
$4,550.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,365.00 |
| Max. Negotiated Rate |
$4,368.00 |
| Rate for Payer: Aetna Commercial |
$3,503.50
|
| Rate for Payer: Anthem Medicaid |
$1,564.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,549.00
|
| Rate for Payer: Cash Price |
$2,275.00
|
| Rate for Payer: Cigna Commercial |
$3,776.50
|
| Rate for Payer: First Health Commercial |
$4,322.50
|
| Rate for Payer: Humana Commercial |
$3,867.50
|
| Rate for Payer: Humana KY Medicaid |
$1,564.74
|
| Rate for Payer: Kentucky WC Medicaid |
$1,580.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,731.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,357.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,365.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,596.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,004.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,412.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,958.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,139.50
|
| Rate for Payer: PHCS Commercial |
$4,368.00
|
| Rate for Payer: United Healthcare All Payer |
$4,004.00
|
|
|
GRAFT Z PROX ZTEG-2P-28-120-US
|
Facility
|
OP
|
$72,820.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21,846.00 |
| Max. Negotiated Rate |
$69,907.20 |
| Rate for Payer: Aetna Commercial |
$56,071.40
|
| Rate for Payer: Anthem Medicaid |
$25,042.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56,799.60
|
| Rate for Payer: Cash Price |
$36,410.00
|
| Rate for Payer: Cigna Commercial |
$60,440.60
|
| Rate for Payer: First Health Commercial |
$69,179.00
|
| Rate for Payer: Humana Commercial |
$61,897.00
|
| Rate for Payer: Humana KY Medicaid |
$25,042.80
|
| Rate for Payer: Kentucky WC Medicaid |
$25,297.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59,712.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53,741.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,846.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,545.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,081.60
|
| Rate for Payer: Ohio Health Group HMO |
$54,615.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,256.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,353.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,245.80
|
| Rate for Payer: PHCS Commercial |
$69,907.20
|
| Rate for Payer: United Healthcare All Payer |
$64,081.60
|
|
