|
GRAFT 6MM*50CM STRAIGHT
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
GRAFT ACUSEAL 4-6X45CM
|
Facility
|
IP
|
$8,271.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.28 |
| Max. Negotiated Rate |
$7,940.50 |
| Rate for Payer: Aetna Commercial |
$6,368.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,451.65
|
| Rate for Payer: Cash Price |
$4,135.68
|
| Rate for Payer: Cigna Commercial |
$6,865.22
|
| Rate for Payer: First Health Commercial |
$7,857.78
|
| Rate for Payer: Humana Commercial |
$7,030.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,782.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,104.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,481.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,278.79
|
| Rate for Payer: Ohio Health Group HMO |
$6,203.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,654.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,564.12
|
| Rate for Payer: PHCS Commercial |
$7,940.50
|
| Rate for Payer: United Healthcare All Payer |
$7,278.79
|
|
|
GRAFT ACUSEAL 4-6X45CM
|
Facility
|
OP
|
$8,271.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.28 |
| Max. Negotiated Rate |
$7,940.50 |
| Rate for Payer: Aetna Commercial |
$6,368.94
|
| Rate for Payer: Anthem Medicaid |
$2,844.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,451.65
|
| Rate for Payer: Cash Price |
$4,135.68
|
| Rate for Payer: Cigna Commercial |
$6,865.22
|
| Rate for Payer: First Health Commercial |
$7,857.78
|
| Rate for Payer: Humana Commercial |
$7,030.65
|
| Rate for Payer: Humana KY Medicaid |
$2,844.52
|
| Rate for Payer: Kentucky WC Medicaid |
$2,873.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,782.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,104.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,481.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,901.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,278.79
|
| Rate for Payer: Ohio Health Group HMO |
$6,203.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,654.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,564.12
|
| Rate for Payer: PHCS Commercial |
$7,940.50
|
| Rate for Payer: United Healthcare All Payer |
$7,278.79
|
|
|
GRAFT ACUSEAL 4-7X45CM
|
Facility
|
IP
|
$8,271.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.28 |
| Max. Negotiated Rate |
$7,940.50 |
| Rate for Payer: Aetna Commercial |
$6,368.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,451.65
|
| Rate for Payer: Cash Price |
$4,135.68
|
| Rate for Payer: Cigna Commercial |
$6,865.22
|
| Rate for Payer: First Health Commercial |
$7,857.78
|
| Rate for Payer: Humana Commercial |
$7,030.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,782.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,104.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,481.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,278.79
|
| Rate for Payer: Ohio Health Group HMO |
$6,203.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,654.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,564.12
|
| Rate for Payer: PHCS Commercial |
$7,940.50
|
| Rate for Payer: United Healthcare All Payer |
$7,278.79
|
|
|
GRAFT ACUSEAL 4-7X45CM
|
Facility
|
OP
|
$8,271.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.28 |
| Max. Negotiated Rate |
$7,940.50 |
| Rate for Payer: Aetna Commercial |
$6,368.94
|
| Rate for Payer: Anthem Medicaid |
$2,844.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,451.65
|
| Rate for Payer: Cash Price |
$4,135.68
|
| Rate for Payer: Cigna Commercial |
$6,865.22
|
| Rate for Payer: First Health Commercial |
$7,857.78
|
| Rate for Payer: Humana Commercial |
$7,030.65
|
| Rate for Payer: Humana KY Medicaid |
$2,844.52
|
| Rate for Payer: Kentucky WC Medicaid |
$2,873.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,782.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,104.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,481.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,901.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,278.79
|
| Rate for Payer: Ohio Health Group HMO |
$6,203.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,654.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,564.12
|
| Rate for Payer: PHCS Commercial |
$7,940.50
|
| Rate for Payer: United Healthcare All Payer |
$7,278.79
|
|
|
GRAFT ANTERIOR TIBIAL ULTRA
|
Facility
|
OP
|
$8,092.50
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,052.02 |
| Max. Negotiated Rate |
$7,768.80 |
| Rate for Payer: Aetna Commercial |
$6,231.22
|
| Rate for Payer: Anthem Medicaid |
$2,783.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,312.15
|
| Rate for Payer: Cash Price |
$4,046.25
|
| Rate for Payer: Cigna Commercial |
$6,716.78
|
| Rate for Payer: First Health Commercial |
$7,687.88
|
| Rate for Payer: Humana Commercial |
$6,878.62
|
| Rate for Payer: Humana KY Medicaid |
$2,783.01
|
| Rate for Payer: Kentucky WC Medicaid |
$2,811.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,635.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,972.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,427.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,838.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,121.40
|
| Rate for Payer: Ohio Health Group HMO |
$6,069.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,618.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,052.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,508.68
|
| Rate for Payer: PHCS Commercial |
$7,768.80
|
| Rate for Payer: United Healthcare All Payer |
$7,121.40
|
|
|
GRAFT ANTERIOR TIBIAL ULTRA
|
Facility
|
IP
|
$8,092.50
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,052.02 |
| Max. Negotiated Rate |
$7,768.80 |
| Rate for Payer: Aetna Commercial |
$6,231.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,312.15
|
| Rate for Payer: Cash Price |
$4,046.25
|
| Rate for Payer: Cigna Commercial |
$6,716.78
|
| Rate for Payer: First Health Commercial |
$7,687.88
|
| Rate for Payer: Humana Commercial |
$6,878.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,635.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,972.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,427.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,121.40
|
| Rate for Payer: Ohio Health Group HMO |
$6,069.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,618.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,052.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,508.68
|
| Rate for Payer: PHCS Commercial |
$7,768.80
|
| Rate for Payer: United Healthcare All Payer |
$7,121.40
|
|
|
GRAFT AORTC EXT A25-25/C75 V
|
Facility
|
OP
|
$18,348.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,385.24 |
| Max. Negotiated Rate |
$17,614.08 |
| Rate for Payer: Aetna Commercial |
$14,127.96
|
| Rate for Payer: Anthem Medicaid |
$6,309.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,311.44
|
| Rate for Payer: Cash Price |
$9,174.00
|
| Rate for Payer: Cigna Commercial |
$15,228.84
|
| Rate for Payer: First Health Commercial |
$17,430.60
|
| Rate for Payer: Humana Commercial |
$15,595.80
|
| Rate for Payer: Humana KY Medicaid |
$6,309.88
|
| Rate for Payer: Kentucky WC Medicaid |
$6,374.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,045.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,540.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,504.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,436.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,146.24
|
| Rate for Payer: Ohio Health Group HMO |
$13,761.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,669.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,385.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,687.88
|
| Rate for Payer: PHCS Commercial |
$17,614.08
|
| Rate for Payer: United Healthcare All Payer |
$16,146.24
|
|
|
GRAFT AORTC EXT A25-25/C75 V
|
Facility
|
IP
|
$18,348.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,385.24 |
| Max. Negotiated Rate |
$17,614.08 |
| Rate for Payer: Aetna Commercial |
$14,127.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,311.44
|
| Rate for Payer: Cash Price |
$9,174.00
|
| Rate for Payer: Cigna Commercial |
$15,228.84
|
| Rate for Payer: First Health Commercial |
$17,430.60
|
| Rate for Payer: Humana Commercial |
$15,595.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,045.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,540.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,504.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,146.24
|
| Rate for Payer: Ohio Health Group HMO |
$13,761.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,669.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,385.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,687.88
|
| Rate for Payer: PHCS Commercial |
$17,614.08
|
| Rate for Payer: United Healthcare All Payer |
$16,146.24
|
|
|
GRAFT AORTC EXT A25-25/C95 V
|
Facility
|
IP
|
$23,177.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,013.11 |
| Max. Negotiated Rate |
$22,250.64 |
| Rate for Payer: Aetna Commercial |
$17,846.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,078.64
|
| Rate for Payer: Cash Price |
$11,588.88
|
| Rate for Payer: Cigna Commercial |
$19,237.53
|
| Rate for Payer: First Health Commercial |
$22,018.86
|
| Rate for Payer: Humana Commercial |
$19,701.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,005.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,105.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,953.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,396.42
|
| Rate for Payer: Ohio Health Group HMO |
$17,383.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,635.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,013.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,185.10
|
| Rate for Payer: PHCS Commercial |
$22,250.64
|
| Rate for Payer: United Healthcare All Payer |
$20,396.42
|
|
|
GRAFT AORTC EXT A25-25/C95 V
|
Facility
|
OP
|
$23,177.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,013.11 |
| Max. Negotiated Rate |
$22,250.64 |
| Rate for Payer: Aetna Commercial |
$17,846.87
|
| Rate for Payer: Anthem Medicaid |
$7,970.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,078.64
|
| Rate for Payer: Cash Price |
$11,588.88
|
| Rate for Payer: Cigna Commercial |
$19,237.53
|
| Rate for Payer: First Health Commercial |
$22,018.86
|
| Rate for Payer: Humana Commercial |
$19,701.09
|
| Rate for Payer: Humana KY Medicaid |
$7,970.83
|
| Rate for Payer: Kentucky WC Medicaid |
$8,051.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,005.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,105.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,953.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,130.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,396.42
|
| Rate for Payer: Ohio Health Group HMO |
$17,383.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,635.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,013.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,185.10
|
| Rate for Payer: PHCS Commercial |
$22,250.64
|
| Rate for Payer: United Healthcare All Payer |
$20,396.42
|
|
|
GRAFT AORTC EXT A28-28/C75-O20
|
Facility
|
IP
|
$17,466.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,270.58 |
| Max. Negotiated Rate |
$16,767.36 |
| Rate for Payer: Aetna Commercial |
$13,448.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,623.48
|
| Rate for Payer: Cash Price |
$8,733.00
|
| Rate for Payer: Cigna Commercial |
$14,496.78
|
| Rate for Payer: First Health Commercial |
$16,592.70
|
| Rate for Payer: Humana Commercial |
$14,846.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,322.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,889.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,239.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,370.08
|
| Rate for Payer: Ohio Health Group HMO |
$13,099.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,493.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,270.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,414.46
|
| Rate for Payer: PHCS Commercial |
$16,767.36
|
| Rate for Payer: United Healthcare All Payer |
$15,370.08
|
|
|
GRAFT AORTC EXT A28-28/C75-O20
|
Facility
|
OP
|
$17,466.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,270.58 |
| Max. Negotiated Rate |
$16,767.36 |
| Rate for Payer: Aetna Commercial |
$13,448.82
|
| Rate for Payer: Anthem Medicaid |
$6,006.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,623.48
|
| Rate for Payer: Cash Price |
$8,733.00
|
| Rate for Payer: Cigna Commercial |
$14,496.78
|
| Rate for Payer: First Health Commercial |
$16,592.70
|
| Rate for Payer: Humana Commercial |
$14,846.10
|
| Rate for Payer: Humana KY Medicaid |
$6,006.56
|
| Rate for Payer: Kentucky WC Medicaid |
$6,067.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,322.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,889.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,239.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,127.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,370.08
|
| Rate for Payer: Ohio Health Group HMO |
$13,099.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,493.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,270.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,414.46
|
| Rate for Payer: PHCS Commercial |
$16,767.36
|
| Rate for Payer: United Healthcare All Payer |
$15,370.08
|
|
|
GRAFT AORTC EXT A28-28/C75 V
|
Facility
|
IP
|
$25,601.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,328.18 |
| Max. Negotiated Rate |
$24,577.30 |
| Rate for Payer: Aetna Commercial |
$19,713.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,969.05
|
| Rate for Payer: Cash Price |
$12,800.67
|
| Rate for Payer: Cigna Commercial |
$21,249.12
|
| Rate for Payer: First Health Commercial |
$24,321.28
|
| Rate for Payer: Humana Commercial |
$21,761.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,993.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,893.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,680.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,529.19
|
| Rate for Payer: Ohio Health Group HMO |
$19,201.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,120.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,328.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,936.42
|
| Rate for Payer: PHCS Commercial |
$24,577.30
|
| Rate for Payer: United Healthcare All Payer |
$22,529.19
|
|
|
GRAFT AORTC EXT A28-28/C75 V
|
Facility
|
OP
|
$25,601.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,328.18 |
| Max. Negotiated Rate |
$24,577.30 |
| Rate for Payer: Aetna Commercial |
$19,713.04
|
| Rate for Payer: Anthem Medicaid |
$8,804.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,969.05
|
| Rate for Payer: Cash Price |
$12,800.67
|
| Rate for Payer: Cigna Commercial |
$21,249.12
|
| Rate for Payer: First Health Commercial |
$24,321.28
|
| Rate for Payer: Humana Commercial |
$21,761.15
|
| Rate for Payer: Humana KY Medicaid |
$8,804.30
|
| Rate for Payer: Kentucky WC Medicaid |
$8,893.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,993.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,893.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,680.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,980.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,529.19
|
| Rate for Payer: Ohio Health Group HMO |
$19,201.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,120.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,328.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,936.42
|
| Rate for Payer: PHCS Commercial |
$24,577.30
|
| Rate for Payer: United Healthcare All Payer |
$22,529.19
|
|
|
GRAFT AORTC EXT A28-28/C95-O20
|
Facility
|
OP
|
$17,862.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,322.06 |
| Max. Negotiated Rate |
$17,147.52 |
| Rate for Payer: Aetna Commercial |
$13,753.74
|
| Rate for Payer: Anthem Medicaid |
$6,142.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,932.36
|
| Rate for Payer: Cash Price |
$8,931.00
|
| Rate for Payer: Cigna Commercial |
$14,825.46
|
| Rate for Payer: First Health Commercial |
$16,968.90
|
| Rate for Payer: Humana Commercial |
$15,182.70
|
| Rate for Payer: Humana KY Medicaid |
$6,142.74
|
| Rate for Payer: Kentucky WC Medicaid |
$6,205.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,646.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,182.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,358.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,265.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,718.56
|
| Rate for Payer: Ohio Health Group HMO |
$13,396.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,572.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,322.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,537.22
|
| Rate for Payer: PHCS Commercial |
$17,147.52
|
| Rate for Payer: United Healthcare All Payer |
$15,718.56
|
|
|
GRAFT AORTC EXT A28-28/C95-O20
|
Facility
|
IP
|
$17,862.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,322.06 |
| Max. Negotiated Rate |
$17,147.52 |
| Rate for Payer: Aetna Commercial |
$13,753.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,932.36
|
| Rate for Payer: Cash Price |
$8,931.00
|
| Rate for Payer: Cigna Commercial |
$14,825.46
|
| Rate for Payer: First Health Commercial |
$16,968.90
|
| Rate for Payer: Humana Commercial |
$15,182.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,646.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,182.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,358.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,718.56
|
| Rate for Payer: Ohio Health Group HMO |
$13,396.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,572.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,322.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,537.22
|
| Rate for Payer: PHCS Commercial |
$17,147.52
|
| Rate for Payer: United Healthcare All Payer |
$15,718.56
|
|
|
GRAFT AORTC EXT A28-28/C95 V
|
Facility
|
IP
|
$23,177.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,013.11 |
| Max. Negotiated Rate |
$22,250.64 |
| Rate for Payer: Aetna Commercial |
$17,846.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,078.64
|
| Rate for Payer: Cash Price |
$11,588.88
|
| Rate for Payer: Cigna Commercial |
$19,237.53
|
| Rate for Payer: First Health Commercial |
$22,018.86
|
| Rate for Payer: Humana Commercial |
$19,701.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,005.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,105.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,953.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,396.42
|
| Rate for Payer: Ohio Health Group HMO |
$17,383.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,635.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,013.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,185.10
|
| Rate for Payer: PHCS Commercial |
$22,250.64
|
| Rate for Payer: United Healthcare All Payer |
$20,396.42
|
|
|
GRAFT AORTC EXT A28-28/C95 V
|
Facility
|
OP
|
$23,177.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,013.11 |
| Max. Negotiated Rate |
$22,250.64 |
| Rate for Payer: Aetna Commercial |
$17,846.87
|
| Rate for Payer: Anthem Medicaid |
$7,970.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,078.64
|
| Rate for Payer: Cash Price |
$11,588.88
|
| Rate for Payer: Cigna Commercial |
$19,237.53
|
| Rate for Payer: First Health Commercial |
$22,018.86
|
| Rate for Payer: Humana Commercial |
$19,701.09
|
| Rate for Payer: Humana KY Medicaid |
$7,970.83
|
| Rate for Payer: Kentucky WC Medicaid |
$8,051.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,005.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,105.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,953.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,130.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,396.42
|
| Rate for Payer: Ohio Health Group HMO |
$17,383.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,635.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,013.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,185.10
|
| Rate for Payer: PHCS Commercial |
$22,250.64
|
| Rate for Payer: United Healthcare All Payer |
$20,396.42
|
|
|
GRAFT AORTC EXT A34-34/C80-O20
|
Facility
|
IP
|
$21,206.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,756.88 |
| Max. Negotiated Rate |
$20,358.48 |
| Rate for Payer: Aetna Commercial |
$16,329.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,541.26
|
| Rate for Payer: Cash Price |
$10,603.38
|
| Rate for Payer: Cigna Commercial |
$17,601.60
|
| Rate for Payer: First Health Commercial |
$20,146.41
|
| Rate for Payer: Humana Commercial |
$18,025.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,389.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,650.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,362.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,661.94
|
| Rate for Payer: Ohio Health Group HMO |
$15,905.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,241.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,756.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,574.09
|
| Rate for Payer: PHCS Commercial |
$20,358.48
|
| Rate for Payer: United Healthcare All Payer |
$18,661.94
|
|
|
GRAFT AORTC EXT A34-34/C80-O20
|
Facility
|
OP
|
$21,206.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,756.88 |
| Max. Negotiated Rate |
$20,358.48 |
| Rate for Payer: Aetna Commercial |
$16,329.20
|
| Rate for Payer: Anthem Medicaid |
$7,293.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,541.26
|
| Rate for Payer: Cash Price |
$10,603.38
|
| Rate for Payer: Cigna Commercial |
$17,601.60
|
| Rate for Payer: First Health Commercial |
$20,146.41
|
| Rate for Payer: Humana Commercial |
$18,025.74
|
| Rate for Payer: Humana KY Medicaid |
$7,293.00
|
| Rate for Payer: Kentucky WC Medicaid |
$7,367.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,389.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,650.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,362.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,439.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,661.94
|
| Rate for Payer: Ohio Health Group HMO |
$15,905.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,241.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,756.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,574.09
|
| Rate for Payer: PHCS Commercial |
$20,358.48
|
| Rate for Payer: United Healthcare All Payer |
$18,661.94
|
|
|
GRAFT AORTC EXT A34-34/C80 V
|
Facility
|
IP
|
$24,141.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,138.38 |
| Max. Negotiated Rate |
$23,175.70 |
| Rate for Payer: Aetna Commercial |
$18,588.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,830.25
|
| Rate for Payer: Cash Price |
$12,070.67
|
| Rate for Payer: Cigna Commercial |
$20,037.32
|
| Rate for Payer: First Health Commercial |
$22,934.28
|
| Rate for Payer: Humana Commercial |
$20,520.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,795.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,816.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,242.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,244.39
|
| Rate for Payer: Ohio Health Group HMO |
$18,106.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,828.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,138.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,483.82
|
| Rate for Payer: PHCS Commercial |
$23,175.70
|
| Rate for Payer: United Healthcare All Payer |
$21,244.39
|
|
|
GRAFT AORTC EXT A34-34/C80 V
|
Facility
|
OP
|
$24,141.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,138.38 |
| Max. Negotiated Rate |
$23,175.70 |
| Rate for Payer: Aetna Commercial |
$18,588.84
|
| Rate for Payer: Anthem Medicaid |
$8,302.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,830.25
|
| Rate for Payer: Cash Price |
$12,070.67
|
| Rate for Payer: Cigna Commercial |
$20,037.32
|
| Rate for Payer: First Health Commercial |
$22,934.28
|
| Rate for Payer: Humana Commercial |
$20,520.15
|
| Rate for Payer: Humana KY Medicaid |
$8,302.21
|
| Rate for Payer: Kentucky WC Medicaid |
$8,386.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,795.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,816.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,242.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,468.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,244.39
|
| Rate for Payer: Ohio Health Group HMO |
$18,106.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,828.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,138.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,483.82
|
| Rate for Payer: PHCS Commercial |
$23,175.70
|
| Rate for Payer: United Healthcare All Payer |
$21,244.39
|
|
|
GRAFT AORT EXT A34-34/C100-O20
|
Facility
|
IP
|
$25,601.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,328.18 |
| Max. Negotiated Rate |
$24,577.30 |
| Rate for Payer: Aetna Commercial |
$19,713.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,969.05
|
| Rate for Payer: Cash Price |
$12,800.67
|
| Rate for Payer: Cigna Commercial |
$21,249.12
|
| Rate for Payer: First Health Commercial |
$24,321.28
|
| Rate for Payer: Humana Commercial |
$21,761.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,993.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,893.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,680.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,529.19
|
| Rate for Payer: Ohio Health Group HMO |
$19,201.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,120.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,328.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,936.42
|
| Rate for Payer: PHCS Commercial |
$24,577.30
|
| Rate for Payer: United Healthcare All Payer |
$22,529.19
|
|
|
GRAFT AORT EXT A34-34/C100-O20
|
Facility
|
OP
|
$25,601.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,328.18 |
| Max. Negotiated Rate |
$24,577.30 |
| Rate for Payer: Aetna Commercial |
$19,713.04
|
| Rate for Payer: Anthem Medicaid |
$8,804.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,969.05
|
| Rate for Payer: Cash Price |
$12,800.67
|
| Rate for Payer: Cigna Commercial |
$21,249.12
|
| Rate for Payer: First Health Commercial |
$24,321.28
|
| Rate for Payer: Humana Commercial |
$21,761.15
|
| Rate for Payer: Humana KY Medicaid |
$8,804.30
|
| Rate for Payer: Kentucky WC Medicaid |
$8,893.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,993.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,893.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,680.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,980.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,529.19
|
| Rate for Payer: Ohio Health Group HMO |
$19,201.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,120.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,328.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,936.42
|
| Rate for Payer: PHCS Commercial |
$24,577.30
|
| Rate for Payer: United Healthcare All Payer |
$22,529.19
|
|
