|
GRAFT EXCLDR CONTRA16*12*10 12
|
Facility
|
OP
|
$22,528.05
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,928.65 |
| Max. Negotiated Rate |
$21,626.93 |
| Rate for Payer: Aetna Commercial |
$17,346.60
|
| Rate for Payer: Anthem Medicaid |
$7,747.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,571.88
|
| Rate for Payer: Cash Price |
$11,264.02
|
| Rate for Payer: Cigna Commercial |
$18,698.28
|
| Rate for Payer: First Health Commercial |
$21,401.65
|
| Rate for Payer: Humana Commercial |
$19,148.84
|
| Rate for Payer: Humana KY Medicaid |
$7,747.40
|
| Rate for Payer: Kentucky WC Medicaid |
$7,826.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,473.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,625.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,758.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,902.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,824.68
|
| Rate for Payer: Ohio Health Group HMO |
$16,896.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,505.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,928.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,983.70
|
| Rate for Payer: PHCS Commercial |
$21,626.93
|
| Rate for Payer: United Healthcare All Payer |
$19,824.68
|
|
|
GRAFT EXCLDR CONTRA16*12*10 12
|
Facility
|
IP
|
$22,528.05
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,928.65 |
| Max. Negotiated Rate |
$21,626.93 |
| Rate for Payer: Aetna Commercial |
$17,346.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,571.88
|
| Rate for Payer: Cash Price |
$11,264.02
|
| Rate for Payer: Cigna Commercial |
$18,698.28
|
| Rate for Payer: First Health Commercial |
$21,401.65
|
| Rate for Payer: Humana Commercial |
$19,148.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,473.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,625.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,758.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,824.68
|
| Rate for Payer: Ohio Health Group HMO |
$16,896.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,505.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,928.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,983.70
|
| Rate for Payer: PHCS Commercial |
$21,626.93
|
| Rate for Payer: United Healthcare All Payer |
$19,824.68
|
|
|
GRAFT EXCLDR CONTRA16*27*12 15
|
Facility
|
IP
|
$22,528.05
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,928.65 |
| Max. Negotiated Rate |
$21,626.93 |
| Rate for Payer: Aetna Commercial |
$17,346.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,571.88
|
| Rate for Payer: Cash Price |
$11,264.02
|
| Rate for Payer: Cigna Commercial |
$18,698.28
|
| Rate for Payer: First Health Commercial |
$21,401.65
|
| Rate for Payer: Humana Commercial |
$19,148.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,473.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,625.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,758.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,824.68
|
| Rate for Payer: Ohio Health Group HMO |
$16,896.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,505.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,928.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,983.70
|
| Rate for Payer: PHCS Commercial |
$21,626.93
|
| Rate for Payer: United Healthcare All Payer |
$19,824.68
|
|
|
GRAFT EXCLDR CONTRA16*27*12 15
|
Facility
|
OP
|
$22,528.05
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,928.65 |
| Max. Negotiated Rate |
$21,626.93 |
| Rate for Payer: Aetna Commercial |
$17,346.60
|
| Rate for Payer: Anthem Medicaid |
$7,747.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,571.88
|
| Rate for Payer: Cash Price |
$11,264.02
|
| Rate for Payer: Cigna Commercial |
$18,698.28
|
| Rate for Payer: First Health Commercial |
$21,401.65
|
| Rate for Payer: Humana Commercial |
$19,148.84
|
| Rate for Payer: Humana KY Medicaid |
$7,747.40
|
| Rate for Payer: Kentucky WC Medicaid |
$7,826.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,473.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,625.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,758.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,902.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,824.68
|
| Rate for Payer: Ohio Health Group HMO |
$16,896.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,505.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,928.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,983.70
|
| Rate for Payer: PHCS Commercial |
$21,626.93
|
| Rate for Payer: United Healthcare All Payer |
$19,824.68
|
|
|
GRAFT EXCLDR TRNK 28.5*14.5*16
|
Facility
|
IP
|
$72,145.60
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,378.93 |
| Max. Negotiated Rate |
$69,259.78 |
| Rate for Payer: Aetna Commercial |
$55,552.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56,273.57
|
| Rate for Payer: Cash Price |
$36,072.80
|
| Rate for Payer: Cigna Commercial |
$59,880.85
|
| Rate for Payer: First Health Commercial |
$68,538.32
|
| Rate for Payer: Humana Commercial |
$61,323.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59,159.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53,243.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,643.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$63,488.13
|
| Rate for Payer: Ohio Health Group HMO |
$54,109.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,429.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,378.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,365.14
|
| Rate for Payer: PHCS Commercial |
$69,259.78
|
| Rate for Payer: United Healthcare All Payer |
$63,488.13
|
|
|
GRAFT EXCLDR TRNK 28.5*14.5*16
|
Facility
|
OP
|
$72,145.60
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,378.93 |
| Max. Negotiated Rate |
$69,259.78 |
| Rate for Payer: Aetna Commercial |
$55,552.11
|
| Rate for Payer: Anthem Medicaid |
$24,810.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56,273.57
|
| Rate for Payer: Cash Price |
$36,072.80
|
| Rate for Payer: Cigna Commercial |
$59,880.85
|
| Rate for Payer: First Health Commercial |
$68,538.32
|
| Rate for Payer: Humana Commercial |
$61,323.76
|
| Rate for Payer: Humana KY Medicaid |
$24,810.87
|
| Rate for Payer: Kentucky WC Medicaid |
$25,063.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59,159.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53,243.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,643.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,308.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$63,488.13
|
| Rate for Payer: Ohio Health Group HMO |
$54,109.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,429.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,378.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,365.14
|
| Rate for Payer: PHCS Commercial |
$69,259.78
|
| Rate for Payer: United Healthcare All Payer |
$63,488.13
|
|
|
GRAFT EXCLUDER ILI 23*10*10 1
|
Facility
|
OP
|
$71,173.60
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,252.57 |
| Max. Negotiated Rate |
$68,326.66 |
| Rate for Payer: Aetna Commercial |
$54,803.67
|
| Rate for Payer: Anthem Medicaid |
$24,476.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55,515.41
|
| Rate for Payer: Cash Price |
$35,586.80
|
| Rate for Payer: Cigna Commercial |
$59,074.09
|
| Rate for Payer: First Health Commercial |
$67,614.92
|
| Rate for Payer: Humana Commercial |
$60,497.56
|
| Rate for Payer: Humana KY Medicaid |
$24,476.60
|
| Rate for Payer: Kentucky WC Medicaid |
$24,725.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58,362.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52,526.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,352.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$24,967.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$62,632.77
|
| Rate for Payer: Ohio Health Group HMO |
$53,380.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,234.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,252.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,063.82
|
| Rate for Payer: PHCS Commercial |
$68,326.66
|
| Rate for Payer: United Healthcare All Payer |
$62,632.77
|
|
|
GRAFT EXCLUDER ILI 23*10*10 1
|
Facility
|
IP
|
$71,173.60
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,252.57 |
| Max. Negotiated Rate |
$68,326.66 |
| Rate for Payer: Aetna Commercial |
$54,803.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55,515.41
|
| Rate for Payer: Cash Price |
$35,586.80
|
| Rate for Payer: Cigna Commercial |
$59,074.09
|
| Rate for Payer: First Health Commercial |
$67,614.92
|
| Rate for Payer: Humana Commercial |
$60,497.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58,362.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52,526.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,352.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$62,632.77
|
| Rate for Payer: Ohio Health Group HMO |
$53,380.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,234.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,252.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,063.82
|
| Rate for Payer: PHCS Commercial |
$68,326.66
|
| Rate for Payer: United Healthcare All Payer |
$62,632.77
|
|
|
GRAFT EXXCEL 5*70 STRAIGHT
|
Facility
|
OP
|
$5,182.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$673.66 |
| Max. Negotiated Rate |
$4,974.72 |
| Rate for Payer: Aetna Commercial |
$3,990.14
|
| Rate for Payer: Anthem Medicaid |
$1,782.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,041.96
|
| Rate for Payer: Cash Price |
$2,591.00
|
| Rate for Payer: Cigna Commercial |
$4,301.06
|
| Rate for Payer: First Health Commercial |
$4,922.90
|
| Rate for Payer: Humana Commercial |
$4,404.70
|
| Rate for Payer: Humana KY Medicaid |
$1,782.09
|
| Rate for Payer: Kentucky WC Medicaid |
$1,800.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,249.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,824.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,554.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,817.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,560.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,886.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,036.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$673.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,606.42
|
| Rate for Payer: PHCS Commercial |
$4,974.72
|
| Rate for Payer: United Healthcare All Payer |
$4,560.16
|
|
|
GRAFT EXXCEL 5*70 STRAIGHT
|
Facility
|
IP
|
$5,182.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$673.66 |
| Max. Negotiated Rate |
$4,974.72 |
| Rate for Payer: Aetna Commercial |
$3,990.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,041.96
|
| Rate for Payer: Cash Price |
$2,591.00
|
| Rate for Payer: Cigna Commercial |
$4,301.06
|
| Rate for Payer: First Health Commercial |
$4,922.90
|
| Rate for Payer: Humana Commercial |
$4,404.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,249.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,824.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,554.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,560.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,886.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,036.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$673.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,606.42
|
| Rate for Payer: PHCS Commercial |
$4,974.72
|
| Rate for Payer: United Healthcare All Payer |
$4,560.16
|
|
|
GRAFT EXXCEL 6*40*40 STR SUP
|
Facility
|
IP
|
$4,902.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$637.26 |
| Max. Negotiated Rate |
$4,705.92 |
| Rate for Payer: Aetna Commercial |
$3,774.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,823.56
|
| Rate for Payer: Cash Price |
$2,451.00
|
| Rate for Payer: Cigna Commercial |
$4,068.66
|
| Rate for Payer: First Health Commercial |
$4,656.90
|
| Rate for Payer: Humana Commercial |
$4,166.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,019.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,617.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,470.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,313.76
|
| Rate for Payer: Ohio Health Group HMO |
$3,676.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$980.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$637.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,519.62
|
| Rate for Payer: PHCS Commercial |
$4,705.92
|
| Rate for Payer: United Healthcare All Payer |
$4,313.76
|
|
|
GRAFT EXXCEL 6*40*40 STR SUP
|
Facility
|
OP
|
$4,902.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$637.26 |
| Max. Negotiated Rate |
$4,705.92 |
| Rate for Payer: Aetna Commercial |
$3,774.54
|
| Rate for Payer: Anthem Medicaid |
$1,685.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,823.56
|
| Rate for Payer: Cash Price |
$2,451.00
|
| Rate for Payer: Cigna Commercial |
$4,068.66
|
| Rate for Payer: First Health Commercial |
$4,656.90
|
| Rate for Payer: Humana Commercial |
$4,166.70
|
| Rate for Payer: Humana KY Medicaid |
$1,685.80
|
| Rate for Payer: Kentucky WC Medicaid |
$1,702.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,019.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,617.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,470.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,719.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,313.76
|
| Rate for Payer: Ohio Health Group HMO |
$3,676.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$980.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$637.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,519.62
|
| Rate for Payer: PHCS Commercial |
$4,705.92
|
| Rate for Payer: United Healthcare All Payer |
$4,313.76
|
|
|
GRAFT EXXCEL 6*40 THIN
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
GRAFT EXXCEL 6*40 THIN
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
GRAFT EXXCEL 6*70 THIN WALL
|
Facility
|
IP
|
$7,043.93
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$915.71 |
| Max. Negotiated Rate |
$6,762.17 |
| Rate for Payer: Aetna Commercial |
$5,423.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,494.27
|
| Rate for Payer: Cash Price |
$3,521.96
|
| Rate for Payer: Cigna Commercial |
$5,846.46
|
| Rate for Payer: First Health Commercial |
$6,691.73
|
| Rate for Payer: Humana Commercial |
$5,987.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,776.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,198.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,113.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,198.66
|
| Rate for Payer: Ohio Health Group HMO |
$5,282.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,408.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$915.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,183.62
|
| Rate for Payer: PHCS Commercial |
$6,762.17
|
| Rate for Payer: United Healthcare All Payer |
$6,198.66
|
|
|
GRAFT EXXCEL 6*70 THIN WALL
|
Facility
|
OP
|
$7,043.93
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$915.71 |
| Max. Negotiated Rate |
$6,762.17 |
| Rate for Payer: Aetna Commercial |
$5,423.83
|
| Rate for Payer: Anthem Medicaid |
$2,422.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,494.27
|
| Rate for Payer: Cash Price |
$3,521.96
|
| Rate for Payer: Cigna Commercial |
$5,846.46
|
| Rate for Payer: First Health Commercial |
$6,691.73
|
| Rate for Payer: Humana Commercial |
$5,987.34
|
| Rate for Payer: Humana KY Medicaid |
$2,422.41
|
| Rate for Payer: Kentucky WC Medicaid |
$2,447.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,776.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,198.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,113.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,471.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,198.66
|
| Rate for Payer: Ohio Health Group HMO |
$5,282.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,408.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$915.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,183.62
|
| Rate for Payer: PHCS Commercial |
$6,762.17
|
| Rate for Payer: United Healthcare All Payer |
$6,198.66
|
|
|
GRAFT FEM CONDYLE HEMI L LAT F
|
Facility
|
IP
|
$72,599.20
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,437.90 |
| Max. Negotiated Rate |
$69,695.23 |
| Rate for Payer: Aetna Commercial |
$55,901.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56,627.38
|
| Rate for Payer: Cash Price |
$36,299.60
|
| Rate for Payer: Cigna Commercial |
$60,257.34
|
| Rate for Payer: First Health Commercial |
$68,969.24
|
| Rate for Payer: Humana Commercial |
$61,709.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59,531.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53,578.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,779.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$63,887.30
|
| Rate for Payer: Ohio Health Group HMO |
$54,449.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,519.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,437.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,505.75
|
| Rate for Payer: PHCS Commercial |
$69,695.23
|
| Rate for Payer: United Healthcare All Payer |
$63,887.30
|
|
|
GRAFT FEM CONDYLE HEMI L LAT F
|
Facility
|
OP
|
$72,599.20
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,437.90 |
| Max. Negotiated Rate |
$69,695.23 |
| Rate for Payer: Aetna Commercial |
$55,901.38
|
| Rate for Payer: Anthem Medicaid |
$24,966.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56,627.38
|
| Rate for Payer: Cash Price |
$36,299.60
|
| Rate for Payer: Cigna Commercial |
$60,257.34
|
| Rate for Payer: First Health Commercial |
$68,969.24
|
| Rate for Payer: Humana Commercial |
$61,709.32
|
| Rate for Payer: Humana KY Medicaid |
$24,966.86
|
| Rate for Payer: Kentucky WC Medicaid |
$25,220.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59,531.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53,578.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,779.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,467.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$63,887.30
|
| Rate for Payer: Ohio Health Group HMO |
$54,449.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,519.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,437.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,505.75
|
| Rate for Payer: PHCS Commercial |
$69,695.23
|
| Rate for Payer: United Healthcare All Payer |
$63,887.30
|
|
|
GRAFT FLIXENE 4-7MM*35MM
|
Facility
|
IP
|
$8,423.92
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,095.11 |
| Max. Negotiated Rate |
$8,086.96 |
| Rate for Payer: Aetna Commercial |
$6,486.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,570.66
|
| Rate for Payer: Cash Price |
$4,211.96
|
| Rate for Payer: Cigna Commercial |
$6,991.85
|
| Rate for Payer: First Health Commercial |
$8,002.72
|
| Rate for Payer: Humana Commercial |
$7,160.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,907.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,216.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,527.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,413.05
|
| Rate for Payer: Ohio Health Group HMO |
$6,317.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,684.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,095.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,611.42
|
| Rate for Payer: PHCS Commercial |
$8,086.96
|
| Rate for Payer: United Healthcare All Payer |
$7,413.05
|
|
|
GRAFT FLIXENE 4-7MM*35MM
|
Facility
|
OP
|
$8,423.92
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,095.11 |
| Max. Negotiated Rate |
$8,086.96 |
| Rate for Payer: Aetna Commercial |
$6,486.42
|
| Rate for Payer: Anthem Medicaid |
$2,896.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,570.66
|
| Rate for Payer: Cash Price |
$4,211.96
|
| Rate for Payer: Cigna Commercial |
$6,991.85
|
| Rate for Payer: First Health Commercial |
$8,002.72
|
| Rate for Payer: Humana Commercial |
$7,160.33
|
| Rate for Payer: Humana KY Medicaid |
$2,896.99
|
| Rate for Payer: Kentucky WC Medicaid |
$2,926.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,907.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,216.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,527.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,955.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,413.05
|
| Rate for Payer: Ohio Health Group HMO |
$6,317.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,684.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,095.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,611.42
|
| Rate for Payer: PHCS Commercial |
$8,086.96
|
| Rate for Payer: United Healthcare All Payer |
$7,413.05
|
|
|
GRAFT FLIXENE 4-7MM*45CM TPR
|
Facility
|
OP
|
$8,056.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,047.28 |
| Max. Negotiated Rate |
$7,733.76 |
| Rate for Payer: Aetna Commercial |
$6,203.12
|
| Rate for Payer: Anthem Medicaid |
$2,770.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,283.68
|
| Rate for Payer: Cash Price |
$4,028.00
|
| Rate for Payer: Cigna Commercial |
$6,686.48
|
| Rate for Payer: First Health Commercial |
$7,653.20
|
| Rate for Payer: Humana Commercial |
$6,847.60
|
| Rate for Payer: Humana KY Medicaid |
$2,770.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,798.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,605.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,945.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,416.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,826.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,089.28
|
| Rate for Payer: Ohio Health Group HMO |
$6,042.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,611.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,047.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,497.36
|
| Rate for Payer: PHCS Commercial |
$7,733.76
|
| Rate for Payer: United Healthcare All Payer |
$7,089.28
|
|
|
GRAFT FLIXENE 4-7MM*45CM TPR
|
Facility
|
IP
|
$8,056.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,047.28 |
| Max. Negotiated Rate |
$7,733.76 |
| Rate for Payer: Aetna Commercial |
$6,203.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,283.68
|
| Rate for Payer: Cash Price |
$4,028.00
|
| Rate for Payer: Cigna Commercial |
$6,686.48
|
| Rate for Payer: First Health Commercial |
$7,653.20
|
| Rate for Payer: Humana Commercial |
$6,847.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,605.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,945.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,416.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,089.28
|
| Rate for Payer: Ohio Health Group HMO |
$6,042.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,611.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,047.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,497.36
|
| Rate for Payer: PHCS Commercial |
$7,733.76
|
| Rate for Payer: United Healthcare All Payer |
$7,089.28
|
|
|
GRAFT FLIXENE 6MM*40CM
|
Facility
|
OP
|
$6,742.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$876.46 |
| Max. Negotiated Rate |
$6,472.32 |
| Rate for Payer: Aetna Commercial |
$5,191.34
|
| Rate for Payer: Anthem Medicaid |
$2,318.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,258.76
|
| Rate for Payer: Cash Price |
$3,371.00
|
| Rate for Payer: Cigna Commercial |
$5,595.86
|
| Rate for Payer: First Health Commercial |
$6,404.90
|
| Rate for Payer: Humana Commercial |
$5,730.70
|
| Rate for Payer: Humana KY Medicaid |
$2,318.57
|
| Rate for Payer: Kentucky WC Medicaid |
$2,342.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,528.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,975.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,022.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,365.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,932.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,056.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,348.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$876.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,090.02
|
| Rate for Payer: PHCS Commercial |
$6,472.32
|
| Rate for Payer: United Healthcare All Payer |
$5,932.96
|
|
|
GRAFT FLIXENE 6MM*40CM
|
Facility
|
IP
|
$6,742.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$876.46 |
| Max. Negotiated Rate |
$6,472.32 |
| Rate for Payer: Aetna Commercial |
$5,191.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,258.76
|
| Rate for Payer: Cash Price |
$3,371.00
|
| Rate for Payer: Cigna Commercial |
$5,595.86
|
| Rate for Payer: First Health Commercial |
$6,404.90
|
| Rate for Payer: Humana Commercial |
$5,730.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,528.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,975.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,022.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,932.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,056.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,348.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$876.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,090.02
|
| Rate for Payer: PHCS Commercial |
$6,472.32
|
| Rate for Payer: United Healthcare All Payer |
$5,932.96
|
|
|
GRAFT FLIXENE 8MM*40CM
|
Facility
|
OP
|
$7,545.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$980.85 |
| Max. Negotiated Rate |
$7,243.20 |
| Rate for Payer: Aetna Commercial |
$5,809.65
|
| Rate for Payer: Anthem Medicaid |
$2,594.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,885.10
|
| Rate for Payer: Cash Price |
$3,772.50
|
| Rate for Payer: Cigna Commercial |
$6,262.35
|
| Rate for Payer: First Health Commercial |
$7,167.75
|
| Rate for Payer: Humana Commercial |
$6,413.25
|
| Rate for Payer: Humana KY Medicaid |
$2,594.73
|
| Rate for Payer: Kentucky WC Medicaid |
$2,621.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,186.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,568.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,263.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,646.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,639.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,658.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,509.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$980.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,338.95
|
| Rate for Payer: PHCS Commercial |
$7,243.20
|
| Rate for Payer: United Healthcare All Payer |
$6,639.60
|
|
