|
GRAFT HEMA 4 BRANCH 30M PLAT
|
Facility
|
IP
|
$6,698.78
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$870.84 |
| Max. Negotiated Rate |
$6,430.83 |
| Rate for Payer: Aetna Commercial |
$5,158.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,225.05
|
| Rate for Payer: Cash Price |
$3,349.39
|
| Rate for Payer: Cigna Commercial |
$5,559.99
|
| Rate for Payer: First Health Commercial |
$6,363.84
|
| Rate for Payer: Humana Commercial |
$5,693.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,493.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,943.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,009.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,894.93
|
| Rate for Payer: Ohio Health Group HMO |
$5,024.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,339.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$870.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,076.62
|
| Rate for Payer: PHCS Commercial |
$6,430.83
|
| Rate for Payer: United Healthcare All Payer |
$5,894.93
|
|
|
GRAFT HEMA 4 BRANCH 30M PLAT
|
Facility
|
OP
|
$6,698.78
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$870.84 |
| Max. Negotiated Rate |
$6,430.83 |
| Rate for Payer: Aetna Commercial |
$5,158.06
|
| Rate for Payer: Anthem Medicaid |
$2,303.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,225.05
|
| Rate for Payer: Cash Price |
$3,349.39
|
| Rate for Payer: Cigna Commercial |
$5,559.99
|
| Rate for Payer: First Health Commercial |
$6,363.84
|
| Rate for Payer: Humana Commercial |
$5,693.96
|
| Rate for Payer: Humana KY Medicaid |
$2,303.71
|
| Rate for Payer: Kentucky WC Medicaid |
$2,327.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,493.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,943.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,009.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,349.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,894.93
|
| Rate for Payer: Ohio Health Group HMO |
$5,024.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,339.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$870.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,076.62
|
| Rate for Payer: PHCS Commercial |
$6,430.83
|
| Rate for Payer: United Healthcare All Payer |
$5,894.93
|
|
|
GRAFT HEMAGARD STRAIGHT 14*40
|
Facility
|
OP
|
$4,478.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$582.20 |
| Max. Negotiated Rate |
$4,299.36 |
| Rate for Payer: Aetna Commercial |
$3,448.44
|
| Rate for Payer: Anthem Medicaid |
$1,540.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,493.23
|
| Rate for Payer: Cash Price |
$2,239.25
|
| Rate for Payer: Cigna Commercial |
$3,717.16
|
| Rate for Payer: First Health Commercial |
$4,254.58
|
| Rate for Payer: Humana Commercial |
$3,806.72
|
| Rate for Payer: Humana KY Medicaid |
$1,540.16
|
| Rate for Payer: Kentucky WC Medicaid |
$1,555.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,672.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,305.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,343.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,571.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,941.08
|
| Rate for Payer: Ohio Health Group HMO |
$3,358.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$895.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$582.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,388.34
|
| Rate for Payer: PHCS Commercial |
$4,299.36
|
| Rate for Payer: United Healthcare All Payer |
$3,941.08
|
|
|
GRAFT HEMAGARD STRAIGHT 14*40
|
Facility
|
IP
|
$4,478.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$582.20 |
| Max. Negotiated Rate |
$4,299.36 |
| Rate for Payer: Aetna Commercial |
$3,448.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,493.23
|
| Rate for Payer: Cash Price |
$2,239.25
|
| Rate for Payer: Cigna Commercial |
$3,717.16
|
| Rate for Payer: First Health Commercial |
$4,254.58
|
| Rate for Payer: Humana Commercial |
$3,806.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,672.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,305.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,343.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,941.08
|
| Rate for Payer: Ohio Health Group HMO |
$3,358.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$895.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$582.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,388.34
|
| Rate for Payer: PHCS Commercial |
$4,299.36
|
| Rate for Payer: United Healthcare All Payer |
$3,941.08
|
|
|
GRAFT HEMASHIELD 12*6MM
|
Facility
|
IP
|
$4,609.16
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$599.19 |
| Max. Negotiated Rate |
$4,424.79 |
| Rate for Payer: Aetna Commercial |
$3,549.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,595.14
|
| Rate for Payer: Cash Price |
$2,304.58
|
| Rate for Payer: Cigna Commercial |
$3,825.60
|
| Rate for Payer: First Health Commercial |
$4,378.70
|
| Rate for Payer: Humana Commercial |
$3,917.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,779.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,401.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,382.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,056.06
|
| Rate for Payer: Ohio Health Group HMO |
$3,456.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$921.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$599.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,428.84
|
| Rate for Payer: PHCS Commercial |
$4,424.79
|
| Rate for Payer: United Healthcare All Payer |
$4,056.06
|
|
|
GRAFT HEMASHIELD 12*6MM
|
Facility
|
OP
|
$4,609.16
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$599.19 |
| Max. Negotiated Rate |
$4,424.79 |
| Rate for Payer: Aetna Commercial |
$3,549.05
|
| Rate for Payer: Anthem Medicaid |
$1,585.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,595.14
|
| Rate for Payer: Cash Price |
$2,304.58
|
| Rate for Payer: Cigna Commercial |
$3,825.60
|
| Rate for Payer: First Health Commercial |
$4,378.70
|
| Rate for Payer: Humana Commercial |
$3,917.79
|
| Rate for Payer: Humana KY Medicaid |
$1,585.09
|
| Rate for Payer: Kentucky WC Medicaid |
$1,601.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,779.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,401.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,382.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,616.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,056.06
|
| Rate for Payer: Ohio Health Group HMO |
$3,456.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$921.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$599.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,428.84
|
| Rate for Payer: PHCS Commercial |
$4,424.79
|
| Rate for Payer: United Healthcare All Payer |
$4,056.06
|
|
|
GRAFT HEMASHIELD 12*7MM
|
Facility
|
IP
|
$3,984.86
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$518.03 |
| Max. Negotiated Rate |
$3,825.47 |
| Rate for Payer: Aetna Commercial |
$3,068.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,108.19
|
| Rate for Payer: Cash Price |
$1,992.43
|
| Rate for Payer: Cigna Commercial |
$3,307.43
|
| Rate for Payer: First Health Commercial |
$3,785.62
|
| Rate for Payer: Humana Commercial |
$3,387.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,267.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,940.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,195.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,506.68
|
| Rate for Payer: Ohio Health Group HMO |
$2,988.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$796.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$518.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,235.31
|
| Rate for Payer: PHCS Commercial |
$3,825.47
|
| Rate for Payer: United Healthcare All Payer |
$3,506.68
|
|
|
GRAFT HEMASHIELD 12*7MM
|
Facility
|
OP
|
$3,984.86
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$518.03 |
| Max. Negotiated Rate |
$3,825.47 |
| Rate for Payer: Aetna Commercial |
$3,068.34
|
| Rate for Payer: Anthem Medicaid |
$1,370.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,108.19
|
| Rate for Payer: Cash Price |
$1,992.43
|
| Rate for Payer: Cigna Commercial |
$3,307.43
|
| Rate for Payer: First Health Commercial |
$3,785.62
|
| Rate for Payer: Humana Commercial |
$3,387.13
|
| Rate for Payer: Humana KY Medicaid |
$1,370.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,384.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,267.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,940.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,195.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,397.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,506.68
|
| Rate for Payer: Ohio Health Group HMO |
$2,988.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$796.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$518.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,235.31
|
| Rate for Payer: PHCS Commercial |
$3,825.47
|
| Rate for Payer: United Healthcare All Payer |
$3,506.68
|
|
|
GRAFT HEMASHIELD 14*7MM
|
Facility
|
IP
|
$4,777.78
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$621.11 |
| Max. Negotiated Rate |
$4,586.67 |
| Rate for Payer: Aetna Commercial |
$3,678.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,726.67
|
| Rate for Payer: Cash Price |
$2,388.89
|
| Rate for Payer: Cigna Commercial |
$3,965.56
|
| Rate for Payer: First Health Commercial |
$4,538.89
|
| Rate for Payer: Humana Commercial |
$4,061.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,917.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,526.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,433.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,204.45
|
| Rate for Payer: Ohio Health Group HMO |
$3,583.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$955.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$621.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,481.11
|
| Rate for Payer: PHCS Commercial |
$4,586.67
|
| Rate for Payer: United Healthcare All Payer |
$4,204.45
|
|
|
GRAFT HEMASHIELD 14*7MM
|
Facility
|
OP
|
$4,777.78
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$621.11 |
| Max. Negotiated Rate |
$4,586.67 |
| Rate for Payer: Aetna Commercial |
$3,678.89
|
| Rate for Payer: Anthem Medicaid |
$1,643.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,726.67
|
| Rate for Payer: Cash Price |
$2,388.89
|
| Rate for Payer: Cigna Commercial |
$3,965.56
|
| Rate for Payer: First Health Commercial |
$4,538.89
|
| Rate for Payer: Humana Commercial |
$4,061.11
|
| Rate for Payer: Humana KY Medicaid |
$1,643.08
|
| Rate for Payer: Kentucky WC Medicaid |
$1,659.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,917.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,526.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,433.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,676.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,204.45
|
| Rate for Payer: Ohio Health Group HMO |
$3,583.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$955.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$621.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,481.11
|
| Rate for Payer: PHCS Commercial |
$4,586.67
|
| Rate for Payer: United Healthcare All Payer |
$4,204.45
|
|
|
GRAFT HEMASHIELD 16*8MM
|
Facility
|
OP
|
$4,609.16
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$599.19 |
| Max. Negotiated Rate |
$4,424.79 |
| Rate for Payer: Aetna Commercial |
$3,549.05
|
| Rate for Payer: Anthem Medicaid |
$1,585.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,595.14
|
| Rate for Payer: Cash Price |
$2,304.58
|
| Rate for Payer: Cigna Commercial |
$3,825.60
|
| Rate for Payer: First Health Commercial |
$4,378.70
|
| Rate for Payer: Humana Commercial |
$3,917.79
|
| Rate for Payer: Humana KY Medicaid |
$1,585.09
|
| Rate for Payer: Kentucky WC Medicaid |
$1,601.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,779.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,401.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,382.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,616.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,056.06
|
| Rate for Payer: Ohio Health Group HMO |
$3,456.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$921.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$599.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,428.84
|
| Rate for Payer: PHCS Commercial |
$4,424.79
|
| Rate for Payer: United Healthcare All Payer |
$4,056.06
|
|
|
GRAFT HEMASHIELD 16*8MM
|
Facility
|
IP
|
$4,609.16
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$599.19 |
| Max. Negotiated Rate |
$4,424.79 |
| Rate for Payer: Aetna Commercial |
$3,549.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,595.14
|
| Rate for Payer: Cash Price |
$2,304.58
|
| Rate for Payer: Cigna Commercial |
$3,825.60
|
| Rate for Payer: First Health Commercial |
$4,378.70
|
| Rate for Payer: Humana Commercial |
$3,917.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,779.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,401.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,382.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,056.06
|
| Rate for Payer: Ohio Health Group HMO |
$3,456.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$921.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$599.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,428.84
|
| Rate for Payer: PHCS Commercial |
$4,424.79
|
| Rate for Payer: United Healthcare All Payer |
$4,056.06
|
|
|
GRAFT HEMASHIELD 18*9MM
|
Facility
|
OP
|
$4,609.16
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$599.19 |
| Max. Negotiated Rate |
$4,424.79 |
| Rate for Payer: Aetna Commercial |
$3,549.05
|
| Rate for Payer: Anthem Medicaid |
$1,585.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,595.14
|
| Rate for Payer: Cash Price |
$2,304.58
|
| Rate for Payer: Cigna Commercial |
$3,825.60
|
| Rate for Payer: First Health Commercial |
$4,378.70
|
| Rate for Payer: Humana Commercial |
$3,917.79
|
| Rate for Payer: Humana KY Medicaid |
$1,585.09
|
| Rate for Payer: Kentucky WC Medicaid |
$1,601.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,779.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,401.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,382.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,616.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,056.06
|
| Rate for Payer: Ohio Health Group HMO |
$3,456.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$921.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$599.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,428.84
|
| Rate for Payer: PHCS Commercial |
$4,424.79
|
| Rate for Payer: United Healthcare All Payer |
$4,056.06
|
|
|
GRAFT HEMASHIELD 18*9MM
|
Facility
|
IP
|
$4,609.16
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$599.19 |
| Max. Negotiated Rate |
$4,424.79 |
| Rate for Payer: Aetna Commercial |
$3,549.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,595.14
|
| Rate for Payer: Cash Price |
$2,304.58
|
| Rate for Payer: Cigna Commercial |
$3,825.60
|
| Rate for Payer: First Health Commercial |
$4,378.70
|
| Rate for Payer: Humana Commercial |
$3,917.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,779.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,401.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,382.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,056.06
|
| Rate for Payer: Ohio Health Group HMO |
$3,456.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$921.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$599.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,428.84
|
| Rate for Payer: PHCS Commercial |
$4,424.79
|
| Rate for Payer: United Healthcare All Payer |
$4,056.06
|
|
|
GRAFT HEMASHIELD 20*10MM
|
Facility
|
IP
|
$3,984.86
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$518.03 |
| Max. Negotiated Rate |
$3,825.47 |
| Rate for Payer: Aetna Commercial |
$3,068.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,108.19
|
| Rate for Payer: Cash Price |
$1,992.43
|
| Rate for Payer: Cigna Commercial |
$3,307.43
|
| Rate for Payer: First Health Commercial |
$3,785.62
|
| Rate for Payer: Humana Commercial |
$3,387.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,267.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,940.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,195.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,506.68
|
| Rate for Payer: Ohio Health Group HMO |
$2,988.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$796.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$518.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,235.31
|
| Rate for Payer: PHCS Commercial |
$3,825.47
|
| Rate for Payer: United Healthcare All Payer |
$3,506.68
|
|
|
GRAFT HEMASHIELD 20*10MM
|
Facility
|
OP
|
$3,984.86
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$518.03 |
| Max. Negotiated Rate |
$3,825.47 |
| Rate for Payer: Aetna Commercial |
$3,068.34
|
| Rate for Payer: Anthem Medicaid |
$1,370.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,108.19
|
| Rate for Payer: Cash Price |
$1,992.43
|
| Rate for Payer: Cigna Commercial |
$3,307.43
|
| Rate for Payer: First Health Commercial |
$3,785.62
|
| Rate for Payer: Humana Commercial |
$3,387.13
|
| Rate for Payer: Humana KY Medicaid |
$1,370.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,384.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,267.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,940.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,195.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,397.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,506.68
|
| Rate for Payer: Ohio Health Group HMO |
$2,988.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$796.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$518.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,235.31
|
| Rate for Payer: PHCS Commercial |
$3,825.47
|
| Rate for Payer: United Healthcare All Payer |
$3,506.68
|
|
|
GRAFT HEMASHIELD 24*12MM
|
Facility
|
OP
|
$3,984.86
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$518.03 |
| Max. Negotiated Rate |
$3,825.47 |
| Rate for Payer: Aetna Commercial |
$3,068.34
|
| Rate for Payer: Anthem Medicaid |
$1,370.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,108.19
|
| Rate for Payer: Cash Price |
$1,992.43
|
| Rate for Payer: Cigna Commercial |
$3,307.43
|
| Rate for Payer: First Health Commercial |
$3,785.62
|
| Rate for Payer: Humana Commercial |
$3,387.13
|
| Rate for Payer: Humana KY Medicaid |
$1,370.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,384.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,267.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,940.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,195.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,397.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,506.68
|
| Rate for Payer: Ohio Health Group HMO |
$2,988.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$796.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$518.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,235.31
|
| Rate for Payer: PHCS Commercial |
$3,825.47
|
| Rate for Payer: United Healthcare All Payer |
$3,506.68
|
|
|
GRAFT HEMASHIELD 24*12MM
|
Facility
|
IP
|
$3,984.86
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$518.03 |
| Max. Negotiated Rate |
$3,825.47 |
| Rate for Payer: Aetna Commercial |
$3,068.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,108.19
|
| Rate for Payer: Cash Price |
$1,992.43
|
| Rate for Payer: Cigna Commercial |
$3,307.43
|
| Rate for Payer: First Health Commercial |
$3,785.62
|
| Rate for Payer: Humana Commercial |
$3,387.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,267.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,940.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,195.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,506.68
|
| Rate for Payer: Ohio Health Group HMO |
$2,988.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$796.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$518.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,235.31
|
| Rate for Payer: PHCS Commercial |
$3,825.47
|
| Rate for Payer: United Healthcare All Payer |
$3,506.68
|
|
|
GRAFT HEMASHIELD 40*6MM
|
Facility
|
OP
|
$3,932.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$511.22 |
| Max. Negotiated Rate |
$3,775.20 |
| Rate for Payer: Aetna Commercial |
$3,028.02
|
| Rate for Payer: Anthem Medicaid |
$1,352.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,067.35
|
| Rate for Payer: Cash Price |
$1,966.25
|
| Rate for Payer: Cigna Commercial |
$3,263.98
|
| Rate for Payer: First Health Commercial |
$3,735.88
|
| Rate for Payer: Humana Commercial |
$3,342.62
|
| Rate for Payer: Humana KY Medicaid |
$1,352.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,366.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,224.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,902.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,179.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,379.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,460.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,949.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$786.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$511.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,219.08
|
| Rate for Payer: PHCS Commercial |
$3,775.20
|
| Rate for Payer: United Healthcare All Payer |
$3,460.60
|
|
|
GRAFT HEMASHIELD 40*6MM
|
Facility
|
IP
|
$3,932.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$511.22 |
| Max. Negotiated Rate |
$3,775.20 |
| Rate for Payer: Aetna Commercial |
$3,028.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,067.35
|
| Rate for Payer: Cash Price |
$1,966.25
|
| Rate for Payer: Cigna Commercial |
$3,263.98
|
| Rate for Payer: First Health Commercial |
$3,735.88
|
| Rate for Payer: Humana Commercial |
$3,342.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,224.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,902.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,179.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,460.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,949.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$786.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$511.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,219.08
|
| Rate for Payer: PHCS Commercial |
$3,775.20
|
| Rate for Payer: United Healthcare All Payer |
$3,460.60
|
|
|
GRAFT HEMASHIELD 40*8MM
|
Facility
|
OP
|
$3,393.92
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$441.21 |
| Max. Negotiated Rate |
$3,258.16 |
| Rate for Payer: Aetna Commercial |
$2,613.32
|
| Rate for Payer: Anthem Medicaid |
$1,167.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,647.26
|
| Rate for Payer: Cash Price |
$1,696.96
|
| Rate for Payer: Cigna Commercial |
$2,816.95
|
| Rate for Payer: First Health Commercial |
$3,224.22
|
| Rate for Payer: Humana Commercial |
$2,884.83
|
| Rate for Payer: Humana KY Medicaid |
$1,167.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,179.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,783.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,504.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,018.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,190.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,986.65
|
| Rate for Payer: Ohio Health Group HMO |
$2,545.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$678.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$441.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,052.12
|
| Rate for Payer: PHCS Commercial |
$3,258.16
|
| Rate for Payer: United Healthcare All Payer |
$2,986.65
|
|
|
GRAFT HEMASHIELD 40*8MM
|
Facility
|
IP
|
$3,393.92
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$441.21 |
| Max. Negotiated Rate |
$3,258.16 |
| Rate for Payer: Aetna Commercial |
$2,613.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,647.26
|
| Rate for Payer: Cash Price |
$1,696.96
|
| Rate for Payer: Cigna Commercial |
$2,816.95
|
| Rate for Payer: First Health Commercial |
$3,224.22
|
| Rate for Payer: Humana Commercial |
$2,884.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,783.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,504.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,018.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,986.65
|
| Rate for Payer: Ohio Health Group HMO |
$2,545.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$678.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$441.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,052.12
|
| Rate for Payer: PHCS Commercial |
$3,258.16
|
| Rate for Payer: United Healthcare All Payer |
$2,986.65
|
|
|
GRAFT HEMASHIELD AORTC 22M*15C
|
Facility
|
OP
|
$3,692.78
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$480.06 |
| Max. Negotiated Rate |
$3,545.07 |
| Rate for Payer: Aetna Commercial |
$2,843.44
|
| Rate for Payer: Anthem Medicaid |
$1,269.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,880.37
|
| Rate for Payer: Cash Price |
$1,846.39
|
| Rate for Payer: Cigna Commercial |
$3,065.01
|
| Rate for Payer: First Health Commercial |
$3,508.14
|
| Rate for Payer: Humana Commercial |
$3,138.86
|
| Rate for Payer: Humana KY Medicaid |
$1,269.95
|
| Rate for Payer: Kentucky WC Medicaid |
$1,282.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,028.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,725.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,107.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,295.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,249.65
|
| Rate for Payer: Ohio Health Group HMO |
$2,769.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$738.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$480.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,144.76
|
| Rate for Payer: PHCS Commercial |
$3,545.07
|
| Rate for Payer: United Healthcare All Payer |
$3,249.65
|
|
|
GRAFT HEMASHIELD AORTC 22M*15C
|
Facility
|
IP
|
$3,692.78
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$480.06 |
| Max. Negotiated Rate |
$3,545.07 |
| Rate for Payer: Aetna Commercial |
$2,843.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,880.37
|
| Rate for Payer: Cash Price |
$1,846.39
|
| Rate for Payer: Cigna Commercial |
$3,065.01
|
| Rate for Payer: First Health Commercial |
$3,508.14
|
| Rate for Payer: Humana Commercial |
$3,138.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,028.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,725.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,107.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,249.65
|
| Rate for Payer: Ohio Health Group HMO |
$2,769.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$738.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$480.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,144.76
|
| Rate for Payer: PHCS Commercial |
$3,545.07
|
| Rate for Payer: United Healthcare All Payer |
$3,249.65
|
|
|
GRAFT HEMASHIELD AORTC 24M*15C
|
Facility
|
OP
|
$3,155.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$410.22 |
| Max. Negotiated Rate |
$3,029.28 |
| Rate for Payer: Aetna Commercial |
$2,429.74
|
| Rate for Payer: Anthem Medicaid |
$1,085.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,461.29
|
| Rate for Payer: Cash Price |
$1,577.75
|
| Rate for Payer: Cigna Commercial |
$2,619.06
|
| Rate for Payer: First Health Commercial |
$2,997.72
|
| Rate for Payer: Humana Commercial |
$2,682.18
|
| Rate for Payer: Humana KY Medicaid |
$1,085.18
|
| Rate for Payer: Kentucky WC Medicaid |
$1,096.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,587.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,328.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$946.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,106.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,776.84
|
| Rate for Payer: Ohio Health Group HMO |
$2,366.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$631.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$410.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$978.20
|
| Rate for Payer: PHCS Commercial |
$3,029.28
|
| Rate for Payer: United Healthcare All Payer |
$2,776.84
|
|
