|
GRAFT HEMASHIELD AORTC 24M*15C
|
Facility
|
IP
|
$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 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: 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: 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
|
|
|
GRAFT HEMASHIELD AORTC 26M*15C
|
Facility
|
IP
|
$3,220.46
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$418.66 |
| Max. Negotiated Rate |
$3,091.64 |
| Rate for Payer: Aetna Commercial |
$2,479.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,511.96
|
| Rate for Payer: Cash Price |
$1,610.23
|
| Rate for Payer: Cigna Commercial |
$2,672.98
|
| Rate for Payer: First Health Commercial |
$3,059.44
|
| Rate for Payer: Humana Commercial |
$2,737.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,640.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,376.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$966.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,834.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,415.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$644.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$418.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$998.34
|
| Rate for Payer: PHCS Commercial |
$3,091.64
|
| Rate for Payer: United Healthcare All Payer |
$2,834.00
|
|
|
GRAFT HEMASHIELD AORTC 26M*15C
|
Facility
|
OP
|
$3,220.46
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$418.66 |
| Max. Negotiated Rate |
$3,091.64 |
| Rate for Payer: Aetna Commercial |
$2,479.75
|
| Rate for Payer: Anthem Medicaid |
$1,107.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,511.96
|
| Rate for Payer: Cash Price |
$1,610.23
|
| Rate for Payer: Cigna Commercial |
$2,672.98
|
| Rate for Payer: First Health Commercial |
$3,059.44
|
| Rate for Payer: Humana Commercial |
$2,737.39
|
| Rate for Payer: Humana KY Medicaid |
$1,107.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1,118.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,640.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,376.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$966.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,129.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,834.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,415.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$644.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$418.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$998.34
|
| Rate for Payer: PHCS Commercial |
$3,091.64
|
| Rate for Payer: United Healthcare All Payer |
$2,834.00
|
|
|
GRAFT HEMASHIELD AORTC 28M*15C
|
Facility
|
IP
|
$3,220.46
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$418.66 |
| Max. Negotiated Rate |
$3,091.64 |
| Rate for Payer: Aetna Commercial |
$2,479.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,511.96
|
| Rate for Payer: Cash Price |
$1,610.23
|
| Rate for Payer: Cigna Commercial |
$2,672.98
|
| Rate for Payer: First Health Commercial |
$3,059.44
|
| Rate for Payer: Humana Commercial |
$2,737.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,640.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,376.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$966.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,834.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,415.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$644.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$418.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$998.34
|
| Rate for Payer: PHCS Commercial |
$3,091.64
|
| Rate for Payer: United Healthcare All Payer |
$2,834.00
|
|
|
GRAFT HEMASHIELD AORTC 28M*15C
|
Facility
|
OP
|
$3,220.46
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$418.66 |
| Max. Negotiated Rate |
$3,091.64 |
| Rate for Payer: Aetna Commercial |
$2,479.75
|
| Rate for Payer: Anthem Medicaid |
$1,107.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,511.96
|
| Rate for Payer: Cash Price |
$1,610.23
|
| Rate for Payer: Cigna Commercial |
$2,672.98
|
| Rate for Payer: First Health Commercial |
$3,059.44
|
| Rate for Payer: Humana Commercial |
$2,737.39
|
| Rate for Payer: Humana KY Medicaid |
$1,107.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1,118.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,640.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,376.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$966.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,129.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,834.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,415.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$644.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$418.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$998.34
|
| Rate for Payer: PHCS Commercial |
$3,091.64
|
| Rate for Payer: United Healthcare All Payer |
$2,834.00
|
|
|
GRAFT HEMASHIELD GOLD 6*30
|
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 GOLD 6*30
|
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 GOLD 7*30
|
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 GOLD 7*30
|
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 GOLD 8*30
|
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 GOLD 8*30
|
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 GOLD BIFR 22*
|
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 GOLD BIFR 22*
|
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 PLAT PATCH 2.
|
Facility
|
IP
|
$1,587.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$206.36 |
| Max. Negotiated Rate |
$1,523.90 |
| Rate for Payer: Aetna Commercial |
$1,222.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,238.17
|
| Rate for Payer: Cash Price |
$793.70
|
| Rate for Payer: Cigna Commercial |
$1,317.54
|
| Rate for Payer: First Health Commercial |
$1,508.03
|
| Rate for Payer: Humana Commercial |
$1,349.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,301.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,171.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$476.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,396.91
|
| Rate for Payer: Ohio Health Group HMO |
$1,190.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$317.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$206.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$492.09
|
| Rate for Payer: PHCS Commercial |
$1,523.90
|
| Rate for Payer: United Healthcare All Payer |
$1,396.91
|
|
|
GRAFT HEMASHIELD PLAT PATCH 2.
|
Facility
|
OP
|
$1,587.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$206.36 |
| Max. Negotiated Rate |
$1,523.90 |
| Rate for Payer: Aetna Commercial |
$1,222.30
|
| Rate for Payer: Anthem Medicaid |
$545.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,238.17
|
| Rate for Payer: Cash Price |
$793.70
|
| Rate for Payer: Cigna Commercial |
$1,317.54
|
| Rate for Payer: First Health Commercial |
$1,508.03
|
| Rate for Payer: Humana Commercial |
$1,349.29
|
| Rate for Payer: Humana KY Medicaid |
$545.91
|
| Rate for Payer: Kentucky WC Medicaid |
$551.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,301.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,171.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$476.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$556.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,396.91
|
| Rate for Payer: Ohio Health Group HMO |
$1,190.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$317.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$206.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$492.09
|
| Rate for Payer: PHCS Commercial |
$1,523.90
|
| Rate for Payer: United Healthcare All Payer |
$1,396.91
|
|
|
GRAFT HEMA STR 30M*15CM PLAT
|
Facility
|
OP
|
$3,220.46
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$418.66 |
| Max. Negotiated Rate |
$3,091.64 |
| Rate for Payer: Aetna Commercial |
$2,479.75
|
| Rate for Payer: Anthem Medicaid |
$1,107.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,511.96
|
| Rate for Payer: Cash Price |
$1,610.23
|
| Rate for Payer: Cigna Commercial |
$2,672.98
|
| Rate for Payer: First Health Commercial |
$3,059.44
|
| Rate for Payer: Humana Commercial |
$2,737.39
|
| Rate for Payer: Humana KY Medicaid |
$1,107.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1,118.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,640.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,376.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$966.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,129.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,834.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,415.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$644.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$418.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$998.34
|
| Rate for Payer: PHCS Commercial |
$3,091.64
|
| Rate for Payer: United Healthcare All Payer |
$2,834.00
|
|
|
GRAFT HEMA STR 30M*15CM PLAT
|
Facility
|
IP
|
$3,220.46
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$418.66 |
| Max. Negotiated Rate |
$3,091.64 |
| Rate for Payer: Aetna Commercial |
$2,479.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,511.96
|
| Rate for Payer: Cash Price |
$1,610.23
|
| Rate for Payer: Cigna Commercial |
$2,672.98
|
| Rate for Payer: First Health Commercial |
$3,059.44
|
| Rate for Payer: Humana Commercial |
$2,737.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,640.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,376.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$966.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,834.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,415.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$644.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$418.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$998.34
|
| Rate for Payer: PHCS Commercial |
$3,091.64
|
| Rate for Payer: United Healthcare All Payer |
$2,834.00
|
|
|
GRAFT ILIAC EXT OVTN 10*10*45
|
Facility
|
OP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem Medicaid |
$6,671.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Humana KY Medicaid |
$6,671.66
|
| Rate for Payer: Kentucky WC Medicaid |
$6,739.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,805.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GRAFT ILIAC EXT OVTN 10*10*45
|
Facility
|
IP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GRAFT ILIAC EXT OVTN 12*12*45
|
Facility
|
IP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GRAFT ILIAC EXT OVTN 12*12*45
|
Facility
|
OP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem Medicaid |
$6,671.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Humana KY Medicaid |
$6,671.66
|
| Rate for Payer: Kentucky WC Medicaid |
$6,739.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,805.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GRAFT ILIAC EXT OVTN 14*14*45
|
Facility
|
IP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GRAFT ILIAC EXT OVTN 14*14*45
|
Facility
|
OP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem Medicaid |
$6,671.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Humana KY Medicaid |
$6,671.66
|
| Rate for Payer: Kentucky WC Medicaid |
$6,739.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,805.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GRAFT ILIAC EXT OVTN 16*16*45
|
Facility
|
OP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem Medicaid |
$6,671.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Humana KY Medicaid |
$6,671.66
|
| Rate for Payer: Kentucky WC Medicaid |
$6,739.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,805.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
|
GRAFT ILIAC EXT OVTN 16*16*45
|
Facility
|
IP
|
$19,400.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,522.00 |
| Max. Negotiated Rate |
$18,624.00 |
| Rate for Payer: Aetna Commercial |
$14,938.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,132.00
|
| Rate for Payer: Cash Price |
$9,700.00
|
| Rate for Payer: Cigna Commercial |
$16,102.00
|
| Rate for Payer: First Health Commercial |
$18,430.00
|
| Rate for Payer: Humana Commercial |
$16,490.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,908.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,317.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,820.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,072.00
|
| Rate for Payer: Ohio Health Group HMO |
$14,550.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,014.00
|
| Rate for Payer: PHCS Commercial |
$18,624.00
|
| Rate for Payer: United Healthcare All Payer |
$17,072.00
|
|
