|
GRAFTJACKET 5CM*5CM 8600-5X05
|
Facility
|
OP
|
$12,906.80
|
|
|
Service Code
|
HCPCS Q4107
|
| Hospital Charge Code |
27000117
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,677.88 |
| Max. Negotiated Rate |
$12,390.53 |
| Rate for Payer: Aetna Commercial |
$9,938.24
|
| Rate for Payer: Anthem Medicaid |
$4,438.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,067.30
|
| Rate for Payer: Cash Price |
$6,453.40
|
| Rate for Payer: Cigna Commercial |
$10,712.64
|
| Rate for Payer: First Health Commercial |
$12,261.46
|
| Rate for Payer: Humana Commercial |
$10,970.78
|
| Rate for Payer: Humana KY Medicaid |
$4,438.65
|
| Rate for Payer: Kentucky WC Medicaid |
$4,483.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,583.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,525.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,872.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,527.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,357.98
|
| Rate for Payer: Ohio Health Group HMO |
$9,680.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,581.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,677.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,001.11
|
| Rate for Payer: PHCS Commercial |
$12,390.53
|
| Rate for Payer: United Healthcare All Payer |
$11,357.98
|
|
|
GRAFTLINK TENDON 60-80*7.5-10.
|
Facility
|
IP
|
$11,677.48
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,518.07 |
| Max. Negotiated Rate |
$11,210.38 |
| Rate for Payer: Aetna Commercial |
$8,991.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,108.43
|
| Rate for Payer: Cash Price |
$5,838.74
|
| Rate for Payer: Cigna Commercial |
$9,692.31
|
| Rate for Payer: First Health Commercial |
$11,093.61
|
| Rate for Payer: Humana Commercial |
$9,925.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,575.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,617.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,503.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,276.18
|
| Rate for Payer: Ohio Health Group HMO |
$8,758.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,335.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,518.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,620.02
|
| Rate for Payer: PHCS Commercial |
$11,210.38
|
| Rate for Payer: United Healthcare All Payer |
$10,276.18
|
|
|
GRAFTLINK TENDON 60-80*7.5-10.
|
Facility
|
OP
|
$11,677.48
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,518.07 |
| Max. Negotiated Rate |
$11,210.38 |
| Rate for Payer: Aetna Commercial |
$8,991.66
|
| Rate for Payer: Anthem Medicaid |
$4,015.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,108.43
|
| Rate for Payer: Cash Price |
$5,838.74
|
| Rate for Payer: Cigna Commercial |
$9,692.31
|
| Rate for Payer: First Health Commercial |
$11,093.61
|
| Rate for Payer: Humana Commercial |
$9,925.86
|
| Rate for Payer: Humana KY Medicaid |
$4,015.89
|
| Rate for Payer: Kentucky WC Medicaid |
$4,056.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,575.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,617.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,503.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,096.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,276.18
|
| Rate for Payer: Ohio Health Group HMO |
$8,758.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,335.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,518.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,620.02
|
| Rate for Payer: PHCS Commercial |
$11,210.38
|
| Rate for Payer: United Healthcare All Payer |
$10,276.18
|
|
|
GRAFT MAIN BDY BIFUR 28*60*13
|
Facility
|
OP
|
$70,162.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,121.06 |
| Max. Negotiated Rate |
$67,355.52 |
| Rate for Payer: Aetna Commercial |
$54,024.74
|
| Rate for Payer: Anthem Medicaid |
$24,128.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,726.36
|
| Rate for Payer: Cash Price |
$35,081.00
|
| Rate for Payer: Cigna Commercial |
$58,234.46
|
| Rate for Payer: First Health Commercial |
$66,653.90
|
| Rate for Payer: Humana Commercial |
$59,637.70
|
| Rate for Payer: Humana KY Medicaid |
$24,128.71
|
| Rate for Payer: Kentucky WC Medicaid |
$24,374.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57,532.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,779.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,048.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$24,612.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$61,742.56
|
| Rate for Payer: Ohio Health Group HMO |
$52,621.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,032.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,121.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,750.22
|
| Rate for Payer: PHCS Commercial |
$67,355.52
|
| Rate for Payer: United Healthcare All Payer |
$61,742.56
|
|
|
GRAFT MAIN BDY BIFUR 28*60*13
|
Facility
|
IP
|
$70,162.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,121.06 |
| Max. Negotiated Rate |
$67,355.52 |
| Rate for Payer: Aetna Commercial |
$54,024.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,726.36
|
| Rate for Payer: Cash Price |
$35,081.00
|
| Rate for Payer: Cigna Commercial |
$58,234.46
|
| Rate for Payer: First Health Commercial |
$66,653.90
|
| Rate for Payer: Humana Commercial |
$59,637.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57,532.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,779.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,048.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$61,742.56
|
| Rate for Payer: Ohio Health Group HMO |
$52,621.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,032.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,121.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,750.22
|
| Rate for Payer: PHCS Commercial |
$67,355.52
|
| Rate for Payer: United Healthcare All Payer |
$61,742.56
|
|
|
GRAFT MAIN BODY EXT RX1-36-54
|
Facility
|
IP
|
$23,834.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,098.52 |
| Max. Negotiated Rate |
$22,881.36 |
| Rate for Payer: Aetna Commercial |
$18,352.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,591.10
|
| Rate for Payer: Cash Price |
$11,917.38
|
| Rate for Payer: Cigna Commercial |
$19,782.84
|
| Rate for Payer: First Health Commercial |
$22,643.01
|
| Rate for Payer: Humana Commercial |
$20,259.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,544.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,590.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,150.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,974.58
|
| Rate for Payer: Ohio Health Group HMO |
$17,876.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,766.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,098.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,388.77
|
| Rate for Payer: PHCS Commercial |
$22,881.36
|
| Rate for Payer: United Healthcare All Payer |
$20,974.58
|
|
|
GRAFT MAIN BODY EXT RX1-36-54
|
Facility
|
OP
|
$23,834.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,098.52 |
| Max. Negotiated Rate |
$22,881.36 |
| Rate for Payer: Aetna Commercial |
$18,352.76
|
| Rate for Payer: Anthem Medicaid |
$8,196.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,591.10
|
| Rate for Payer: Cash Price |
$11,917.38
|
| Rate for Payer: Cigna Commercial |
$19,782.84
|
| Rate for Payer: First Health Commercial |
$22,643.01
|
| Rate for Payer: Humana Commercial |
$20,259.54
|
| Rate for Payer: Humana KY Medicaid |
$8,196.77
|
| Rate for Payer: Kentucky WC Medicaid |
$8,280.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,544.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,590.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,150.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,361.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,974.58
|
| Rate for Payer: Ohio Health Group HMO |
$17,876.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,766.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,098.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,388.77
|
| Rate for Payer: PHCS Commercial |
$22,881.36
|
| Rate for Payer: United Healthcare All Payer |
$20,974.58
|
|
|
GRAFT MARKER RADIOPAQUE
|
Facility
|
IP
|
$483.30
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$62.83 |
| Max. Negotiated Rate |
$463.97 |
| Rate for Payer: Aetna Commercial |
$372.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$376.97
|
| Rate for Payer: Cash Price |
$241.65
|
| Rate for Payer: Cigna Commercial |
$401.14
|
| Rate for Payer: First Health Commercial |
$459.14
|
| Rate for Payer: Humana Commercial |
$410.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$396.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$356.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$144.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$425.30
|
| Rate for Payer: Ohio Health Group HMO |
$362.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$149.82
|
| Rate for Payer: PHCS Commercial |
$463.97
|
| Rate for Payer: United Healthcare All Payer |
$425.30
|
|
|
GRAFT MARKER RADIOPAQUE
|
Facility
|
OP
|
$483.30
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$62.83 |
| Max. Negotiated Rate |
$463.97 |
| Rate for Payer: Aetna Commercial |
$372.14
|
| Rate for Payer: Anthem Medicaid |
$166.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$376.97
|
| Rate for Payer: Cash Price |
$241.65
|
| Rate for Payer: Cigna Commercial |
$401.14
|
| Rate for Payer: First Health Commercial |
$459.14
|
| Rate for Payer: Humana Commercial |
$410.80
|
| Rate for Payer: Humana KY Medicaid |
$166.21
|
| Rate for Payer: Kentucky WC Medicaid |
$167.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$396.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$356.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$144.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$169.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$425.30
|
| Rate for Payer: Ohio Health Group HMO |
$362.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$149.82
|
| Rate for Payer: PHCS Commercial |
$463.97
|
| Rate for Payer: United Healthcare All Payer |
$425.30
|
|
|
GRAFTMASTER 2.8*16
|
Facility
|
OP
|
$12,041.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,565.43 |
| Max. Negotiated Rate |
$11,560.08 |
| Rate for Payer: Aetna Commercial |
$9,272.15
|
| Rate for Payer: Anthem Medicaid |
$4,141.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,392.56
|
| Rate for Payer: Cash Price |
$6,020.88
|
| Rate for Payer: Cigna Commercial |
$9,994.65
|
| Rate for Payer: First Health Commercial |
$11,439.66
|
| Rate for Payer: Humana Commercial |
$10,235.49
|
| Rate for Payer: Humana KY Medicaid |
$4,141.16
|
| Rate for Payer: Kentucky WC Medicaid |
$4,183.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,874.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,886.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,612.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,224.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,596.74
|
| Rate for Payer: Ohio Health Group HMO |
$9,031.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,408.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,565.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,732.94
|
| Rate for Payer: PHCS Commercial |
$11,560.08
|
| Rate for Payer: United Healthcare All Payer |
$10,596.74
|
|
|
GRAFTMASTER 2.8*16
|
Facility
|
IP
|
$12,041.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,565.43 |
| Max. Negotiated Rate |
$11,560.08 |
| Rate for Payer: Aetna Commercial |
$9,272.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,392.56
|
| Rate for Payer: Cash Price |
$6,020.88
|
| Rate for Payer: Cigna Commercial |
$9,994.65
|
| Rate for Payer: First Health Commercial |
$11,439.66
|
| Rate for Payer: Humana Commercial |
$10,235.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,874.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,886.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,612.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,596.74
|
| Rate for Payer: Ohio Health Group HMO |
$9,031.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,408.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,565.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,732.94
|
| Rate for Payer: PHCS Commercial |
$11,560.08
|
| Rate for Payer: United Healthcare All Payer |
$10,596.74
|
|
|
GRAFTMASTER 3.5*16
|
Facility
|
OP
|
$12,041.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,565.43 |
| Max. Negotiated Rate |
$11,560.08 |
| Rate for Payer: Aetna Commercial |
$9,272.15
|
| Rate for Payer: Anthem Medicaid |
$4,141.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,392.56
|
| Rate for Payer: Cash Price |
$6,020.88
|
| Rate for Payer: Cigna Commercial |
$9,994.65
|
| Rate for Payer: First Health Commercial |
$11,439.66
|
| Rate for Payer: Humana Commercial |
$10,235.49
|
| Rate for Payer: Humana KY Medicaid |
$4,141.16
|
| Rate for Payer: Kentucky WC Medicaid |
$4,183.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,874.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,886.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,612.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,224.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,596.74
|
| Rate for Payer: Ohio Health Group HMO |
$9,031.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,408.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,565.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,732.94
|
| Rate for Payer: PHCS Commercial |
$11,560.08
|
| Rate for Payer: United Healthcare All Payer |
$10,596.74
|
|
|
GRAFTMASTER 3.5*16
|
Facility
|
IP
|
$12,041.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,565.43 |
| Max. Negotiated Rate |
$11,560.08 |
| Rate for Payer: Aetna Commercial |
$9,272.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,392.56
|
| Rate for Payer: Cash Price |
$6,020.88
|
| Rate for Payer: Cigna Commercial |
$9,994.65
|
| Rate for Payer: First Health Commercial |
$11,439.66
|
| Rate for Payer: Humana Commercial |
$10,235.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,874.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,886.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,612.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,596.74
|
| Rate for Payer: Ohio Health Group HMO |
$9,031.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,408.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,565.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,732.94
|
| Rate for Payer: PHCS Commercial |
$11,560.08
|
| Rate for Payer: United Healthcare All Payer |
$10,596.74
|
|
|
GRAFTMASTER 4.0*16
|
Facility
|
IP
|
$12,041.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,565.43 |
| Max. Negotiated Rate |
$11,560.08 |
| Rate for Payer: First Health Commercial |
$11,439.66
|
| Rate for Payer: Aetna Commercial |
$9,272.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,392.56
|
| Rate for Payer: Cash Price |
$6,020.88
|
| Rate for Payer: Cigna Commercial |
$9,994.65
|
| Rate for Payer: Humana Commercial |
$10,235.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,874.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,886.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,612.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,596.74
|
| Rate for Payer: Ohio Health Group HMO |
$9,031.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,408.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,565.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,732.94
|
| Rate for Payer: PHCS Commercial |
$11,560.08
|
| Rate for Payer: United Healthcare All Payer |
$10,596.74
|
|
|
GRAFTMASTER 4.0*16
|
Facility
|
OP
|
$12,041.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,565.43 |
| Max. Negotiated Rate |
$11,560.08 |
| Rate for Payer: Aetna Commercial |
$9,272.15
|
| Rate for Payer: Anthem Medicaid |
$4,141.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,392.56
|
| Rate for Payer: Cash Price |
$6,020.88
|
| Rate for Payer: Cigna Commercial |
$9,994.65
|
| Rate for Payer: First Health Commercial |
$11,439.66
|
| Rate for Payer: Humana Commercial |
$10,235.49
|
| Rate for Payer: Humana KY Medicaid |
$4,141.16
|
| Rate for Payer: Kentucky WC Medicaid |
$4,183.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,874.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,886.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,612.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,224.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,596.74
|
| Rate for Payer: Ohio Health Group HMO |
$9,031.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,408.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,565.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,732.94
|
| Rate for Payer: PHCS Commercial |
$11,560.08
|
| Rate for Payer: United Healthcare All Payer |
$10,596.74
|
|
|
GRAFTMASTER 4.8*16
|
Facility
|
OP
|
$12,041.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,565.43 |
| Max. Negotiated Rate |
$11,560.08 |
| Rate for Payer: Aetna Commercial |
$9,272.15
|
| Rate for Payer: Anthem Medicaid |
$4,141.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,392.56
|
| Rate for Payer: Cash Price |
$6,020.88
|
| Rate for Payer: Cigna Commercial |
$9,994.65
|
| Rate for Payer: First Health Commercial |
$11,439.66
|
| Rate for Payer: Humana Commercial |
$10,235.49
|
| Rate for Payer: Humana KY Medicaid |
$4,141.16
|
| Rate for Payer: Kentucky WC Medicaid |
$4,183.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,874.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,886.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,612.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,224.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,596.74
|
| Rate for Payer: Ohio Health Group HMO |
$9,031.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,408.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,565.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,732.94
|
| Rate for Payer: PHCS Commercial |
$11,560.08
|
| Rate for Payer: United Healthcare All Payer |
$10,596.74
|
|
|
GRAFTMASTER 4.8*16
|
Facility
|
IP
|
$12,041.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,565.43 |
| Max. Negotiated Rate |
$11,560.08 |
| Rate for Payer: Aetna Commercial |
$9,272.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,392.56
|
| Rate for Payer: Cash Price |
$6,020.88
|
| Rate for Payer: Cigna Commercial |
$9,994.65
|
| Rate for Payer: First Health Commercial |
$11,439.66
|
| Rate for Payer: Humana Commercial |
$10,235.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,874.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,886.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,612.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,596.74
|
| Rate for Payer: Ohio Health Group HMO |
$9,031.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,408.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,565.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,732.94
|
| Rate for Payer: PHCS Commercial |
$11,560.08
|
| Rate for Payer: United Healthcare All Payer |
$10,596.74
|
|
|
GRAFTMASTER RX 2.8*19
|
Facility
|
IP
|
$12,041.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,565.43 |
| Max. Negotiated Rate |
$11,560.08 |
| Rate for Payer: Aetna Commercial |
$9,272.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,392.56
|
| Rate for Payer: Cash Price |
$6,020.88
|
| Rate for Payer: Cigna Commercial |
$9,994.65
|
| Rate for Payer: First Health Commercial |
$11,439.66
|
| Rate for Payer: Humana Commercial |
$10,235.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,874.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,886.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,612.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,596.74
|
| Rate for Payer: Ohio Health Group HMO |
$9,031.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,408.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,565.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,732.94
|
| Rate for Payer: PHCS Commercial |
$11,560.08
|
| Rate for Payer: United Healthcare All Payer |
$10,596.74
|
|
|
GRAFTMASTER RX 2.8*19
|
Facility
|
OP
|
$12,041.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,565.43 |
| Max. Negotiated Rate |
$11,560.08 |
| Rate for Payer: Aetna Commercial |
$9,272.15
|
| Rate for Payer: Anthem Medicaid |
$4,141.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,392.56
|
| Rate for Payer: Cash Price |
$6,020.88
|
| Rate for Payer: Cigna Commercial |
$9,994.65
|
| Rate for Payer: First Health Commercial |
$11,439.66
|
| Rate for Payer: Humana Commercial |
$10,235.49
|
| Rate for Payer: Humana KY Medicaid |
$4,141.16
|
| Rate for Payer: Kentucky WC Medicaid |
$4,183.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,874.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,886.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,612.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,224.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,596.74
|
| Rate for Payer: Ohio Health Group HMO |
$9,031.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,408.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,565.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,732.94
|
| Rate for Payer: PHCS Commercial |
$11,560.08
|
| Rate for Payer: United Healthcare All Payer |
$10,596.74
|
|
|
GRAFTMASTER RX 3.5*19
|
Facility
|
OP
|
$12,041.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,565.43 |
| Max. Negotiated Rate |
$11,560.08 |
| Rate for Payer: Aetna Commercial |
$9,272.15
|
| Rate for Payer: Anthem Medicaid |
$4,141.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,392.56
|
| Rate for Payer: Cash Price |
$6,020.88
|
| Rate for Payer: Cigna Commercial |
$9,994.65
|
| Rate for Payer: First Health Commercial |
$11,439.66
|
| Rate for Payer: Humana Commercial |
$10,235.49
|
| Rate for Payer: Humana KY Medicaid |
$4,141.16
|
| Rate for Payer: Kentucky WC Medicaid |
$4,183.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,874.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,886.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,612.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,224.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,596.74
|
| Rate for Payer: Ohio Health Group HMO |
$9,031.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,408.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,565.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,732.94
|
| Rate for Payer: PHCS Commercial |
$11,560.08
|
| Rate for Payer: United Healthcare All Payer |
$10,596.74
|
|
|
GRAFTMASTER RX 3.5*19
|
Facility
|
IP
|
$12,041.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,565.43 |
| Max. Negotiated Rate |
$11,560.08 |
| Rate for Payer: Aetna Commercial |
$9,272.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,392.56
|
| Rate for Payer: Cash Price |
$6,020.88
|
| Rate for Payer: Cigna Commercial |
$9,994.65
|
| Rate for Payer: First Health Commercial |
$11,439.66
|
| Rate for Payer: Humana Commercial |
$10,235.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,874.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,886.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,612.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,596.74
|
| Rate for Payer: Ohio Health Group HMO |
$9,031.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,408.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,565.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,732.94
|
| Rate for Payer: PHCS Commercial |
$11,560.08
|
| Rate for Payer: United Healthcare All Payer |
$10,596.74
|
|
|
GRAFTMASTER RX 4.0*19
|
Facility
|
OP
|
$12,041.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,565.43 |
| Max. Negotiated Rate |
$11,560.08 |
| Rate for Payer: Aetna Commercial |
$9,272.15
|
| Rate for Payer: Anthem Medicaid |
$4,141.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,392.56
|
| Rate for Payer: Cash Price |
$6,020.88
|
| Rate for Payer: Cigna Commercial |
$9,994.65
|
| Rate for Payer: First Health Commercial |
$11,439.66
|
| Rate for Payer: Humana Commercial |
$10,235.49
|
| Rate for Payer: Humana KY Medicaid |
$4,141.16
|
| Rate for Payer: Kentucky WC Medicaid |
$4,183.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,874.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,886.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,612.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,224.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,596.74
|
| Rate for Payer: Ohio Health Group HMO |
$9,031.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,408.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,565.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,732.94
|
| Rate for Payer: PHCS Commercial |
$11,560.08
|
| Rate for Payer: United Healthcare All Payer |
$10,596.74
|
|
|
GRAFTMASTER RX 4.0*19
|
Facility
|
IP
|
$12,041.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,565.43 |
| Max. Negotiated Rate |
$11,560.08 |
| Rate for Payer: Aetna Commercial |
$9,272.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,392.56
|
| Rate for Payer: Cash Price |
$6,020.88
|
| Rate for Payer: Cigna Commercial |
$9,994.65
|
| Rate for Payer: First Health Commercial |
$11,439.66
|
| Rate for Payer: Humana Commercial |
$10,235.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,874.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,886.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,612.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,596.74
|
| Rate for Payer: Ohio Health Group HMO |
$9,031.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,408.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,565.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,732.94
|
| Rate for Payer: PHCS Commercial |
$11,560.08
|
| Rate for Payer: United Healthcare All Payer |
$10,596.74
|
|
|
GRAFTMASTER RX 4.5*19
|
Facility
|
IP
|
$12,041.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,565.43 |
| Max. Negotiated Rate |
$11,560.08 |
| Rate for Payer: Aetna Commercial |
$9,272.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,392.56
|
| Rate for Payer: Cash Price |
$6,020.88
|
| Rate for Payer: Cigna Commercial |
$9,994.65
|
| Rate for Payer: First Health Commercial |
$11,439.66
|
| Rate for Payer: Humana Commercial |
$10,235.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,874.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,886.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,612.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,596.74
|
| Rate for Payer: Ohio Health Group HMO |
$9,031.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,408.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,565.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,732.94
|
| Rate for Payer: PHCS Commercial |
$11,560.08
|
| Rate for Payer: United Healthcare All Payer |
$10,596.74
|
|
|
GRAFTMASTER RX 4.5*19
|
Facility
|
OP
|
$12,041.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,565.43 |
| Max. Negotiated Rate |
$11,560.08 |
| Rate for Payer: Aetna Commercial |
$9,272.15
|
| Rate for Payer: Anthem Medicaid |
$4,141.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,392.56
|
| Rate for Payer: Cash Price |
$6,020.88
|
| Rate for Payer: Cigna Commercial |
$9,994.65
|
| Rate for Payer: First Health Commercial |
$11,439.66
|
| Rate for Payer: Humana Commercial |
$10,235.49
|
| Rate for Payer: Humana KY Medicaid |
$4,141.16
|
| Rate for Payer: Kentucky WC Medicaid |
$4,183.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,874.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,886.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,612.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,224.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,596.74
|
| Rate for Payer: Ohio Health Group HMO |
$9,031.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,408.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,565.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,732.94
|
| Rate for Payer: PHCS Commercial |
$11,560.08
|
| Rate for Payer: United Healthcare All Payer |
$10,596.74
|
|
