|
GRAFT PROPATEN INTERING 8*40
|
Facility
|
OP
|
$8,282.30
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,076.70 |
| Max. Negotiated Rate |
$7,951.01 |
| Rate for Payer: Aetna Commercial |
$6,377.37
|
| Rate for Payer: Anthem Medicaid |
$2,848.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,460.19
|
| Rate for Payer: Cash Price |
$4,141.15
|
| Rate for Payer: Cigna Commercial |
$6,874.31
|
| Rate for Payer: First Health Commercial |
$7,868.18
|
| Rate for Payer: Humana Commercial |
$7,039.96
|
| Rate for Payer: Humana KY Medicaid |
$2,848.28
|
| Rate for Payer: Kentucky WC Medicaid |
$2,877.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,791.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,112.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,484.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,905.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,288.42
|
| Rate for Payer: Ohio Health Group HMO |
$6,211.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,656.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,076.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,567.51
|
| Rate for Payer: PHCS Commercial |
$7,951.01
|
| Rate for Payer: United Healthcare All Payer |
$7,288.42
|
|
|
GRAFT PROPATEN RING TW 8*80
|
Facility
|
OP
|
$13,552.85
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,761.87 |
| Max. Negotiated Rate |
$13,010.74 |
| Rate for Payer: Aetna Commercial |
$10,435.69
|
| Rate for Payer: Anthem Medicaid |
$4,660.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,571.22
|
| Rate for Payer: Cash Price |
$6,776.42
|
| Rate for Payer: Cigna Commercial |
$11,248.87
|
| Rate for Payer: First Health Commercial |
$12,875.21
|
| Rate for Payer: Humana Commercial |
$11,519.92
|
| Rate for Payer: Humana KY Medicaid |
$4,660.83
|
| Rate for Payer: Kentucky WC Medicaid |
$4,708.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,113.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,002.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,065.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,754.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,926.51
|
| Rate for Payer: Ohio Health Group HMO |
$10,164.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,710.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,761.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,201.38
|
| Rate for Payer: PHCS Commercial |
$13,010.74
|
| Rate for Payer: United Healthcare All Payer |
$11,926.51
|
|
|
GRAFT PROPATEN RING TW 8*80
|
Facility
|
IP
|
$13,552.85
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,761.87 |
| Max. Negotiated Rate |
$13,010.74 |
| Rate for Payer: Aetna Commercial |
$10,435.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,571.22
|
| Rate for Payer: Cash Price |
$6,776.42
|
| Rate for Payer: Cigna Commercial |
$11,248.87
|
| Rate for Payer: First Health Commercial |
$12,875.21
|
| Rate for Payer: Humana Commercial |
$11,519.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,113.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,002.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,065.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,926.51
|
| Rate for Payer: Ohio Health Group HMO |
$10,164.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,710.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,761.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,201.38
|
| Rate for Payer: PHCS Commercial |
$13,010.74
|
| Rate for Payer: United Healthcare All Payer |
$11,926.51
|
|
|
GRAFT PROPATEN RMVL RING 8MM*4
|
Facility
|
IP
|
$7,986.65
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,038.26 |
| Max. Negotiated Rate |
$7,667.18 |
| Rate for Payer: Aetna Commercial |
$6,149.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,229.59
|
| Rate for Payer: Cash Price |
$3,993.32
|
| Rate for Payer: Cigna Commercial |
$6,628.92
|
| Rate for Payer: First Health Commercial |
$7,587.32
|
| Rate for Payer: Humana Commercial |
$6,788.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,549.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,894.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,396.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,028.25
|
| Rate for Payer: Ohio Health Group HMO |
$5,989.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,597.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,038.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,475.86
|
| Rate for Payer: PHCS Commercial |
$7,667.18
|
| Rate for Payer: United Healthcare All Payer |
$7,028.25
|
|
|
GRAFT PROPATEN RMVL RING 8MM*4
|
Facility
|
OP
|
$7,986.65
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,038.26 |
| Max. Negotiated Rate |
$7,667.18 |
| Rate for Payer: Aetna Commercial |
$6,149.72
|
| Rate for Payer: Anthem Medicaid |
$2,746.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,229.59
|
| Rate for Payer: Cash Price |
$3,993.32
|
| Rate for Payer: Cigna Commercial |
$6,628.92
|
| Rate for Payer: First Health Commercial |
$7,587.32
|
| Rate for Payer: Humana Commercial |
$6,788.65
|
| Rate for Payer: Humana KY Medicaid |
$2,746.61
|
| Rate for Payer: Kentucky WC Medicaid |
$2,774.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,549.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,894.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,396.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,801.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,028.25
|
| Rate for Payer: Ohio Health Group HMO |
$5,989.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,597.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,038.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,475.86
|
| Rate for Payer: PHCS Commercial |
$7,667.18
|
| Rate for Payer: United Healthcare All Payer |
$7,028.25
|
|
|
GRAFT PROPATEN STD R/RNG 90*40
|
Facility
|
OP
|
$20,801.60
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,704.21 |
| Max. Negotiated Rate |
$19,969.54 |
| Rate for Payer: Aetna Commercial |
$16,017.23
|
| Rate for Payer: Anthem Medicaid |
$7,153.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,225.25
|
| Rate for Payer: Cash Price |
$10,400.80
|
| Rate for Payer: Cigna Commercial |
$17,265.33
|
| Rate for Payer: First Health Commercial |
$19,761.52
|
| Rate for Payer: Humana Commercial |
$17,681.36
|
| Rate for Payer: Humana KY Medicaid |
$7,153.67
|
| Rate for Payer: Kentucky WC Medicaid |
$7,226.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,057.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,351.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,240.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,297.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,305.41
|
| Rate for Payer: Ohio Health Group HMO |
$15,601.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,160.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,704.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,448.50
|
| Rate for Payer: PHCS Commercial |
$19,969.54
|
| Rate for Payer: United Healthcare All Payer |
$18,305.41
|
|
|
GRAFT PROPATEN STD R/RNG 90*40
|
Facility
|
IP
|
$20,801.60
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,704.21 |
| Max. Negotiated Rate |
$19,969.54 |
| Rate for Payer: Aetna Commercial |
$16,017.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,225.25
|
| Rate for Payer: Cash Price |
$10,400.80
|
| Rate for Payer: Cigna Commercial |
$17,265.33
|
| Rate for Payer: First Health Commercial |
$19,761.52
|
| Rate for Payer: Humana Commercial |
$17,681.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,057.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,351.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,240.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,305.41
|
| Rate for Payer: Ohio Health Group HMO |
$15,601.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,160.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,704.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,448.50
|
| Rate for Payer: PHCS Commercial |
$19,969.54
|
| Rate for Payer: United Healthcare All Payer |
$18,305.41
|
|
|
GRAFT PROPATN ACUSL DIA 6*40
|
Facility
|
IP
|
$7,472.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$971.36 |
| Max. Negotiated Rate |
$7,173.12 |
| Rate for Payer: Aetna Commercial |
$5,753.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,828.16
|
| Rate for Payer: Cash Price |
$3,736.00
|
| Rate for Payer: Cigna Commercial |
$6,201.76
|
| Rate for Payer: First Health Commercial |
$7,098.40
|
| Rate for Payer: Humana Commercial |
$6,351.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,127.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,514.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,241.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,575.36
|
| Rate for Payer: Ohio Health Group HMO |
$5,604.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,494.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$971.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,316.32
|
| Rate for Payer: PHCS Commercial |
$7,173.12
|
| Rate for Payer: United Healthcare All Payer |
$6,575.36
|
|
|
GRAFT PROPATN ACUSL DIA 6*40
|
Facility
|
OP
|
$7,472.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$971.36 |
| Max. Negotiated Rate |
$7,173.12 |
| Rate for Payer: Aetna Commercial |
$5,753.44
|
| Rate for Payer: Anthem Medicaid |
$2,569.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,828.16
|
| Rate for Payer: Cash Price |
$3,736.00
|
| Rate for Payer: Cigna Commercial |
$6,201.76
|
| Rate for Payer: First Health Commercial |
$7,098.40
|
| Rate for Payer: Humana Commercial |
$6,351.20
|
| Rate for Payer: Humana KY Medicaid |
$2,569.62
|
| Rate for Payer: Kentucky WC Medicaid |
$2,595.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,127.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,514.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,241.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,621.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,575.36
|
| Rate for Payer: Ohio Health Group HMO |
$5,604.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,494.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$971.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,316.32
|
| Rate for Payer: PHCS Commercial |
$7,173.12
|
| Rate for Payer: United Healthcare All Payer |
$6,575.36
|
|
|
GRAFT PROX EXT ZENITH 38*77
|
Facility
|
OP
|
$23,772.70
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,090.45 |
| Max. Negotiated Rate |
$22,821.79 |
| Rate for Payer: Aetna Commercial |
$18,304.98
|
| Rate for Payer: Anthem Medicaid |
$8,175.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,542.71
|
| Rate for Payer: Cash Price |
$11,886.35
|
| Rate for Payer: Cigna Commercial |
$19,731.34
|
| Rate for Payer: First Health Commercial |
$22,584.06
|
| Rate for Payer: Humana Commercial |
$20,206.80
|
| Rate for Payer: Humana KY Medicaid |
$8,175.43
|
| Rate for Payer: Kentucky WC Medicaid |
$8,258.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,493.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,544.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,131.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,339.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,919.98
|
| Rate for Payer: Ohio Health Group HMO |
$17,829.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,754.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,090.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,369.54
|
| Rate for Payer: PHCS Commercial |
$22,821.79
|
| Rate for Payer: United Healthcare All Payer |
$20,919.98
|
|
|
GRAFT PROX EXT ZENITH 38*77
|
Facility
|
IP
|
$23,772.70
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,090.45 |
| Max. Negotiated Rate |
$22,821.79 |
| Rate for Payer: Aetna Commercial |
$18,304.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,542.71
|
| Rate for Payer: Cash Price |
$11,886.35
|
| Rate for Payer: Cigna Commercial |
$19,731.34
|
| Rate for Payer: First Health Commercial |
$22,584.06
|
| Rate for Payer: Humana Commercial |
$20,206.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,493.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,544.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,131.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,919.98
|
| Rate for Payer: Ohio Health Group HMO |
$17,829.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,754.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,090.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,369.54
|
| Rate for Payer: PHCS Commercial |
$22,821.79
|
| Rate for Payer: United Healthcare All Payer |
$20,919.98
|
|
|
GRAFT PROX EXT ZENITH 40*81*75
|
Facility
|
IP
|
$23,772.70
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,090.45 |
| Max. Negotiated Rate |
$22,821.79 |
| Rate for Payer: Aetna Commercial |
$18,304.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,542.71
|
| Rate for Payer: Cash Price |
$11,886.35
|
| Rate for Payer: Cigna Commercial |
$19,731.34
|
| Rate for Payer: First Health Commercial |
$22,584.06
|
| Rate for Payer: Humana Commercial |
$20,206.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,493.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,544.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,131.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,919.98
|
| Rate for Payer: Ohio Health Group HMO |
$17,829.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,754.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,090.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,369.54
|
| Rate for Payer: PHCS Commercial |
$22,821.79
|
| Rate for Payer: United Healthcare All Payer |
$20,919.98
|
|
|
GRAFT PROX EXT ZENITH 40*81*75
|
Facility
|
OP
|
$23,772.70
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,090.45 |
| Max. Negotiated Rate |
$22,821.79 |
| Rate for Payer: Aetna Commercial |
$18,304.98
|
| Rate for Payer: Anthem Medicaid |
$8,175.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,542.71
|
| Rate for Payer: Cash Price |
$11,886.35
|
| Rate for Payer: Cigna Commercial |
$19,731.34
|
| Rate for Payer: First Health Commercial |
$22,584.06
|
| Rate for Payer: Humana Commercial |
$20,206.80
|
| Rate for Payer: Humana KY Medicaid |
$8,175.43
|
| Rate for Payer: Kentucky WC Medicaid |
$8,258.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,493.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,544.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,131.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,339.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,919.98
|
| Rate for Payer: Ohio Health Group HMO |
$17,829.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,754.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,090.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,369.54
|
| Rate for Payer: PHCS Commercial |
$22,821.79
|
| Rate for Payer: United Healthcare All Payer |
$20,919.98
|
|
|
GRAFT PROX EXT ZENITH 42*81
|
Facility
|
OP
|
$23,772.70
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,090.45 |
| Max. Negotiated Rate |
$22,821.79 |
| Rate for Payer: Aetna Commercial |
$18,304.98
|
| Rate for Payer: Anthem Medicaid |
$8,175.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,542.71
|
| Rate for Payer: Cash Price |
$11,886.35
|
| Rate for Payer: Cigna Commercial |
$19,731.34
|
| Rate for Payer: First Health Commercial |
$22,584.06
|
| Rate for Payer: Humana Commercial |
$20,206.80
|
| Rate for Payer: Humana KY Medicaid |
$8,175.43
|
| Rate for Payer: Kentucky WC Medicaid |
$8,258.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,493.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,544.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,131.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,339.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,919.98
|
| Rate for Payer: Ohio Health Group HMO |
$17,829.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,754.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,090.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,369.54
|
| Rate for Payer: PHCS Commercial |
$22,821.79
|
| Rate for Payer: United Healthcare All Payer |
$20,919.98
|
|
|
GRAFT PROX EXT ZENITH 42*81
|
Facility
|
IP
|
$23,772.70
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,090.45 |
| Max. Negotiated Rate |
$22,821.79 |
| Rate for Payer: Aetna Commercial |
$18,304.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,542.71
|
| Rate for Payer: Cash Price |
$11,886.35
|
| Rate for Payer: Cigna Commercial |
$19,731.34
|
| Rate for Payer: First Health Commercial |
$22,584.06
|
| Rate for Payer: Humana Commercial |
$20,206.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,493.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,544.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,131.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,919.98
|
| Rate for Payer: Ohio Health Group HMO |
$17,829.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,754.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,090.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,369.54
|
| Rate for Payer: PHCS Commercial |
$22,821.79
|
| Rate for Payer: United Healthcare All Payer |
$20,919.98
|
|
|
GRAFT SM REM RING 6*40
|
Facility
|
OP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem Medicaid |
$1,418.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Humana KY Medicaid |
$1,418.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,433.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,447.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
GRAFT SM REM RING 6*40
|
Facility
|
IP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
GRAFT STANDARD WALL 6*30CM
|
Facility
|
OP
|
$3,295.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$428.42 |
| Max. Negotiated Rate |
$3,163.68 |
| Rate for Payer: Aetna Commercial |
$2,537.54
|
| Rate for Payer: Anthem Medicaid |
$1,133.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,570.49
|
| Rate for Payer: Cash Price |
$1,647.75
|
| Rate for Payer: Cigna Commercial |
$2,735.26
|
| Rate for Payer: First Health Commercial |
$3,130.72
|
| Rate for Payer: Humana Commercial |
$2,801.18
|
| Rate for Payer: Humana KY Medicaid |
$1,133.32
|
| Rate for Payer: Kentucky WC Medicaid |
$1,144.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,702.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,432.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$988.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,156.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,900.04
|
| Rate for Payer: Ohio Health Group HMO |
$2,471.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$659.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$428.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,021.60
|
| Rate for Payer: PHCS Commercial |
$3,163.68
|
| Rate for Payer: United Healthcare All Payer |
$2,900.04
|
|
|
GRAFT STANDARD WALL 6*30CM
|
Facility
|
IP
|
$3,295.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$428.42 |
| Max. Negotiated Rate |
$3,163.68 |
| Rate for Payer: Aetna Commercial |
$2,537.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,570.49
|
| Rate for Payer: Cash Price |
$1,647.75
|
| Rate for Payer: Cigna Commercial |
$2,735.26
|
| Rate for Payer: First Health Commercial |
$3,130.72
|
| Rate for Payer: Humana Commercial |
$2,801.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,702.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,432.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$988.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,900.04
|
| Rate for Payer: Ohio Health Group HMO |
$2,471.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$659.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$428.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,021.60
|
| Rate for Payer: PHCS Commercial |
$3,163.68
|
| Rate for Payer: United Healthcare All Payer |
$2,900.04
|
|
|
GRAFT STANDARD WALL 6*70CM
|
Facility
|
OP
|
$4,097.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$532.61 |
| Max. Negotiated Rate |
$3,933.12 |
| Rate for Payer: Aetna Commercial |
$3,154.69
|
| Rate for Payer: Anthem Medicaid |
$1,408.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,195.66
|
| Rate for Payer: Cash Price |
$2,048.50
|
| Rate for Payer: Cigna Commercial |
$3,400.51
|
| Rate for Payer: First Health Commercial |
$3,892.15
|
| Rate for Payer: Humana Commercial |
$3,482.45
|
| Rate for Payer: Humana KY Medicaid |
$1,408.96
|
| Rate for Payer: Kentucky WC Medicaid |
$1,423.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,359.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,023.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,229.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,437.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,605.36
|
| Rate for Payer: Ohio Health Group HMO |
$3,072.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$819.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$532.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,270.07
|
| Rate for Payer: PHCS Commercial |
$3,933.12
|
| Rate for Payer: United Healthcare All Payer |
$3,605.36
|
|
|
GRAFT STANDARD WALL 6*70CM
|
Facility
|
IP
|
$4,097.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$532.61 |
| Max. Negotiated Rate |
$3,933.12 |
| Rate for Payer: Aetna Commercial |
$3,154.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,195.66
|
| Rate for Payer: Cash Price |
$2,048.50
|
| Rate for Payer: Cigna Commercial |
$3,400.51
|
| Rate for Payer: First Health Commercial |
$3,892.15
|
| Rate for Payer: Humana Commercial |
$3,482.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,359.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,023.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,229.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,605.36
|
| Rate for Payer: Ohio Health Group HMO |
$3,072.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$819.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$532.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,270.07
|
| Rate for Payer: PHCS Commercial |
$3,933.12
|
| Rate for Payer: United Healthcare All Payer |
$3,605.36
|
|
|
GRAFT STANDARD WALL 8*70CM
|
Facility
|
OP
|
$4,167.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$541.71 |
| Max. Negotiated Rate |
$4,000.32 |
| Rate for Payer: Aetna Commercial |
$3,208.59
|
| Rate for Payer: Anthem Medicaid |
$1,433.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,250.26
|
| Rate for Payer: Cash Price |
$2,083.50
|
| Rate for Payer: Cigna Commercial |
$3,458.61
|
| Rate for Payer: First Health Commercial |
$3,958.65
|
| Rate for Payer: Humana Commercial |
$3,541.95
|
| Rate for Payer: Humana KY Medicaid |
$1,433.03
|
| Rate for Payer: Kentucky WC Medicaid |
$1,447.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,416.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,075.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,250.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,461.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,666.96
|
| Rate for Payer: Ohio Health Group HMO |
$3,125.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$833.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$541.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,291.77
|
| Rate for Payer: PHCS Commercial |
$4,000.32
|
| Rate for Payer: United Healthcare All Payer |
$3,666.96
|
|
|
GRAFT STANDARD WALL 8*70CM
|
Facility
|
IP
|
$4,167.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$541.71 |
| Max. Negotiated Rate |
$4,000.32 |
| Rate for Payer: Aetna Commercial |
$3,208.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,250.26
|
| Rate for Payer: Cash Price |
$2,083.50
|
| Rate for Payer: Cigna Commercial |
$3,458.61
|
| Rate for Payer: First Health Commercial |
$3,958.65
|
| Rate for Payer: Humana Commercial |
$3,541.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,416.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,075.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,250.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,666.96
|
| Rate for Payer: Ohio Health Group HMO |
$3,125.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$833.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$541.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,291.77
|
| Rate for Payer: PHCS Commercial |
$4,000.32
|
| Rate for Payer: United Healthcare All Payer |
$3,666.96
|
|
|
GRAFT STD WALL STRETCH 10*40CM
|
Facility
|
OP
|
$3,908.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$508.04 |
| Max. Negotiated Rate |
$3,751.68 |
| Rate for Payer: Aetna Commercial |
$3,009.16
|
| Rate for Payer: Anthem Medicaid |
$1,343.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,048.24
|
| Rate for Payer: Cash Price |
$1,954.00
|
| Rate for Payer: Cigna Commercial |
$3,243.64
|
| Rate for Payer: First Health Commercial |
$3,712.60
|
| Rate for Payer: Humana Commercial |
$3,321.80
|
| Rate for Payer: Humana KY Medicaid |
$1,343.96
|
| Rate for Payer: Kentucky WC Medicaid |
$1,357.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,204.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,884.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,172.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,370.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,439.04
|
| Rate for Payer: Ohio Health Group HMO |
$2,931.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$781.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$508.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,211.48
|
| Rate for Payer: PHCS Commercial |
$3,751.68
|
| Rate for Payer: United Healthcare All Payer |
$3,439.04
|
|
|
GRAFT STD WALL STRETCH 10*40CM
|
Facility
|
IP
|
$3,908.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$508.04 |
| Max. Negotiated Rate |
$3,751.68 |
| Rate for Payer: Aetna Commercial |
$3,009.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,048.24
|
| Rate for Payer: Cash Price |
$1,954.00
|
| Rate for Payer: Cigna Commercial |
$3,243.64
|
| Rate for Payer: First Health Commercial |
$3,712.60
|
| Rate for Payer: Humana Commercial |
$3,321.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,204.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,884.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,172.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,439.04
|
| Rate for Payer: Ohio Health Group HMO |
$2,931.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$781.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$508.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,211.48
|
| Rate for Payer: PHCS Commercial |
$3,751.68
|
| Rate for Payer: United Healthcare All Payer |
$3,439.04
|
|
