|
GRAFT SW FEP RINGED 6*45CM
|
Facility
|
IP
|
$4,307.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$559.91 |
| Max. Negotiated Rate |
$4,134.72 |
| Rate for Payer: Aetna Commercial |
$3,316.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,359.46
|
| Rate for Payer: Cash Price |
$2,153.50
|
| Rate for Payer: Cigna Commercial |
$3,574.81
|
| Rate for Payer: First Health Commercial |
$4,091.65
|
| Rate for Payer: Humana Commercial |
$3,660.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,531.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,178.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,292.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,790.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,230.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$861.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$559.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,335.17
|
| Rate for Payer: PHCS Commercial |
$4,134.72
|
| Rate for Payer: United Healthcare All Payer |
$3,790.16
|
|
|
GRAFT SW FEP RINGED 6*45CM
|
Facility
|
OP
|
$4,307.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$559.91 |
| Max. Negotiated Rate |
$4,134.72 |
| Rate for Payer: Aetna Commercial |
$3,316.39
|
| Rate for Payer: Anthem Medicaid |
$1,481.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,359.46
|
| Rate for Payer: Cash Price |
$2,153.50
|
| Rate for Payer: Cigna Commercial |
$3,574.81
|
| Rate for Payer: First Health Commercial |
$4,091.65
|
| Rate for Payer: Humana Commercial |
$3,660.95
|
| Rate for Payer: Humana KY Medicaid |
$1,481.18
|
| Rate for Payer: Kentucky WC Medicaid |
$1,496.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,531.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,178.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,292.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,510.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,790.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,230.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$861.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$559.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,335.17
|
| Rate for Payer: PHCS Commercial |
$4,134.72
|
| Rate for Payer: United Healthcare All Payer |
$3,790.16
|
|
|
GRAFT SW RINGED 4*7MM
|
Facility
|
IP
|
$4,408.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$573.10 |
| Max. Negotiated Rate |
$4,232.16 |
| Rate for Payer: Aetna Commercial |
$3,394.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,438.63
|
| Rate for Payer: Cash Price |
$2,204.25
|
| Rate for Payer: Cigna Commercial |
$3,659.06
|
| Rate for Payer: First Health Commercial |
$4,188.08
|
| Rate for Payer: Humana Commercial |
$3,747.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,614.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,253.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,322.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,879.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,306.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$881.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$573.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,366.64
|
| Rate for Payer: PHCS Commercial |
$4,232.16
|
| Rate for Payer: United Healthcare All Payer |
$3,879.48
|
|
|
GRAFT SW RINGED 4*7MM
|
Facility
|
OP
|
$4,408.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$573.10 |
| Max. Negotiated Rate |
$4,232.16 |
| Rate for Payer: Aetna Commercial |
$3,394.54
|
| Rate for Payer: Anthem Medicaid |
$1,516.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,438.63
|
| Rate for Payer: Cash Price |
$2,204.25
|
| Rate for Payer: Cigna Commercial |
$3,659.06
|
| Rate for Payer: First Health Commercial |
$4,188.08
|
| Rate for Payer: Humana Commercial |
$3,747.22
|
| Rate for Payer: Humana KY Medicaid |
$1,516.08
|
| Rate for Payer: Kentucky WC Medicaid |
$1,531.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,614.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,253.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,322.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,546.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,879.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,306.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$881.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$573.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,366.64
|
| Rate for Payer: PHCS Commercial |
$4,232.16
|
| Rate for Payer: United Healthcare All Payer |
$3,879.48
|
|
|
GRAFT TIBIA DISTAL LF LSH
|
Facility
|
IP
|
$29,598.10
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,847.75 |
| Max. Negotiated Rate |
$28,414.18 |
| Rate for Payer: Aetna Commercial |
$22,790.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23,086.52
|
| Rate for Payer: Cash Price |
$14,799.05
|
| Rate for Payer: Cigna Commercial |
$24,566.42
|
| Rate for Payer: First Health Commercial |
$28,118.20
|
| Rate for Payer: Humana Commercial |
$25,158.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24,270.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,843.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,879.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$26,046.33
|
| Rate for Payer: Ohio Health Group HMO |
$22,198.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,919.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,847.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,175.41
|
| Rate for Payer: PHCS Commercial |
$28,414.18
|
| Rate for Payer: United Healthcare All Payer |
$26,046.33
|
|
|
GRAFT TIBIA DISTAL LF LSH
|
Facility
|
OP
|
$29,598.10
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,847.75 |
| Max. Negotiated Rate |
$28,414.18 |
| Rate for Payer: Aetna Commercial |
$22,790.54
|
| Rate for Payer: Anthem Medicaid |
$10,178.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23,086.52
|
| Rate for Payer: Cash Price |
$14,799.05
|
| Rate for Payer: Cigna Commercial |
$24,566.42
|
| Rate for Payer: First Health Commercial |
$28,118.20
|
| Rate for Payer: Humana Commercial |
$25,158.38
|
| Rate for Payer: Humana KY Medicaid |
$10,178.79
|
| Rate for Payer: Kentucky WC Medicaid |
$10,282.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24,270.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,843.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,879.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,383.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$26,046.33
|
| Rate for Payer: Ohio Health Group HMO |
$22,198.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,919.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,847.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,175.41
|
| Rate for Payer: PHCS Commercial |
$28,414.18
|
| Rate for Payer: United Healthcare All Payer |
$26,046.33
|
|
|
GRAFT TW BIFURCATED LIMB 10*20
|
Facility
|
IP
|
$4,849.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$630.44 |
| Max. Negotiated Rate |
$4,655.52 |
| Rate for Payer: Aetna Commercial |
$3,734.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,782.61
|
| Rate for Payer: Cash Price |
$2,424.75
|
| Rate for Payer: Cigna Commercial |
$4,025.08
|
| Rate for Payer: First Health Commercial |
$4,607.02
|
| Rate for Payer: Humana Commercial |
$4,122.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,976.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,578.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,454.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,267.56
|
| Rate for Payer: Ohio Health Group HMO |
$3,637.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$969.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$630.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,503.34
|
| Rate for Payer: PHCS Commercial |
$4,655.52
|
| Rate for Payer: United Healthcare All Payer |
$4,267.56
|
|
|
GRAFT TW BIFURCATED LIMB 10*20
|
Facility
|
OP
|
$4,849.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$630.44 |
| Max. Negotiated Rate |
$4,655.52 |
| Rate for Payer: Aetna Commercial |
$3,734.12
|
| Rate for Payer: Anthem Medicaid |
$1,667.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,782.61
|
| Rate for Payer: Cash Price |
$2,424.75
|
| Rate for Payer: Cigna Commercial |
$4,025.08
|
| Rate for Payer: First Health Commercial |
$4,607.02
|
| Rate for Payer: Humana Commercial |
$4,122.08
|
| Rate for Payer: Humana KY Medicaid |
$1,667.74
|
| Rate for Payer: Kentucky WC Medicaid |
$1,684.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,976.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,578.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,454.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,701.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,267.56
|
| Rate for Payer: Ohio Health Group HMO |
$3,637.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$969.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$630.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,503.34
|
| Rate for Payer: PHCS Commercial |
$4,655.52
|
| Rate for Payer: United Healthcare All Payer |
$4,267.56
|
|
|
GRAFT TW BIFURCATED LIMB 16*8
|
Facility
|
IP
|
$4,849.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$630.44 |
| Max. Negotiated Rate |
$4,655.52 |
| Rate for Payer: Aetna Commercial |
$3,734.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,782.61
|
| Rate for Payer: Cash Price |
$2,424.75
|
| Rate for Payer: Cigna Commercial |
$4,025.08
|
| Rate for Payer: First Health Commercial |
$4,607.02
|
| Rate for Payer: Humana Commercial |
$4,122.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,976.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,578.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,454.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,267.56
|
| Rate for Payer: Ohio Health Group HMO |
$3,637.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$969.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$630.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,503.34
|
| Rate for Payer: PHCS Commercial |
$4,655.52
|
| Rate for Payer: United Healthcare All Payer |
$4,267.56
|
|
|
GRAFT TW BIFURCATED LIMB 16*8
|
Facility
|
OP
|
$4,849.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$630.44 |
| Max. Negotiated Rate |
$4,655.52 |
| Rate for Payer: Aetna Commercial |
$3,734.12
|
| Rate for Payer: Anthem Medicaid |
$1,667.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,782.61
|
| Rate for Payer: Cash Price |
$2,424.75
|
| Rate for Payer: Cigna Commercial |
$4,025.08
|
| Rate for Payer: First Health Commercial |
$4,607.02
|
| Rate for Payer: Humana Commercial |
$4,122.08
|
| Rate for Payer: Humana KY Medicaid |
$1,667.74
|
| Rate for Payer: Kentucky WC Medicaid |
$1,684.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,976.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,578.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,454.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,701.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,267.56
|
| Rate for Payer: Ohio Health Group HMO |
$3,637.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$969.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$630.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,503.34
|
| Rate for Payer: PHCS Commercial |
$4,655.52
|
| Rate for Payer: United Healthcare All Payer |
$4,267.56
|
|
|
GRAFT TW BIFURCATED LIMB 7*14
|
Facility
|
IP
|
$5,133.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$667.29 |
| Max. Negotiated Rate |
$4,927.68 |
| Rate for Payer: Aetna Commercial |
$3,952.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,003.74
|
| Rate for Payer: Cash Price |
$2,566.50
|
| Rate for Payer: Cigna Commercial |
$4,260.39
|
| Rate for Payer: First Health Commercial |
$4,876.35
|
| Rate for Payer: Humana Commercial |
$4,363.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,209.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,788.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,539.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,517.04
|
| Rate for Payer: Ohio Health Group HMO |
$3,849.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,026.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$667.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,591.23
|
| Rate for Payer: PHCS Commercial |
$4,927.68
|
| Rate for Payer: United Healthcare All Payer |
$4,517.04
|
|
|
GRAFT TW BIFURCATED LIMB 7*14
|
Facility
|
OP
|
$5,133.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$667.29 |
| Max. Negotiated Rate |
$4,927.68 |
| Rate for Payer: Aetna Commercial |
$3,952.41
|
| Rate for Payer: Anthem Medicaid |
$1,765.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,003.74
|
| Rate for Payer: Cash Price |
$2,566.50
|
| Rate for Payer: Cigna Commercial |
$4,260.39
|
| Rate for Payer: First Health Commercial |
$4,876.35
|
| Rate for Payer: Humana Commercial |
$4,363.05
|
| Rate for Payer: Humana KY Medicaid |
$1,765.24
|
| Rate for Payer: Kentucky WC Medicaid |
$1,783.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,209.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,788.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,539.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,800.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,517.04
|
| Rate for Payer: Ohio Health Group HMO |
$3,849.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,026.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$667.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,591.23
|
| Rate for Payer: PHCS Commercial |
$4,927.68
|
| Rate for Payer: United Healthcare All Payer |
$4,517.04
|
|
|
GRAFT TW BIFURCATED LIMB 9*18
|
Facility
|
OP
|
$4,849.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$630.44 |
| Max. Negotiated Rate |
$4,655.52 |
| Rate for Payer: Aetna Commercial |
$3,734.12
|
| Rate for Payer: Anthem Medicaid |
$1,667.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,782.61
|
| Rate for Payer: Cash Price |
$2,424.75
|
| Rate for Payer: Cigna Commercial |
$4,025.08
|
| Rate for Payer: First Health Commercial |
$4,607.02
|
| Rate for Payer: Humana Commercial |
$4,122.08
|
| Rate for Payer: Humana KY Medicaid |
$1,667.74
|
| Rate for Payer: Kentucky WC Medicaid |
$1,684.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,976.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,578.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,454.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,701.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,267.56
|
| Rate for Payer: Ohio Health Group HMO |
$3,637.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$969.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$630.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,503.34
|
| Rate for Payer: PHCS Commercial |
$4,655.52
|
| Rate for Payer: United Healthcare All Payer |
$4,267.56
|
|
|
GRAFT TW BIFURCATED LIMB 9*18
|
Facility
|
IP
|
$4,849.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$630.44 |
| Max. Negotiated Rate |
$4,655.52 |
| Rate for Payer: Aetna Commercial |
$3,734.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,782.61
|
| Rate for Payer: Cash Price |
$2,424.75
|
| Rate for Payer: Cigna Commercial |
$4,025.08
|
| Rate for Payer: First Health Commercial |
$4,607.02
|
| Rate for Payer: Humana Commercial |
$4,122.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,976.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,578.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,454.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,267.56
|
| Rate for Payer: Ohio Health Group HMO |
$3,637.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$969.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$630.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,503.34
|
| Rate for Payer: PHCS Commercial |
$4,655.52
|
| Rate for Payer: United Healthcare All Payer |
$4,267.56
|
|
|
GRAFT TW FEP RINGED 6*40CM
|
Facility
|
IP
|
$4,391.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$570.83 |
| Max. Negotiated Rate |
$4,215.36 |
| Rate for Payer: Aetna Commercial |
$3,381.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,424.98
|
| Rate for Payer: Cash Price |
$2,195.50
|
| Rate for Payer: Cigna Commercial |
$3,644.53
|
| Rate for Payer: First Health Commercial |
$4,171.45
|
| Rate for Payer: Humana Commercial |
$3,732.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,600.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,240.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,317.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,864.08
|
| Rate for Payer: Ohio Health Group HMO |
$3,293.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$878.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$570.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,361.21
|
| Rate for Payer: PHCS Commercial |
$4,215.36
|
| Rate for Payer: United Healthcare All Payer |
$3,864.08
|
|
|
GRAFT TW FEP RINGED 6*40CM
|
Facility
|
OP
|
$4,391.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$570.83 |
| Max. Negotiated Rate |
$4,215.36 |
| Rate for Payer: Aetna Commercial |
$3,381.07
|
| Rate for Payer: Anthem Medicaid |
$1,510.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,424.98
|
| Rate for Payer: Cash Price |
$2,195.50
|
| Rate for Payer: Cigna Commercial |
$3,644.53
|
| Rate for Payer: First Health Commercial |
$4,171.45
|
| Rate for Payer: Humana Commercial |
$3,732.35
|
| Rate for Payer: Humana KY Medicaid |
$1,510.06
|
| Rate for Payer: Kentucky WC Medicaid |
$1,525.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,600.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,240.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,317.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,540.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,864.08
|
| Rate for Payer: Ohio Health Group HMO |
$3,293.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$878.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$570.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,361.21
|
| Rate for Payer: PHCS Commercial |
$4,215.36
|
| Rate for Payer: United Healthcare All Payer |
$3,864.08
|
|
|
GRAFT TW FEP RINGED 6*70CM
|
Facility
|
OP
|
$7,413.60
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$963.77 |
| Max. Negotiated Rate |
$7,117.06 |
| Rate for Payer: Aetna Commercial |
$5,708.47
|
| Rate for Payer: Anthem Medicaid |
$2,549.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,782.61
|
| Rate for Payer: Cash Price |
$3,706.80
|
| Rate for Payer: Cigna Commercial |
$6,153.29
|
| Rate for Payer: First Health Commercial |
$7,042.92
|
| Rate for Payer: Humana Commercial |
$6,301.56
|
| Rate for Payer: Humana KY Medicaid |
$2,549.54
|
| Rate for Payer: Kentucky WC Medicaid |
$2,575.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,079.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,471.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,224.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,600.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,523.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,560.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,482.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$963.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,298.22
|
| Rate for Payer: PHCS Commercial |
$7,117.06
|
| Rate for Payer: United Healthcare All Payer |
$6,523.97
|
|
|
GRAFT TW FEP RINGED 6*70CM
|
Facility
|
IP
|
$7,413.60
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$963.77 |
| Max. Negotiated Rate |
$7,117.06 |
| Rate for Payer: Aetna Commercial |
$5,708.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,782.61
|
| Rate for Payer: Cash Price |
$3,706.80
|
| Rate for Payer: Cigna Commercial |
$6,153.29
|
| Rate for Payer: First Health Commercial |
$7,042.92
|
| Rate for Payer: Humana Commercial |
$6,301.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,079.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,471.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,224.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,523.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,560.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,482.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$963.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,298.22
|
| Rate for Payer: PHCS Commercial |
$7,117.06
|
| Rate for Payer: United Healthcare All Payer |
$6,523.97
|
|
|
GRAFT TW FEP RINGED 8*40CM
|
Facility
|
OP
|
$4,769.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$619.97 |
| Max. Negotiated Rate |
$4,578.24 |
| Rate for Payer: Aetna Commercial |
$3,672.13
|
| Rate for Payer: Anthem Medicaid |
$1,640.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,719.82
|
| Rate for Payer: Cash Price |
$2,384.50
|
| Rate for Payer: Cigna Commercial |
$3,958.27
|
| Rate for Payer: First Health Commercial |
$4,530.55
|
| Rate for Payer: Humana Commercial |
$4,053.65
|
| Rate for Payer: Humana KY Medicaid |
$1,640.06
|
| Rate for Payer: Kentucky WC Medicaid |
$1,656.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,910.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,519.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,430.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,672.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,196.72
|
| Rate for Payer: Ohio Health Group HMO |
$3,576.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$953.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$619.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,478.39
|
| Rate for Payer: PHCS Commercial |
$4,578.24
|
| Rate for Payer: United Healthcare All Payer |
$4,196.72
|
|
|
GRAFT TW FEP RINGED 8*40CM
|
Facility
|
IP
|
$4,769.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$619.97 |
| Max. Negotiated Rate |
$4,578.24 |
| Rate for Payer: Aetna Commercial |
$3,672.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,719.82
|
| Rate for Payer: Cash Price |
$2,384.50
|
| Rate for Payer: Cigna Commercial |
$3,958.27
|
| Rate for Payer: First Health Commercial |
$4,530.55
|
| Rate for Payer: Humana Commercial |
$4,053.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,910.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,519.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,430.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,196.72
|
| Rate for Payer: Ohio Health Group HMO |
$3,576.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$953.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$619.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,478.39
|
| Rate for Payer: PHCS Commercial |
$4,578.24
|
| Rate for Payer: United Healthcare All Payer |
$4,196.72
|
|
|
GRAFT TW FEP RINGED 8*70CM
|
Facility
|
OP
|
$7,625.30
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$991.29 |
| Max. Negotiated Rate |
$7,320.29 |
| Rate for Payer: Aetna Commercial |
$5,871.48
|
| Rate for Payer: Anthem Medicaid |
$2,622.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,947.73
|
| Rate for Payer: Cash Price |
$3,812.65
|
| Rate for Payer: Cigna Commercial |
$6,329.00
|
| Rate for Payer: First Health Commercial |
$7,244.04
|
| Rate for Payer: Humana Commercial |
$6,481.50
|
| Rate for Payer: Humana KY Medicaid |
$2,622.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,649.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,252.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,627.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,287.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,674.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,710.26
|
| Rate for Payer: Ohio Health Group HMO |
$5,718.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,525.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$991.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,363.84
|
| Rate for Payer: PHCS Commercial |
$7,320.29
|
| Rate for Payer: United Healthcare All Payer |
$6,710.26
|
|
|
GRAFT TW FEP RINGED 8*70CM
|
Facility
|
IP
|
$7,625.30
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$991.29 |
| Max. Negotiated Rate |
$7,320.29 |
| Rate for Payer: Aetna Commercial |
$5,871.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,947.73
|
| Rate for Payer: Cash Price |
$3,812.65
|
| Rate for Payer: Cigna Commercial |
$6,329.00
|
| Rate for Payer: First Health Commercial |
$7,244.04
|
| Rate for Payer: Humana Commercial |
$6,481.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,252.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,627.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,287.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,710.26
|
| Rate for Payer: Ohio Health Group HMO |
$5,718.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,525.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$991.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,363.84
|
| Rate for Payer: PHCS Commercial |
$7,320.29
|
| Rate for Payer: United Healthcare All Payer |
$6,710.26
|
|
|
GRAFT TW RINGED 8*90CM
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
GRAFT TW RINGED 8*90CM
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
GRAFT TW STRETCH 10*40CM
|
Facility
|
OP
|
$4,156.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$540.34 |
| Max. Negotiated Rate |
$3,990.24 |
| Rate for Payer: Aetna Commercial |
$3,200.50
|
| Rate for Payer: Anthem Medicaid |
$1,429.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,242.07
|
| Rate for Payer: Cash Price |
$2,078.25
|
| Rate for Payer: Cigna Commercial |
$3,449.90
|
| Rate for Payer: First Health Commercial |
$3,948.68
|
| Rate for Payer: Humana Commercial |
$3,533.02
|
| Rate for Payer: Humana KY Medicaid |
$1,429.42
|
| Rate for Payer: Kentucky WC Medicaid |
$1,443.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,408.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,067.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,246.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,458.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,657.72
|
| Rate for Payer: Ohio Health Group HMO |
$3,117.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$831.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$540.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,288.52
|
| Rate for Payer: PHCS Commercial |
$3,990.24
|
| Rate for Payer: United Healthcare All Payer |
$3,657.72
|
|
