|
GRAFT 4-7MM*45CM TAPER
|
Facility
|
OP
|
$8,110.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,433.00 |
| Max. Negotiated Rate |
$7,785.60 |
| Rate for Payer: Aetna Commercial |
$6,244.70
|
| Rate for Payer: Anthem Medicaid |
$2,789.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,325.80
|
| Rate for Payer: Cash Price |
$4,055.00
|
| Rate for Payer: Cigna Commercial |
$6,731.30
|
| Rate for Payer: First Health Commercial |
$7,704.50
|
| Rate for Payer: Humana Commercial |
$6,893.50
|
| Rate for Payer: Humana KY Medicaid |
$2,789.03
|
| Rate for Payer: Kentucky WC Medicaid |
$2,817.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,650.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,985.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,433.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,844.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,136.80
|
| Rate for Payer: Ohio Health Group HMO |
$6,082.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,488.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,055.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,595.90
|
| Rate for Payer: PHCS Commercial |
$7,785.60
|
| Rate for Payer: United Healthcare All Payer |
$7,136.80
|
|
|
GRAFT 4-7MM*45CM TAPER
|
Facility
|
IP
|
$8,110.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,433.00 |
| Max. Negotiated Rate |
$7,785.60 |
| Rate for Payer: Aetna Commercial |
$6,244.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,325.80
|
| Rate for Payer: Cash Price |
$4,055.00
|
| Rate for Payer: Cigna Commercial |
$6,731.30
|
| Rate for Payer: First Health Commercial |
$7,704.50
|
| Rate for Payer: Humana Commercial |
$6,893.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,650.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,985.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,433.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,136.80
|
| Rate for Payer: Ohio Health Group HMO |
$6,082.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,488.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,055.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,595.90
|
| Rate for Payer: PHCS Commercial |
$7,785.60
|
| Rate for Payer: United Healthcare All Payer |
$7,136.80
|
|
|
GRAFT 4-7MM*45CM TAPER TS
|
Facility
|
OP
|
$4,550.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,365.00 |
| Max. Negotiated Rate |
$4,368.00 |
| Rate for Payer: Aetna Commercial |
$3,503.50
|
| Rate for Payer: Anthem Medicaid |
$1,564.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,549.00
|
| Rate for Payer: Cash Price |
$2,275.00
|
| Rate for Payer: Cigna Commercial |
$3,776.50
|
| Rate for Payer: First Health Commercial |
$4,322.50
|
| Rate for Payer: Humana Commercial |
$3,867.50
|
| Rate for Payer: Humana KY Medicaid |
$1,564.74
|
| Rate for Payer: Kentucky WC Medicaid |
$1,580.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,731.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,357.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,365.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,596.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,004.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,412.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,958.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,139.50
|
| Rate for Payer: PHCS Commercial |
$4,368.00
|
| Rate for Payer: United Healthcare All Payer |
$4,004.00
|
|
|
GRAFT 4-7MM*45CM TAPER TS
|
Facility
|
IP
|
$4,550.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,365.00 |
| Max. Negotiated Rate |
$4,368.00 |
| Rate for Payer: Aetna Commercial |
$3,503.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,549.00
|
| Rate for Payer: Cash Price |
$2,275.00
|
| Rate for Payer: Cigna Commercial |
$3,776.50
|
| Rate for Payer: First Health Commercial |
$4,322.50
|
| Rate for Payer: Humana Commercial |
$3,867.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,731.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,357.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,365.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,004.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,412.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,958.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,139.50
|
| Rate for Payer: PHCS Commercial |
$4,368.00
|
| Rate for Payer: United Healthcare All Payer |
$4,004.00
|
|
|
GRAFT 6MM*50CM STRAIGHT
|
Facility
|
IP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
GRAFT 6MM*50CM STRAIGHT
|
Facility
|
OP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem Medicaid |
$2,412.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Humana KY Medicaid |
$2,412.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,437.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,460.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
GRAFT ACUSEAL 4-6X45CM
|
Facility
|
IP
|
$8,471.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,541.41 |
| Max. Negotiated Rate |
$8,132.50 |
| Rate for Payer: Aetna Commercial |
$6,522.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,607.65
|
| Rate for Payer: Cash Price |
$4,235.68
|
| Rate for Payer: Cigna Commercial |
$7,031.22
|
| Rate for Payer: First Health Commercial |
$8,047.78
|
| Rate for Payer: Humana Commercial |
$7,200.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,946.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,251.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,541.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,454.79
|
| Rate for Payer: Ohio Health Group HMO |
$6,353.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,777.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,370.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,845.23
|
| Rate for Payer: PHCS Commercial |
$8,132.50
|
| Rate for Payer: United Healthcare All Payer |
$7,454.79
|
|
|
GRAFT ACUSEAL 4-6X45CM
|
Facility
|
OP
|
$8,471.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,541.41 |
| Max. Negotiated Rate |
$8,132.50 |
| Rate for Payer: Aetna Commercial |
$6,522.94
|
| Rate for Payer: Anthem Medicaid |
$2,913.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,607.65
|
| Rate for Payer: Cash Price |
$4,235.68
|
| Rate for Payer: Cigna Commercial |
$7,031.22
|
| Rate for Payer: First Health Commercial |
$8,047.78
|
| Rate for Payer: Humana Commercial |
$7,200.65
|
| Rate for Payer: Humana KY Medicaid |
$2,913.30
|
| Rate for Payer: Kentucky WC Medicaid |
$2,942.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,946.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,251.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,541.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,971.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,454.79
|
| Rate for Payer: Ohio Health Group HMO |
$6,353.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,777.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,370.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,845.23
|
| Rate for Payer: PHCS Commercial |
$8,132.50
|
| Rate for Payer: United Healthcare All Payer |
$7,454.79
|
|
|
GRAFT ACUSEAL 4-7X45CM
|
Facility
|
IP
|
$8,471.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,541.41 |
| Max. Negotiated Rate |
$8,132.50 |
| Rate for Payer: Aetna Commercial |
$6,522.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,607.65
|
| Rate for Payer: Cash Price |
$4,235.68
|
| Rate for Payer: Cigna Commercial |
$7,031.22
|
| Rate for Payer: First Health Commercial |
$8,047.78
|
| Rate for Payer: Humana Commercial |
$7,200.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,946.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,251.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,541.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,454.79
|
| Rate for Payer: Ohio Health Group HMO |
$6,353.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,777.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,370.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,845.23
|
| Rate for Payer: PHCS Commercial |
$8,132.50
|
| Rate for Payer: United Healthcare All Payer |
$7,454.79
|
|
|
GRAFT ACUSEAL 4-7X45CM
|
Facility
|
OP
|
$8,471.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,541.41 |
| Max. Negotiated Rate |
$8,132.50 |
| Rate for Payer: Aetna Commercial |
$6,522.94
|
| Rate for Payer: Anthem Medicaid |
$2,913.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,607.65
|
| Rate for Payer: Cash Price |
$4,235.68
|
| Rate for Payer: Cigna Commercial |
$7,031.22
|
| Rate for Payer: First Health Commercial |
$8,047.78
|
| Rate for Payer: Humana Commercial |
$7,200.65
|
| Rate for Payer: Humana KY Medicaid |
$2,913.30
|
| Rate for Payer: Kentucky WC Medicaid |
$2,942.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,946.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,251.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,541.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,971.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,454.79
|
| Rate for Payer: Ohio Health Group HMO |
$6,353.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,777.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,370.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,845.23
|
| Rate for Payer: PHCS Commercial |
$8,132.50
|
| Rate for Payer: United Healthcare All Payer |
$7,454.79
|
|
|
GRAFT ANTERIOR TIBIAL ULTRA
|
Facility
|
OP
|
$8,292.50
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,487.75 |
| Max. Negotiated Rate |
$7,960.80 |
| Rate for Payer: Aetna Commercial |
$6,385.23
|
| Rate for Payer: Anthem Medicaid |
$2,851.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,468.15
|
| Rate for Payer: Cash Price |
$4,146.25
|
| Rate for Payer: Cigna Commercial |
$6,882.77
|
| Rate for Payer: First Health Commercial |
$7,877.88
|
| Rate for Payer: Humana Commercial |
$7,048.62
|
| Rate for Payer: Humana KY Medicaid |
$2,851.79
|
| Rate for Payer: Kentucky WC Medicaid |
$2,880.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,799.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,119.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,487.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,909.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,297.40
|
| Rate for Payer: Ohio Health Group HMO |
$6,219.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,634.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,214.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,721.82
|
| Rate for Payer: PHCS Commercial |
$7,960.80
|
| Rate for Payer: United Healthcare All Payer |
$7,297.40
|
|
|
GRAFT ANTERIOR TIBIAL ULTRA
|
Facility
|
IP
|
$8,292.50
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,487.75 |
| Max. Negotiated Rate |
$7,960.80 |
| Rate for Payer: Aetna Commercial |
$6,385.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,468.15
|
| Rate for Payer: Cash Price |
$4,146.25
|
| Rate for Payer: Cigna Commercial |
$6,882.77
|
| Rate for Payer: First Health Commercial |
$7,877.88
|
| Rate for Payer: Humana Commercial |
$7,048.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,799.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,119.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,487.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,297.40
|
| Rate for Payer: Ohio Health Group HMO |
$6,219.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,634.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,214.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,721.82
|
| Rate for Payer: PHCS Commercial |
$7,960.80
|
| Rate for Payer: United Healthcare All Payer |
$7,297.40
|
|
|
GRAFT AORTC EXT A25-25/C75 V
|
Facility
|
IP
|
$26,371.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,911.38 |
| Max. Negotiated Rate |
$25,316.40 |
| Rate for Payer: Aetna Commercial |
$20,305.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,569.58
|
| Rate for Payer: Cash Price |
$13,185.62
|
| Rate for Payer: Cigna Commercial |
$21,888.14
|
| Rate for Payer: First Health Commercial |
$25,052.69
|
| Rate for Payer: Humana Commercial |
$22,415.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,624.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,461.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,911.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,206.70
|
| Rate for Payer: Ohio Health Group HMO |
$19,778.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,097.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,942.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,196.16
|
| Rate for Payer: PHCS Commercial |
$25,316.40
|
| Rate for Payer: United Healthcare All Payer |
$23,206.70
|
|
|
GRAFT AORTC EXT A25-25/C75 V
|
Facility
|
OP
|
$26,371.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,911.38 |
| Max. Negotiated Rate |
$25,316.40 |
| Rate for Payer: Aetna Commercial |
$20,305.86
|
| Rate for Payer: Anthem Medicaid |
$9,069.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,569.58
|
| Rate for Payer: Cash Price |
$13,185.62
|
| Rate for Payer: Cigna Commercial |
$21,888.14
|
| Rate for Payer: First Health Commercial |
$25,052.69
|
| Rate for Payer: Humana Commercial |
$22,415.56
|
| Rate for Payer: Humana KY Medicaid |
$9,069.07
|
| Rate for Payer: Kentucky WC Medicaid |
$9,161.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,624.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,461.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,911.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,251.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,206.70
|
| Rate for Payer: Ohio Health Group HMO |
$19,778.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,097.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,942.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,196.16
|
| Rate for Payer: PHCS Commercial |
$25,316.40
|
| Rate for Payer: United Healthcare All Payer |
$23,206.70
|
|
|
GRAFT AORTC EXT A25-25/C95 V
|
Facility
|
IP
|
$23,881.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,164.38 |
| Max. Negotiated Rate |
$22,926.00 |
| Rate for Payer: Aetna Commercial |
$18,388.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,627.38
|
| Rate for Payer: Cash Price |
$11,940.62
|
| Rate for Payer: Cigna Commercial |
$19,821.44
|
| Rate for Payer: First Health Commercial |
$22,687.19
|
| Rate for Payer: Humana Commercial |
$20,299.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,582.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,624.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,164.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,015.50
|
| Rate for Payer: Ohio Health Group HMO |
$17,910.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,776.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,478.06
|
| Rate for Payer: PHCS Commercial |
$22,926.00
|
| Rate for Payer: United Healthcare All Payer |
$21,015.50
|
|
|
GRAFT AORTC EXT A25-25/C95 V
|
Facility
|
OP
|
$23,881.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,164.38 |
| Max. Negotiated Rate |
$22,926.00 |
| Rate for Payer: Aetna Commercial |
$18,388.56
|
| Rate for Payer: Anthem Medicaid |
$8,212.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,627.38
|
| Rate for Payer: Cash Price |
$11,940.62
|
| Rate for Payer: Cigna Commercial |
$19,821.44
|
| Rate for Payer: First Health Commercial |
$22,687.19
|
| Rate for Payer: Humana Commercial |
$20,299.06
|
| Rate for Payer: Humana KY Medicaid |
$8,212.76
|
| Rate for Payer: Kentucky WC Medicaid |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,582.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,624.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,164.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,377.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,015.50
|
| Rate for Payer: Ohio Health Group HMO |
$17,910.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,776.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,478.06
|
| Rate for Payer: PHCS Commercial |
$22,926.00
|
| Rate for Payer: United Healthcare All Payer |
$21,015.50
|
|
|
GRAFT AORTC EXT A28-28/C75-O20
|
Facility
|
OP
|
$18,034.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,410.35 |
| Max. Negotiated Rate |
$17,313.12 |
| Rate for Payer: Aetna Commercial |
$13,886.57
|
| Rate for Payer: Anthem Medicaid |
$6,202.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,066.91
|
| Rate for Payer: Cash Price |
$9,017.25
|
| Rate for Payer: Cigna Commercial |
$14,968.64
|
| Rate for Payer: First Health Commercial |
$17,132.78
|
| Rate for Payer: Humana Commercial |
$15,329.33
|
| Rate for Payer: Humana KY Medicaid |
$6,202.06
|
| Rate for Payer: Kentucky WC Medicaid |
$6,265.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,788.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,309.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,410.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,326.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,870.36
|
| Rate for Payer: Ohio Health Group HMO |
$13,525.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,427.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,690.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,443.81
|
| Rate for Payer: PHCS Commercial |
$17,313.12
|
| Rate for Payer: United Healthcare All Payer |
$15,870.36
|
|
|
GRAFT AORTC EXT A28-28/C75-O20
|
Facility
|
IP
|
$18,034.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,410.35 |
| Max. Negotiated Rate |
$17,313.12 |
| Rate for Payer: Aetna Commercial |
$13,886.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,066.91
|
| Rate for Payer: Cash Price |
$9,017.25
|
| Rate for Payer: Cigna Commercial |
$14,968.64
|
| Rate for Payer: First Health Commercial |
$17,132.78
|
| Rate for Payer: Humana Commercial |
$15,329.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,788.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,309.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,410.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,870.36
|
| Rate for Payer: Ohio Health Group HMO |
$13,525.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,427.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,690.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,443.81
|
| Rate for Payer: PHCS Commercial |
$17,313.12
|
| Rate for Payer: United Healthcare All Payer |
$15,870.36
|
|
|
GRAFT AORTC EXT A28-28/C75 V
|
Facility
|
IP
|
$26,371.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,911.38 |
| Max. Negotiated Rate |
$25,316.40 |
| Rate for Payer: Aetna Commercial |
$20,305.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,569.58
|
| Rate for Payer: Cash Price |
$13,185.62
|
| Rate for Payer: Cigna Commercial |
$21,888.14
|
| Rate for Payer: First Health Commercial |
$25,052.69
|
| Rate for Payer: Humana Commercial |
$22,415.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,624.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,461.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,911.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,206.70
|
| Rate for Payer: Ohio Health Group HMO |
$19,778.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,097.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,942.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,196.16
|
| Rate for Payer: PHCS Commercial |
$25,316.40
|
| Rate for Payer: United Healthcare All Payer |
$23,206.70
|
|
|
GRAFT AORTC EXT A28-28/C75 V
|
Facility
|
OP
|
$26,371.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,911.38 |
| Max. Negotiated Rate |
$25,316.40 |
| Rate for Payer: Aetna Commercial |
$20,305.86
|
| Rate for Payer: Anthem Medicaid |
$9,069.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,569.58
|
| Rate for Payer: Cash Price |
$13,185.62
|
| Rate for Payer: Cigna Commercial |
$21,888.14
|
| Rate for Payer: First Health Commercial |
$25,052.69
|
| Rate for Payer: Humana Commercial |
$22,415.56
|
| Rate for Payer: Humana KY Medicaid |
$9,069.07
|
| Rate for Payer: Kentucky WC Medicaid |
$9,161.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,624.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,461.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,911.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,251.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,206.70
|
| Rate for Payer: Ohio Health Group HMO |
$19,778.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,097.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,942.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,196.16
|
| Rate for Payer: PHCS Commercial |
$25,316.40
|
| Rate for Payer: United Healthcare All Payer |
$23,206.70
|
|
|
GRAFT AORTC EXT A28-28/C95-O20
|
Facility
|
IP
|
$18,441.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,532.45 |
| Max. Negotiated Rate |
$17,703.84 |
| Rate for Payer: Aetna Commercial |
$14,199.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,384.37
|
| Rate for Payer: Cash Price |
$9,220.75
|
| Rate for Payer: Cigna Commercial |
$15,306.44
|
| Rate for Payer: First Health Commercial |
$17,519.42
|
| Rate for Payer: Humana Commercial |
$15,675.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,122.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,609.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,532.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,228.52
|
| Rate for Payer: Ohio Health Group HMO |
$13,831.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,753.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,044.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,724.64
|
| Rate for Payer: PHCS Commercial |
$17,703.84
|
| Rate for Payer: United Healthcare All Payer |
$16,228.52
|
|
|
GRAFT AORTC EXT A28-28/C95-O20
|
Facility
|
OP
|
$18,441.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,532.45 |
| Max. Negotiated Rate |
$17,703.84 |
| Rate for Payer: Aetna Commercial |
$14,199.95
|
| Rate for Payer: Anthem Medicaid |
$6,342.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,384.37
|
| Rate for Payer: Cash Price |
$9,220.75
|
| Rate for Payer: Cigna Commercial |
$15,306.44
|
| Rate for Payer: First Health Commercial |
$17,519.42
|
| Rate for Payer: Humana Commercial |
$15,675.27
|
| Rate for Payer: Humana KY Medicaid |
$6,342.03
|
| Rate for Payer: Kentucky WC Medicaid |
$6,406.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,122.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,609.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,532.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,469.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,228.52
|
| Rate for Payer: Ohio Health Group HMO |
$13,831.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,753.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,044.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,724.64
|
| Rate for Payer: PHCS Commercial |
$17,703.84
|
| Rate for Payer: United Healthcare All Payer |
$16,228.52
|
|
|
GRAFT AORTC EXT A28-28/C95 V
|
Facility
|
OP
|
$23,881.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,164.38 |
| Max. Negotiated Rate |
$22,926.00 |
| Rate for Payer: Aetna Commercial |
$18,388.56
|
| Rate for Payer: Anthem Medicaid |
$8,212.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,627.38
|
| Rate for Payer: Cash Price |
$11,940.62
|
| Rate for Payer: Cigna Commercial |
$19,821.44
|
| Rate for Payer: First Health Commercial |
$22,687.19
|
| Rate for Payer: Humana Commercial |
$20,299.06
|
| Rate for Payer: Humana KY Medicaid |
$8,212.76
|
| Rate for Payer: Kentucky WC Medicaid |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,582.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,624.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,164.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,377.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,015.50
|
| Rate for Payer: Ohio Health Group HMO |
$17,910.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,776.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,478.06
|
| Rate for Payer: PHCS Commercial |
$22,926.00
|
| Rate for Payer: United Healthcare All Payer |
$21,015.50
|
|
|
GRAFT AORTC EXT A28-28/C95 V
|
Facility
|
IP
|
$23,881.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,164.38 |
| Max. Negotiated Rate |
$22,926.00 |
| Rate for Payer: Aetna Commercial |
$18,388.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,627.38
|
| Rate for Payer: Cash Price |
$11,940.62
|
| Rate for Payer: Cigna Commercial |
$19,821.44
|
| Rate for Payer: First Health Commercial |
$22,687.19
|
| Rate for Payer: Humana Commercial |
$20,299.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,582.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,624.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,164.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,015.50
|
| Rate for Payer: Ohio Health Group HMO |
$17,910.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,776.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,478.06
|
| Rate for Payer: PHCS Commercial |
$22,926.00
|
| Rate for Payer: United Healthcare All Payer |
$21,015.50
|
|
|
GRAFT AORTC EXT A34-34/C80-O20
|
Facility
|
OP
|
$21,856.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,556.88 |
| Max. Negotiated Rate |
$20,982.00 |
| Rate for Payer: Aetna Commercial |
$16,829.31
|
| Rate for Payer: Anthem Medicaid |
$7,516.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,047.88
|
| Rate for Payer: Cash Price |
$10,928.12
|
| Rate for Payer: Cigna Commercial |
$18,140.69
|
| Rate for Payer: First Health Commercial |
$20,763.44
|
| Rate for Payer: Humana Commercial |
$18,577.81
|
| Rate for Payer: Humana KY Medicaid |
$7,516.36
|
| Rate for Payer: Kentucky WC Medicaid |
$7,592.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,922.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,129.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,556.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,667.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,233.50
|
| Rate for Payer: Ohio Health Group HMO |
$16,392.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,485.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,014.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,080.81
|
| Rate for Payer: PHCS Commercial |
$20,982.00
|
| Rate for Payer: United Healthcare All Payer |
$19,233.50
|
|
