|
GRAFT AORTIC EXT A28-28/C55
|
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 AORTIC EXT A28-28/C55
|
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 AORTIC EXT A28-28/C75-O2
|
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 AORTIC EXT A28-28/C75-O2
|
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 AORTIC EXT A34-34/C100 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 AORTIC EXT A34-34/C100 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 APLIGRAF 7.5CM DIAMETER
|
Facility
|
OP
|
$7,653.75
|
|
|
Service Code
|
HCPCS Q4101
|
| Hospital Charge Code |
27000115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,296.12 |
| Max. Negotiated Rate |
$7,347.60 |
| Rate for Payer: Aetna Commercial |
$5,893.39
|
| Rate for Payer: Anthem Medicaid |
$2,632.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,969.93
|
| Rate for Payer: Cash Price |
$3,826.88
|
| Rate for Payer: Cigna Commercial |
$6,352.61
|
| Rate for Payer: First Health Commercial |
$7,271.06
|
| Rate for Payer: Humana Commercial |
$6,505.69
|
| Rate for Payer: Humana KY Medicaid |
$2,632.12
|
| Rate for Payer: Kentucky WC Medicaid |
$2,658.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,276.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,648.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,296.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,684.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,735.30
|
| Rate for Payer: Ohio Health Group HMO |
$5,740.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,123.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,658.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,281.09
|
| Rate for Payer: PHCS Commercial |
$7,347.60
|
| Rate for Payer: United Healthcare All Payer |
$6,735.30
|
|
|
GRAFT APLIGRAF 7.5CM DIAMETER
|
Facility
|
IP
|
$7,653.75
|
|
|
Service Code
|
HCPCS Q4101
|
| Hospital Charge Code |
27000115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,296.12 |
| Max. Negotiated Rate |
$7,347.60 |
| Rate for Payer: Aetna Commercial |
$5,893.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,969.93
|
| Rate for Payer: Cash Price |
$3,826.88
|
| Rate for Payer: Cigna Commercial |
$6,352.61
|
| Rate for Payer: First Health Commercial |
$7,271.06
|
| Rate for Payer: Humana Commercial |
$6,505.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,276.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,648.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,296.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,735.30
|
| Rate for Payer: Ohio Health Group HMO |
$5,740.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,123.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,658.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,281.09
|
| Rate for Payer: PHCS Commercial |
$7,347.60
|
| Rate for Payer: United Healthcare All Payer |
$6,735.30
|
|
|
GRAFT AX-BYFEM STD W/RING 70*4
|
Facility
|
IP
|
$11,192.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,357.70 |
| Max. Negotiated Rate |
$10,744.63 |
| Rate for Payer: Aetna Commercial |
$8,618.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,730.01
|
| Rate for Payer: Cash Price |
$5,596.16
|
| Rate for Payer: Cigna Commercial |
$9,289.63
|
| Rate for Payer: First Health Commercial |
$10,632.70
|
| Rate for Payer: Humana Commercial |
$9,513.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,177.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,259.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,357.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,849.24
|
| Rate for Payer: Ohio Health Group HMO |
$8,394.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,953.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,737.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,722.70
|
| Rate for Payer: PHCS Commercial |
$10,744.63
|
| Rate for Payer: United Healthcare All Payer |
$9,849.24
|
|
|
GRAFT AX-BYFEM STD W/RING 70*4
|
Facility
|
OP
|
$11,192.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,357.70 |
| Max. Negotiated Rate |
$10,744.63 |
| Rate for Payer: Aetna Commercial |
$8,618.09
|
| Rate for Payer: Anthem Medicaid |
$3,849.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,730.01
|
| Rate for Payer: Cash Price |
$5,596.16
|
| Rate for Payer: Cigna Commercial |
$9,289.63
|
| Rate for Payer: First Health Commercial |
$10,632.70
|
| Rate for Payer: Humana Commercial |
$9,513.47
|
| Rate for Payer: Humana KY Medicaid |
$3,849.04
|
| Rate for Payer: Kentucky WC Medicaid |
$3,888.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,177.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,259.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,357.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,926.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,849.24
|
| Rate for Payer: Ohio Health Group HMO |
$8,394.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,953.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,737.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,722.70
|
| Rate for Payer: PHCS Commercial |
$10,744.63
|
| Rate for Payer: United Healthcare All Payer |
$9,849.24
|
|
|
GRAFT BONE BIORESORABLE 10CC
|
Facility
|
IP
|
$7,690.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,307.07 |
| Max. Negotiated Rate |
$7,382.64 |
| Rate for Payer: Aetna Commercial |
$5,921.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,998.40
|
| Rate for Payer: Cash Price |
$3,845.12
|
| Rate for Payer: Cigna Commercial |
$6,382.91
|
| Rate for Payer: First Health Commercial |
$7,305.74
|
| Rate for Payer: Humana Commercial |
$6,536.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,306.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,675.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,307.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,767.42
|
| Rate for Payer: Ohio Health Group HMO |
$5,767.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,152.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,690.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,306.27
|
| Rate for Payer: PHCS Commercial |
$7,382.64
|
| Rate for Payer: United Healthcare All Payer |
$6,767.42
|
|
|
GRAFT BONE BIORESORABLE 10CC
|
Facility
|
OP
|
$7,690.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,307.07 |
| Max. Negotiated Rate |
$7,382.64 |
| Rate for Payer: Aetna Commercial |
$5,921.49
|
| Rate for Payer: Anthem Medicaid |
$2,644.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,998.40
|
| Rate for Payer: Cash Price |
$3,845.12
|
| Rate for Payer: Cigna Commercial |
$6,382.91
|
| Rate for Payer: First Health Commercial |
$7,305.74
|
| Rate for Payer: Humana Commercial |
$6,536.71
|
| Rate for Payer: Humana KY Medicaid |
$2,644.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,671.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,306.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,675.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,307.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,697.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,767.42
|
| Rate for Payer: Ohio Health Group HMO |
$5,767.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,152.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,690.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,306.27
|
| Rate for Payer: PHCS Commercial |
$7,382.64
|
| Rate for Payer: United Healthcare All Payer |
$6,767.42
|
|
|
GRAFT BONE BIORESORABLE 2.5CC
|
Facility
|
OP
|
$3,443.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,033.12 |
| Max. Negotiated Rate |
$3,306.00 |
| Rate for Payer: Aetna Commercial |
$2,651.69
|
| Rate for Payer: Anthem Medicaid |
$1,184.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,686.12
|
| Rate for Payer: Cash Price |
$1,721.88
|
| Rate for Payer: Cigna Commercial |
$2,858.31
|
| Rate for Payer: First Health Commercial |
$3,271.56
|
| Rate for Payer: Humana Commercial |
$2,927.19
|
| Rate for Payer: Humana KY Medicaid |
$1,184.31
|
| Rate for Payer: Kentucky WC Medicaid |
$1,196.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,823.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,541.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,033.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,208.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,030.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,582.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,755.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,996.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,376.19
|
| Rate for Payer: PHCS Commercial |
$3,306.00
|
| Rate for Payer: United Healthcare All Payer |
$3,030.50
|
|
|
GRAFT BONE BIORESORABLE 2.5CC
|
Facility
|
IP
|
$3,443.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,033.12 |
| Max. Negotiated Rate |
$3,306.00 |
| Rate for Payer: Aetna Commercial |
$2,651.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,686.12
|
| Rate for Payer: Cash Price |
$1,721.88
|
| Rate for Payer: Cigna Commercial |
$2,858.31
|
| Rate for Payer: First Health Commercial |
$3,271.56
|
| Rate for Payer: Humana Commercial |
$2,927.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,823.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,541.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,033.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,030.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,582.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,755.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,996.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,376.19
|
| Rate for Payer: PHCS Commercial |
$3,306.00
|
| Rate for Payer: United Healthcare All Payer |
$3,030.50
|
|
|
GRAFT BONE BIORESORABLE 5CC
|
Facility
|
OP
|
$4,512.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,353.75 |
| Max. Negotiated Rate |
$4,332.00 |
| Rate for Payer: Aetna Commercial |
$3,474.62
|
| Rate for Payer: Anthem Medicaid |
$1,551.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,519.75
|
| Rate for Payer: Cash Price |
$2,256.25
|
| Rate for Payer: Cigna Commercial |
$3,745.38
|
| Rate for Payer: First Health Commercial |
$4,286.88
|
| Rate for Payer: Humana Commercial |
$3,835.62
|
| Rate for Payer: Humana KY Medicaid |
$1,551.85
|
| Rate for Payer: Kentucky WC Medicaid |
$1,567.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,700.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,330.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,353.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,582.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,971.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,384.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,610.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,925.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,113.62
|
| Rate for Payer: PHCS Commercial |
$4,332.00
|
| Rate for Payer: United Healthcare All Payer |
$3,971.00
|
|
|
GRAFT BONE BIORESORABLE 5CC
|
Facility
|
IP
|
$4,512.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,353.75 |
| Max. Negotiated Rate |
$4,332.00 |
| Rate for Payer: Aetna Commercial |
$3,474.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,519.75
|
| Rate for Payer: Cash Price |
$2,256.25
|
| Rate for Payer: Cigna Commercial |
$3,745.38
|
| Rate for Payer: First Health Commercial |
$4,286.88
|
| Rate for Payer: Humana Commercial |
$3,835.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,700.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,330.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,353.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,971.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,384.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,610.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,925.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,113.62
|
| Rate for Payer: PHCS Commercial |
$4,332.00
|
| Rate for Payer: United Healthcare All Payer |
$3,971.00
|
|
|
GRAFT CARBOFLO STR 6*40
|
Facility
|
IP
|
$4,100.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,230.00 |
| Max. Negotiated Rate |
$3,936.00 |
| Rate for Payer: Aetna Commercial |
$3,157.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,198.00
|
| Rate for Payer: Cash Price |
$2,050.00
|
| Rate for Payer: Cigna Commercial |
$3,403.00
|
| Rate for Payer: First Health Commercial |
$3,895.00
|
| Rate for Payer: Humana Commercial |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,362.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,025.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,230.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,608.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,075.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,567.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,829.00
|
| Rate for Payer: PHCS Commercial |
$3,936.00
|
| Rate for Payer: United Healthcare All Payer |
$3,608.00
|
|
|
GRAFT CARBOFLO STR 6*40
|
Facility
|
OP
|
$4,100.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,230.00 |
| Max. Negotiated Rate |
$3,936.00 |
| Rate for Payer: Aetna Commercial |
$3,157.00
|
| Rate for Payer: Anthem Medicaid |
$1,409.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,198.00
|
| Rate for Payer: Cash Price |
$2,050.00
|
| Rate for Payer: Cigna Commercial |
$3,403.00
|
| Rate for Payer: First Health Commercial |
$3,895.00
|
| Rate for Payer: Humana Commercial |
$3,485.00
|
| Rate for Payer: Humana KY Medicaid |
$1,409.99
|
| Rate for Payer: Kentucky WC Medicaid |
$1,424.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,362.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,025.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,230.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,438.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,608.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,075.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,567.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,829.00
|
| Rate for Payer: PHCS Commercial |
$3,936.00
|
| Rate for Payer: United Healthcare All Payer |
$3,608.00
|
|
|
GRAFT DIASTAT 6MM*40CM*25CM
|
Facility
|
OP
|
$5,423.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,627.12 |
| Max. Negotiated Rate |
$5,206.80 |
| Rate for Payer: Aetna Commercial |
$4,176.29
|
| Rate for Payer: Anthem Medicaid |
$1,865.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,230.52
|
| Rate for Payer: Cash Price |
$2,711.88
|
| Rate for Payer: Cigna Commercial |
$4,501.71
|
| Rate for Payer: First Health Commercial |
$5,152.56
|
| Rate for Payer: Humana Commercial |
$4,610.19
|
| Rate for Payer: Humana KY Medicaid |
$1,865.23
|
| Rate for Payer: Kentucky WC Medicaid |
$1,884.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,447.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,002.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,627.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,902.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,772.90
|
| Rate for Payer: Ohio Health Group HMO |
$4,067.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,339.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,718.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,742.39
|
| Rate for Payer: PHCS Commercial |
$5,206.80
|
| Rate for Payer: United Healthcare All Payer |
$4,772.90
|
|
|
GRAFT DIASTAT 6MM*40CM*25CM
|
Facility
|
IP
|
$5,423.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,627.12 |
| Max. Negotiated Rate |
$5,206.80 |
| Rate for Payer: Aetna Commercial |
$4,176.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,230.52
|
| Rate for Payer: Cash Price |
$2,711.88
|
| Rate for Payer: Cigna Commercial |
$4,501.71
|
| Rate for Payer: First Health Commercial |
$5,152.56
|
| Rate for Payer: Humana Commercial |
$4,610.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,447.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,002.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,627.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,772.90
|
| Rate for Payer: Ohio Health Group HMO |
$4,067.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,339.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,718.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,742.39
|
| Rate for Payer: PHCS Commercial |
$5,206.80
|
| Rate for Payer: United Healthcare All Payer |
$4,772.90
|
|
|
GRAFT DISTAFLO BYPASS FLEX SM
|
Facility
|
OP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem Medicaid |
$3,479.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Humana KY Medicaid |
$3,479.41
|
| Rate for Payer: Kentucky WC Medicaid |
$3,514.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,549.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
|
GRAFT DISTAFLO BYPASS FLEX SM
|
Facility
|
IP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
|
GRAFT EPIFIX 18MM DISK
|
Facility
|
IP
|
$4,568.75
|
|
|
Service Code
|
HCPCS Q4186
|
| Hospital Charge Code |
27000054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,370.62 |
| Max. Negotiated Rate |
$4,386.00 |
| Rate for Payer: Aetna Commercial |
$3,517.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,563.62
|
| Rate for Payer: Cash Price |
$2,284.38
|
| Rate for Payer: Cigna Commercial |
$3,792.06
|
| Rate for Payer: First Health Commercial |
$4,340.31
|
| Rate for Payer: Humana Commercial |
$3,883.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,746.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,371.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,370.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,020.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,426.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,974.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,152.44
|
| Rate for Payer: PHCS Commercial |
$4,386.00
|
| Rate for Payer: United Healthcare All Payer |
$4,020.50
|
|
|
GRAFT EPIFIX 18MM DISK
|
Facility
|
OP
|
$4,568.75
|
|
|
Service Code
|
HCPCS Q4186
|
| Hospital Charge Code |
27000054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,370.62 |
| Max. Negotiated Rate |
$4,386.00 |
| Rate for Payer: Aetna Commercial |
$3,517.94
|
| Rate for Payer: Anthem Medicaid |
$1,571.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,563.62
|
| Rate for Payer: Cash Price |
$2,284.38
|
| Rate for Payer: Cigna Commercial |
$3,792.06
|
| Rate for Payer: First Health Commercial |
$4,340.31
|
| Rate for Payer: Humana Commercial |
$3,883.44
|
| Rate for Payer: Humana KY Medicaid |
$1,571.19
|
| Rate for Payer: Kentucky WC Medicaid |
$1,587.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,746.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,371.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,370.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,602.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,020.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,426.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,974.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,152.44
|
| Rate for Payer: PHCS Commercial |
$4,386.00
|
| Rate for Payer: United Healthcare All Payer |
$4,020.50
|
|
|
GRAFT EPIFIX 2*3CM
|
Facility
|
IP
|
$7,175.60
|
|
|
Service Code
|
HCPCS Q4186
|
| Hospital Charge Code |
27000054
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,152.68 |
| Max. Negotiated Rate |
$6,888.58 |
| Rate for Payer: Aetna Commercial |
$5,525.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,596.97
|
| Rate for Payer: Cash Price |
$3,587.80
|
| Rate for Payer: Cigna Commercial |
$5,955.75
|
| Rate for Payer: First Health Commercial |
$6,816.82
|
| Rate for Payer: Humana Commercial |
$6,099.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,883.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,295.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,152.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,314.53
|
| Rate for Payer: Ohio Health Group HMO |
$5,381.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,740.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,242.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,951.16
|
| Rate for Payer: PHCS Commercial |
$6,888.58
|
| Rate for Payer: United Healthcare All Payer |
$6,314.53
|
|
