|
GRAFT FLIXENE 6MM*40CM
|
Facility
|
OP
|
$6,942.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,082.60 |
| Max. Negotiated Rate |
$6,664.32 |
| Rate for Payer: Aetna Commercial |
$5,345.34
|
| Rate for Payer: Anthem Medicaid |
$2,387.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,414.76
|
| Rate for Payer: Cash Price |
$3,471.00
|
| Rate for Payer: Cigna Commercial |
$5,761.86
|
| Rate for Payer: First Health Commercial |
$6,594.90
|
| Rate for Payer: Humana Commercial |
$5,900.70
|
| Rate for Payer: Humana KY Medicaid |
$2,387.35
|
| Rate for Payer: Kentucky WC Medicaid |
$2,411.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,692.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,123.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,082.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,435.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,108.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,206.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,553.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,039.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,789.98
|
| Rate for Payer: PHCS Commercial |
$6,664.32
|
| Rate for Payer: United Healthcare All Payer |
$6,108.96
|
|
|
GRAFT FLIXENE 6MM*40CM
|
Facility
|
IP
|
$6,942.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,082.60 |
| Max. Negotiated Rate |
$6,664.32 |
| Rate for Payer: Aetna Commercial |
$5,345.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,414.76
|
| Rate for Payer: Cash Price |
$3,471.00
|
| Rate for Payer: Cigna Commercial |
$5,761.86
|
| Rate for Payer: First Health Commercial |
$6,594.90
|
| Rate for Payer: Humana Commercial |
$5,900.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,692.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,123.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,082.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,108.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,206.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,553.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,039.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,789.98
|
| Rate for Payer: PHCS Commercial |
$6,664.32
|
| Rate for Payer: United Healthcare All Payer |
$6,108.96
|
|
|
GRAFT FLIXENE 8MM*40CM
|
Facility
|
OP
|
$7,745.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,323.50 |
| Max. Negotiated Rate |
$7,435.20 |
| Rate for Payer: Aetna Commercial |
$5,963.65
|
| Rate for Payer: Anthem Medicaid |
$2,663.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,041.10
|
| Rate for Payer: Cash Price |
$3,872.50
|
| Rate for Payer: Cigna Commercial |
$6,428.35
|
| Rate for Payer: First Health Commercial |
$7,357.75
|
| Rate for Payer: Humana Commercial |
$6,583.25
|
| Rate for Payer: Humana KY Medicaid |
$2,663.51
|
| Rate for Payer: Kentucky WC Medicaid |
$2,690.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,350.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,715.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,323.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,716.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,815.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,808.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,196.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,738.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,344.05
|
| Rate for Payer: PHCS Commercial |
$7,435.20
|
| Rate for Payer: United Healthcare All Payer |
$6,815.60
|
|
|
GRAFT FLIXENE 8MM*40CM
|
Facility
|
IP
|
$7,745.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,323.50 |
| Max. Negotiated Rate |
$7,435.20 |
| Rate for Payer: Aetna Commercial |
$5,963.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,041.10
|
| Rate for Payer: Cash Price |
$3,872.50
|
| Rate for Payer: Cigna Commercial |
$6,428.35
|
| Rate for Payer: First Health Commercial |
$7,357.75
|
| Rate for Payer: Humana Commercial |
$6,583.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,350.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,715.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,323.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,815.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,808.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,196.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,738.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,344.05
|
| Rate for Payer: PHCS Commercial |
$7,435.20
|
| Rate for Payer: United Healthcare All Payer |
$6,815.60
|
|
|
GRAFT FLIXENE 8MM*50CM
|
Facility
|
IP
|
$7,380.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,214.00 |
| Max. Negotiated Rate |
$7,084.80 |
| Rate for Payer: Aetna Commercial |
$5,682.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,756.40
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cigna Commercial |
$6,125.40
|
| Rate for Payer: First Health Commercial |
$7,011.00
|
| Rate for Payer: Humana Commercial |
$6,273.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,051.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,446.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,214.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,494.40
|
| Rate for Payer: Ohio Health Group HMO |
$5,535.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,904.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,420.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,092.20
|
| Rate for Payer: PHCS Commercial |
$7,084.80
|
| Rate for Payer: United Healthcare All Payer |
$6,494.40
|
|
|
GRAFT FLIXENE 8MM*50CM
|
Facility
|
OP
|
$7,380.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,214.00 |
| Max. Negotiated Rate |
$7,084.80 |
| Rate for Payer: Aetna Commercial |
$5,682.60
|
| Rate for Payer: Anthem Medicaid |
$2,537.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,756.40
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cigna Commercial |
$6,125.40
|
| Rate for Payer: First Health Commercial |
$7,011.00
|
| Rate for Payer: Humana Commercial |
$6,273.00
|
| Rate for Payer: Humana KY Medicaid |
$2,537.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,563.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,051.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,446.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,214.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,588.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,494.40
|
| Rate for Payer: Ohio Health Group HMO |
$5,535.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,904.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,420.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,092.20
|
| Rate for Payer: PHCS Commercial |
$7,084.80
|
| Rate for Payer: United Healthcare All Payer |
$6,494.40
|
|
|
GRAFT FUSION BIOLINE CTD 6M*60
|
Facility
|
OP
|
$8,256.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,476.80 |
| Max. Negotiated Rate |
$7,925.76 |
| Rate for Payer: Aetna Commercial |
$6,357.12
|
| Rate for Payer: Anthem Medicaid |
$2,839.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,439.68
|
| Rate for Payer: Cash Price |
$4,128.00
|
| Rate for Payer: Cigna Commercial |
$6,852.48
|
| Rate for Payer: First Health Commercial |
$7,843.20
|
| Rate for Payer: Humana Commercial |
$7,017.60
|
| Rate for Payer: Humana KY Medicaid |
$2,839.24
|
| Rate for Payer: Kentucky WC Medicaid |
$2,868.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,769.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,092.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,476.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,896.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,265.28
|
| Rate for Payer: Ohio Health Group HMO |
$6,192.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,604.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,182.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,696.64
|
| Rate for Payer: PHCS Commercial |
$7,925.76
|
| Rate for Payer: United Healthcare All Payer |
$7,265.28
|
|
|
GRAFT FUSION BIOLINE CTD 6M*60
|
Facility
|
IP
|
$8,256.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,476.80 |
| Max. Negotiated Rate |
$7,925.76 |
| Rate for Payer: Aetna Commercial |
$6,357.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,439.68
|
| Rate for Payer: Cash Price |
$4,128.00
|
| Rate for Payer: Cigna Commercial |
$6,852.48
|
| Rate for Payer: First Health Commercial |
$7,843.20
|
| Rate for Payer: Humana Commercial |
$7,017.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,769.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,092.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,476.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,265.28
|
| Rate for Payer: Ohio Health Group HMO |
$6,192.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,604.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,182.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,696.64
|
| Rate for Payer: PHCS Commercial |
$7,925.76
|
| Rate for Payer: United Healthcare All Payer |
$7,265.28
|
|
|
GRAFT GORE HYBRID 7-5CM*6*40
|
Facility
|
IP
|
$12,491.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,747.45 |
| Max. Negotiated Rate |
$11,991.84 |
| Rate for Payer: Aetna Commercial |
$9,618.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,743.37
|
| Rate for Payer: Cash Price |
$6,245.75
|
| Rate for Payer: Cigna Commercial |
$10,367.94
|
| Rate for Payer: First Health Commercial |
$11,866.92
|
| Rate for Payer: Humana Commercial |
$10,617.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,243.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,218.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,747.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,992.52
|
| Rate for Payer: Ohio Health Group HMO |
$9,368.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,993.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,867.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,619.14
|
| Rate for Payer: PHCS Commercial |
$11,991.84
|
| Rate for Payer: United Healthcare All Payer |
$10,992.52
|
|
|
GRAFT GORE HYBRID 7-5CM*6*40
|
Facility
|
OP
|
$12,491.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,747.45 |
| Max. Negotiated Rate |
$11,991.84 |
| Rate for Payer: Aetna Commercial |
$9,618.45
|
| Rate for Payer: Anthem Medicaid |
$4,295.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,743.37
|
| Rate for Payer: Cash Price |
$6,245.75
|
| Rate for Payer: Cigna Commercial |
$10,367.94
|
| Rate for Payer: First Health Commercial |
$11,866.92
|
| Rate for Payer: Humana Commercial |
$10,617.77
|
| Rate for Payer: Humana KY Medicaid |
$4,295.83
|
| Rate for Payer: Kentucky WC Medicaid |
$4,339.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,243.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,218.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,747.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,382.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,992.52
|
| Rate for Payer: Ohio Health Group HMO |
$9,368.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,993.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,867.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,619.14
|
| Rate for Payer: PHCS Commercial |
$11,991.84
|
| Rate for Payer: United Healthcare All Payer |
$10,992.52
|
|
|
GRAFT HEMA 1 BRANCH PLAT 22*50
|
Facility
|
IP
|
$7,804.57
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,341.37 |
| Max. Negotiated Rate |
$7,492.39 |
| Rate for Payer: Aetna Commercial |
$6,009.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,087.56
|
| Rate for Payer: Cash Price |
$3,902.28
|
| Rate for Payer: Cigna Commercial |
$6,477.79
|
| Rate for Payer: First Health Commercial |
$7,414.34
|
| Rate for Payer: Humana Commercial |
$6,633.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,399.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,759.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,341.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,868.02
|
| Rate for Payer: Ohio Health Group HMO |
$5,853.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,243.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,789.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,385.15
|
| Rate for Payer: PHCS Commercial |
$7,492.39
|
| Rate for Payer: United Healthcare All Payer |
$6,868.02
|
|
|
GRAFT HEMA 1 BRANCH PLAT 22*50
|
Facility
|
OP
|
$7,804.57
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,341.37 |
| Max. Negotiated Rate |
$7,492.39 |
| Rate for Payer: Aetna Commercial |
$6,009.52
|
| Rate for Payer: Anthem Medicaid |
$2,683.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,087.56
|
| Rate for Payer: Cash Price |
$3,902.28
|
| Rate for Payer: Cigna Commercial |
$6,477.79
|
| Rate for Payer: First Health Commercial |
$7,414.34
|
| Rate for Payer: Humana Commercial |
$6,633.88
|
| Rate for Payer: Humana KY Medicaid |
$2,683.99
|
| Rate for Payer: Kentucky WC Medicaid |
$2,711.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,399.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,759.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,341.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,737.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,868.02
|
| Rate for Payer: Ohio Health Group HMO |
$5,853.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,243.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,789.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,385.15
|
| Rate for Payer: PHCS Commercial |
$7,492.39
|
| Rate for Payer: United Healthcare All Payer |
$6,868.02
|
|
|
GRAFT HEMA 1 BRANCH PLAT 24*50
|
Facility
|
OP
|
$5,425.77
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,627.73 |
| Max. Negotiated Rate |
$5,208.74 |
| Rate for Payer: Aetna Commercial |
$4,177.84
|
| Rate for Payer: Anthem Medicaid |
$1,865.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,232.10
|
| Rate for Payer: Cash Price |
$2,712.89
|
| Rate for Payer: Cigna Commercial |
$4,503.39
|
| Rate for Payer: First Health Commercial |
$5,154.48
|
| Rate for Payer: Humana Commercial |
$4,611.90
|
| Rate for Payer: Humana KY Medicaid |
$1,865.92
|
| Rate for Payer: Kentucky WC Medicaid |
$1,884.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,449.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,004.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,627.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,903.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,774.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,069.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,340.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,720.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,743.78
|
| Rate for Payer: PHCS Commercial |
$5,208.74
|
| Rate for Payer: United Healthcare All Payer |
$4,774.68
|
|
|
GRAFT HEMA 1 BRANCH PLAT 24*50
|
Facility
|
IP
|
$5,425.77
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,627.73 |
| Max. Negotiated Rate |
$5,208.74 |
| Rate for Payer: Aetna Commercial |
$4,177.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,232.10
|
| Rate for Payer: Cash Price |
$2,712.89
|
| Rate for Payer: Cigna Commercial |
$4,503.39
|
| Rate for Payer: First Health Commercial |
$5,154.48
|
| Rate for Payer: Humana Commercial |
$4,611.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,449.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,004.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,627.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,774.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,069.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,340.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,720.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,743.78
|
| Rate for Payer: PHCS Commercial |
$5,208.74
|
| Rate for Payer: United Healthcare All Payer |
$4,774.68
|
|
|
GRAFT HEMA 1 BRANCH PLAT 26*50
|
Facility
|
OP
|
$5,425.77
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,627.73 |
| Max. Negotiated Rate |
$5,208.74 |
| Rate for Payer: Aetna Commercial |
$4,177.84
|
| Rate for Payer: Anthem Medicaid |
$1,865.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,232.10
|
| Rate for Payer: Cash Price |
$2,712.89
|
| Rate for Payer: Cigna Commercial |
$4,503.39
|
| Rate for Payer: First Health Commercial |
$5,154.48
|
| Rate for Payer: Humana Commercial |
$4,611.90
|
| Rate for Payer: Humana KY Medicaid |
$1,865.92
|
| Rate for Payer: Kentucky WC Medicaid |
$1,884.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,449.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,004.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,627.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,903.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,774.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,069.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,340.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,720.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,743.78
|
| Rate for Payer: PHCS Commercial |
$5,208.74
|
| Rate for Payer: United Healthcare All Payer |
$4,774.68
|
|
|
GRAFT HEMA 1 BRANCH PLAT 26*50
|
Facility
|
IP
|
$5,425.77
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,627.73 |
| Max. Negotiated Rate |
$5,208.74 |
| Rate for Payer: Aetna Commercial |
$4,177.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,232.10
|
| Rate for Payer: Cash Price |
$2,712.89
|
| Rate for Payer: Cigna Commercial |
$4,503.39
|
| Rate for Payer: First Health Commercial |
$5,154.48
|
| Rate for Payer: Humana Commercial |
$4,611.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,449.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,004.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,627.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,774.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,069.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,340.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,720.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,743.78
|
| Rate for Payer: PHCS Commercial |
$5,208.74
|
| Rate for Payer: United Healthcare All Payer |
$4,774.68
|
|
|
GRAFT HEMA 1 BRANCH PLAT 28*50
|
Facility
|
IP
|
$5,425.77
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,627.73 |
| Max. Negotiated Rate |
$5,208.74 |
| Rate for Payer: Aetna Commercial |
$4,177.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,232.10
|
| Rate for Payer: Cash Price |
$2,712.89
|
| Rate for Payer: Cigna Commercial |
$4,503.39
|
| Rate for Payer: First Health Commercial |
$5,154.48
|
| Rate for Payer: Humana Commercial |
$4,611.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,449.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,004.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,627.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,774.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,069.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,340.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,720.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,743.78
|
| Rate for Payer: PHCS Commercial |
$5,208.74
|
| Rate for Payer: United Healthcare All Payer |
$4,774.68
|
|
|
GRAFT HEMA 1 BRANCH PLAT 28*50
|
Facility
|
OP
|
$5,425.77
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,627.73 |
| Max. Negotiated Rate |
$5,208.74 |
| Rate for Payer: Aetna Commercial |
$4,177.84
|
| Rate for Payer: Anthem Medicaid |
$1,865.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,232.10
|
| Rate for Payer: Cash Price |
$2,712.89
|
| Rate for Payer: Cigna Commercial |
$4,503.39
|
| Rate for Payer: First Health Commercial |
$5,154.48
|
| Rate for Payer: Humana Commercial |
$4,611.90
|
| Rate for Payer: Humana KY Medicaid |
$1,865.92
|
| Rate for Payer: Kentucky WC Medicaid |
$1,884.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,449.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,004.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,627.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,903.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,774.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,069.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,340.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,720.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,743.78
|
| Rate for Payer: PHCS Commercial |
$5,208.74
|
| Rate for Payer: United Healthcare All Payer |
$4,774.68
|
|
|
GRAFT HEMA 1 BRANCH PLAT 30*50
|
Facility
|
IP
|
$5,425.77
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,627.73 |
| Max. Negotiated Rate |
$5,208.74 |
| Rate for Payer: Aetna Commercial |
$4,177.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,232.10
|
| Rate for Payer: Cash Price |
$2,712.89
|
| Rate for Payer: Cigna Commercial |
$4,503.39
|
| Rate for Payer: First Health Commercial |
$5,154.48
|
| Rate for Payer: Humana Commercial |
$4,611.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,449.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,004.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,627.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,774.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,069.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,340.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,720.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,743.78
|
| Rate for Payer: PHCS Commercial |
$5,208.74
|
| Rate for Payer: United Healthcare All Payer |
$4,774.68
|
|
|
GRAFT HEMA 1 BRANCH PLAT 30*50
|
Facility
|
OP
|
$5,425.77
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,627.73 |
| Max. Negotiated Rate |
$5,208.74 |
| Rate for Payer: Aetna Commercial |
$4,177.84
|
| Rate for Payer: Anthem Medicaid |
$1,865.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,232.10
|
| Rate for Payer: Cash Price |
$2,712.89
|
| Rate for Payer: Cigna Commercial |
$4,503.39
|
| Rate for Payer: First Health Commercial |
$5,154.48
|
| Rate for Payer: Humana Commercial |
$4,611.90
|
| Rate for Payer: Humana KY Medicaid |
$1,865.92
|
| Rate for Payer: Kentucky WC Medicaid |
$1,884.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,449.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,004.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,627.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,903.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,774.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,069.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,340.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,720.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,743.78
|
| Rate for Payer: PHCS Commercial |
$5,208.74
|
| Rate for Payer: United Healthcare All Payer |
$4,774.68
|
|
|
GRAFT HEMA 4 BRANCH 22M PLAT
|
Facility
|
OP
|
$6,898.78
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,069.63 |
| Max. Negotiated Rate |
$6,622.83 |
| Rate for Payer: Aetna Commercial |
$5,312.06
|
| Rate for Payer: Anthem Medicaid |
$2,372.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,381.05
|
| Rate for Payer: Cash Price |
$3,449.39
|
| Rate for Payer: Cigna Commercial |
$5,725.99
|
| Rate for Payer: First Health Commercial |
$6,553.84
|
| Rate for Payer: Humana Commercial |
$5,863.96
|
| Rate for Payer: Humana KY Medicaid |
$2,372.49
|
| Rate for Payer: Kentucky WC Medicaid |
$2,396.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,657.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,091.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,069.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,420.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,070.93
|
| Rate for Payer: Ohio Health Group HMO |
$5,174.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,519.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,001.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,760.16
|
| Rate for Payer: PHCS Commercial |
$6,622.83
|
| Rate for Payer: United Healthcare All Payer |
$6,070.93
|
|
|
GRAFT HEMA 4 BRANCH 22M PLAT
|
Facility
|
IP
|
$6,898.78
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,069.63 |
| Max. Negotiated Rate |
$6,622.83 |
| Rate for Payer: Aetna Commercial |
$5,312.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,381.05
|
| Rate for Payer: Cash Price |
$3,449.39
|
| Rate for Payer: Cigna Commercial |
$5,725.99
|
| Rate for Payer: First Health Commercial |
$6,553.84
|
| Rate for Payer: Humana Commercial |
$5,863.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,657.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,091.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,069.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,070.93
|
| Rate for Payer: Ohio Health Group HMO |
$5,174.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,519.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,001.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,760.16
|
| Rate for Payer: PHCS Commercial |
$6,622.83
|
| Rate for Payer: United Healthcare All Payer |
$6,070.93
|
|
|
GRAFT HEMA 4 BRANCH 24M PLAT
|
Facility
|
OP
|
$6,898.78
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,069.63 |
| Max. Negotiated Rate |
$6,622.83 |
| Rate for Payer: Aetna Commercial |
$5,312.06
|
| Rate for Payer: Anthem Medicaid |
$2,372.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,381.05
|
| Rate for Payer: Cash Price |
$3,449.39
|
| Rate for Payer: Cigna Commercial |
$5,725.99
|
| Rate for Payer: First Health Commercial |
$6,553.84
|
| Rate for Payer: Humana Commercial |
$5,863.96
|
| Rate for Payer: Humana KY Medicaid |
$2,372.49
|
| Rate for Payer: Kentucky WC Medicaid |
$2,396.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,657.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,091.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,069.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,420.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,070.93
|
| Rate for Payer: Ohio Health Group HMO |
$5,174.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,519.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,001.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,760.16
|
| Rate for Payer: PHCS Commercial |
$6,622.83
|
| Rate for Payer: United Healthcare All Payer |
$6,070.93
|
|
|
GRAFT HEMA 4 BRANCH 24M PLAT
|
Facility
|
IP
|
$6,898.78
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,069.63 |
| Max. Negotiated Rate |
$6,622.83 |
| Rate for Payer: Aetna Commercial |
$5,312.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,381.05
|
| Rate for Payer: Cash Price |
$3,449.39
|
| Rate for Payer: Cigna Commercial |
$5,725.99
|
| Rate for Payer: First Health Commercial |
$6,553.84
|
| Rate for Payer: Humana Commercial |
$5,863.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,657.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,091.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,069.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,070.93
|
| Rate for Payer: Ohio Health Group HMO |
$5,174.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,519.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,001.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,760.16
|
| Rate for Payer: PHCS Commercial |
$6,622.83
|
| Rate for Payer: United Healthcare All Payer |
$6,070.93
|
|
|
GRAFT HEMA 4 BRANCH 26M PLAT
|
Facility
|
IP
|
$6,898.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,069.66 |
| Max. Negotiated Rate |
$6,622.91 |
| Rate for Payer: Aetna Commercial |
$5,312.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,381.11
|
| Rate for Payer: Cash Price |
$3,449.43
|
| Rate for Payer: Cigna Commercial |
$5,726.05
|
| Rate for Payer: First Health Commercial |
$6,553.92
|
| Rate for Payer: Humana Commercial |
$5,864.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,657.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,091.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,069.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,071.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,174.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,519.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,002.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,760.21
|
| Rate for Payer: PHCS Commercial |
$6,622.91
|
| Rate for Payer: United Healthcare All Payer |
$6,071.00
|
|
