|
GRAFT HEMA 4 BRANCH 26M PLAT
|
Facility
|
OP
|
$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 Medicaid |
$2,372.52
|
| 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: Humana KY Medicaid |
$2,372.52
|
| Rate for Payer: Kentucky WC Medicaid |
$2,396.66
|
| 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: Molina Healthcare Medicaid |
$2,420.12
|
| 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
|
|
|
GRAFT HEMA 4 BRANCH 28M 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 28M 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 30M 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 30M 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 HEMAGARD STRAIGHT 14*40
|
Facility
|
OP
|
$4,441.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,332.38 |
| Max. Negotiated Rate |
$4,263.60 |
| Rate for Payer: Aetna Commercial |
$3,419.76
|
| Rate for Payer: Anthem Medicaid |
$1,527.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,464.18
|
| Rate for Payer: Cash Price |
$2,220.62
|
| Rate for Payer: Cigna Commercial |
$3,686.24
|
| Rate for Payer: First Health Commercial |
$4,219.19
|
| Rate for Payer: Humana Commercial |
$3,775.06
|
| Rate for Payer: Humana KY Medicaid |
$1,527.35
|
| Rate for Payer: Kentucky WC Medicaid |
$1,542.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,641.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,277.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,332.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,557.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,908.30
|
| Rate for Payer: Ohio Health Group HMO |
$3,330.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,553.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,863.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,064.46
|
| Rate for Payer: PHCS Commercial |
$4,263.60
|
| Rate for Payer: United Healthcare All Payer |
$3,908.30
|
|
|
GRAFT HEMAGARD STRAIGHT 14*40
|
Facility
|
IP
|
$4,441.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,332.38 |
| Max. Negotiated Rate |
$4,263.60 |
| Rate for Payer: Aetna Commercial |
$3,419.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,464.18
|
| Rate for Payer: Cash Price |
$2,220.62
|
| Rate for Payer: Cigna Commercial |
$3,686.24
|
| Rate for Payer: First Health Commercial |
$4,219.19
|
| Rate for Payer: Humana Commercial |
$3,775.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,641.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,277.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,332.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,908.30
|
| Rate for Payer: Ohio Health Group HMO |
$3,330.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,553.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,863.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,064.46
|
| Rate for Payer: PHCS Commercial |
$4,263.60
|
| Rate for Payer: United Healthcare All Payer |
$3,908.30
|
|
|
GRAFT HEMASHIELD 12*6MM
|
Facility
|
IP
|
$4,761.91
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,428.57 |
| Max. Negotiated Rate |
$4,571.43 |
| Rate for Payer: Aetna Commercial |
$3,666.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,714.29
|
| Rate for Payer: Cash Price |
$2,380.96
|
| Rate for Payer: Cigna Commercial |
$3,952.39
|
| Rate for Payer: First Health Commercial |
$4,523.81
|
| Rate for Payer: Humana Commercial |
$4,047.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,904.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,514.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,428.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,190.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,571.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,809.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,142.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,285.72
|
| Rate for Payer: PHCS Commercial |
$4,571.43
|
| Rate for Payer: United Healthcare All Payer |
$4,190.48
|
|
|
GRAFT HEMASHIELD 12*6MM
|
Facility
|
OP
|
$4,761.91
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,428.57 |
| Max. Negotiated Rate |
$4,571.43 |
| Rate for Payer: Aetna Commercial |
$3,666.67
|
| Rate for Payer: Anthem Medicaid |
$1,637.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,714.29
|
| Rate for Payer: Cash Price |
$2,380.96
|
| Rate for Payer: Cigna Commercial |
$3,952.39
|
| Rate for Payer: First Health Commercial |
$4,523.81
|
| Rate for Payer: Humana Commercial |
$4,047.62
|
| Rate for Payer: Humana KY Medicaid |
$1,637.62
|
| Rate for Payer: Kentucky WC Medicaid |
$1,654.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,904.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,514.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,428.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,670.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,190.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,571.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,809.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,142.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,285.72
|
| Rate for Payer: PHCS Commercial |
$4,571.43
|
| Rate for Payer: United Healthcare All Payer |
$4,190.48
|
|
|
GRAFT HEMASHIELD 12*7MM
|
Facility
|
OP
|
$3,912.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,173.70 |
| Max. Negotiated Rate |
$3,755.86 |
| Rate for Payer: Aetna Commercial |
$3,012.51
|
| Rate for Payer: Anthem Medicaid |
$1,345.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,051.63
|
| Rate for Payer: Cash Price |
$1,956.17
|
| Rate for Payer: Cigna Commercial |
$3,247.25
|
| Rate for Payer: First Health Commercial |
$3,716.73
|
| Rate for Payer: Humana Commercial |
$3,325.50
|
| Rate for Payer: Humana KY Medicaid |
$1,345.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1,359.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,208.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,887.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,173.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,372.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,442.87
|
| Rate for Payer: Ohio Health Group HMO |
$2,934.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,129.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,403.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,699.52
|
| Rate for Payer: PHCS Commercial |
$3,755.86
|
| Rate for Payer: United Healthcare All Payer |
$3,442.87
|
|
|
GRAFT HEMASHIELD 12*7MM
|
Facility
|
IP
|
$3,912.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,173.70 |
| Max. Negotiated Rate |
$3,755.86 |
| Rate for Payer: Aetna Commercial |
$3,012.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,051.63
|
| Rate for Payer: Cash Price |
$1,956.17
|
| Rate for Payer: Cigna Commercial |
$3,247.25
|
| Rate for Payer: First Health Commercial |
$3,716.73
|
| Rate for Payer: Humana Commercial |
$3,325.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,208.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,887.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,173.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,442.87
|
| Rate for Payer: Ohio Health Group HMO |
$2,934.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,129.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,403.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,699.52
|
| Rate for Payer: PHCS Commercial |
$3,755.86
|
| Rate for Payer: United Healthcare All Payer |
$3,442.87
|
|
|
GRAFT HEMASHIELD 14*7MM
|
Facility
|
IP
|
$4,761.91
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,428.57 |
| Max. Negotiated Rate |
$4,571.43 |
| Rate for Payer: Aetna Commercial |
$3,666.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,714.29
|
| Rate for Payer: Cash Price |
$2,380.96
|
| Rate for Payer: Cigna Commercial |
$3,952.39
|
| Rate for Payer: First Health Commercial |
$4,523.81
|
| Rate for Payer: Humana Commercial |
$4,047.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,904.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,514.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,428.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,190.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,571.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,809.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,142.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,285.72
|
| Rate for Payer: PHCS Commercial |
$4,571.43
|
| Rate for Payer: United Healthcare All Payer |
$4,190.48
|
|
|
GRAFT HEMASHIELD 14*7MM
|
Facility
|
OP
|
$4,761.91
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,428.57 |
| Max. Negotiated Rate |
$4,571.43 |
| Rate for Payer: Aetna Commercial |
$3,666.67
|
| Rate for Payer: Anthem Medicaid |
$1,637.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,714.29
|
| Rate for Payer: Cash Price |
$2,380.96
|
| Rate for Payer: Cigna Commercial |
$3,952.39
|
| Rate for Payer: First Health Commercial |
$4,523.81
|
| Rate for Payer: Humana Commercial |
$4,047.62
|
| Rate for Payer: Humana KY Medicaid |
$1,637.62
|
| Rate for Payer: Kentucky WC Medicaid |
$1,654.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,904.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,514.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,428.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,670.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,190.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,571.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,809.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,142.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,285.72
|
| Rate for Payer: PHCS Commercial |
$4,571.43
|
| Rate for Payer: United Healthcare All Payer |
$4,190.48
|
|
|
GRAFT HEMASHIELD 16*8MM
|
Facility
|
OP
|
$4,761.91
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,428.57 |
| Max. Negotiated Rate |
$4,571.43 |
| Rate for Payer: Aetna Commercial |
$3,666.67
|
| Rate for Payer: Anthem Medicaid |
$1,637.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,714.29
|
| Rate for Payer: Cash Price |
$2,380.96
|
| Rate for Payer: Cigna Commercial |
$3,952.39
|
| Rate for Payer: First Health Commercial |
$4,523.81
|
| Rate for Payer: Humana Commercial |
$4,047.62
|
| Rate for Payer: Humana KY Medicaid |
$1,637.62
|
| Rate for Payer: Kentucky WC Medicaid |
$1,654.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,904.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,514.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,428.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,670.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,190.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,571.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,809.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,142.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,285.72
|
| Rate for Payer: PHCS Commercial |
$4,571.43
|
| Rate for Payer: United Healthcare All Payer |
$4,190.48
|
|
|
GRAFT HEMASHIELD 16*8MM
|
Facility
|
IP
|
$4,761.91
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,428.57 |
| Max. Negotiated Rate |
$4,571.43 |
| Rate for Payer: Aetna Commercial |
$3,666.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,714.29
|
| Rate for Payer: Cash Price |
$2,380.96
|
| Rate for Payer: Cigna Commercial |
$3,952.39
|
| Rate for Payer: First Health Commercial |
$4,523.81
|
| Rate for Payer: Humana Commercial |
$4,047.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,904.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,514.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,428.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,190.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,571.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,809.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,142.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,285.72
|
| Rate for Payer: PHCS Commercial |
$4,571.43
|
| Rate for Payer: United Healthcare All Payer |
$4,190.48
|
|
|
GRAFT HEMASHIELD 18*9MM
|
Facility
|
OP
|
$4,761.91
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,428.57 |
| Max. Negotiated Rate |
$4,571.43 |
| Rate for Payer: Aetna Commercial |
$3,666.67
|
| Rate for Payer: Anthem Medicaid |
$1,637.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,714.29
|
| Rate for Payer: Cash Price |
$2,380.96
|
| Rate for Payer: Cigna Commercial |
$3,952.39
|
| Rate for Payer: First Health Commercial |
$4,523.81
|
| Rate for Payer: Humana Commercial |
$4,047.62
|
| Rate for Payer: Humana KY Medicaid |
$1,637.62
|
| Rate for Payer: Kentucky WC Medicaid |
$1,654.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,904.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,514.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,428.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,670.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,190.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,571.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,809.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,142.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,285.72
|
| Rate for Payer: PHCS Commercial |
$4,571.43
|
| Rate for Payer: United Healthcare All Payer |
$4,190.48
|
|
|
GRAFT HEMASHIELD 18*9MM
|
Facility
|
IP
|
$4,761.91
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,428.57 |
| Max. Negotiated Rate |
$4,571.43 |
| Rate for Payer: Aetna Commercial |
$3,666.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,714.29
|
| Rate for Payer: Cash Price |
$2,380.96
|
| Rate for Payer: Cigna Commercial |
$3,952.39
|
| Rate for Payer: First Health Commercial |
$4,523.81
|
| Rate for Payer: Humana Commercial |
$4,047.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,904.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,514.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,428.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,190.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,571.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,809.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,142.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,285.72
|
| Rate for Payer: PHCS Commercial |
$4,571.43
|
| Rate for Payer: United Healthcare All Payer |
$4,190.48
|
|
|
GRAFT HEMASHIELD 20*10MM
|
Facility
|
IP
|
$4,761.91
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,428.57 |
| Max. Negotiated Rate |
$4,571.43 |
| Rate for Payer: Aetna Commercial |
$3,666.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,714.29
|
| Rate for Payer: Cash Price |
$2,380.96
|
| Rate for Payer: Cigna Commercial |
$3,952.39
|
| Rate for Payer: First Health Commercial |
$4,523.81
|
| Rate for Payer: Humana Commercial |
$4,047.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,904.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,514.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,428.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,190.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,571.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,809.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,142.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,285.72
|
| Rate for Payer: PHCS Commercial |
$4,571.43
|
| Rate for Payer: United Healthcare All Payer |
$4,190.48
|
|
|
GRAFT HEMASHIELD 20*10MM
|
Facility
|
OP
|
$4,761.91
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,428.57 |
| Max. Negotiated Rate |
$4,571.43 |
| Rate for Payer: Aetna Commercial |
$3,666.67
|
| Rate for Payer: Anthem Medicaid |
$1,637.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,714.29
|
| Rate for Payer: Cash Price |
$2,380.96
|
| Rate for Payer: Cigna Commercial |
$3,952.39
|
| Rate for Payer: First Health Commercial |
$4,523.81
|
| Rate for Payer: Humana Commercial |
$4,047.62
|
| Rate for Payer: Humana KY Medicaid |
$1,637.62
|
| Rate for Payer: Kentucky WC Medicaid |
$1,654.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,904.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,514.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,428.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,670.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,190.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,571.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,809.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,142.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,285.72
|
| Rate for Payer: PHCS Commercial |
$4,571.43
|
| Rate for Payer: United Healthcare All Payer |
$4,190.48
|
|
|
GRAFT HEMASHIELD 24*12MM
|
Facility
|
OP
|
$3,912.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,173.70 |
| Max. Negotiated Rate |
$3,755.86 |
| Rate for Payer: Aetna Commercial |
$3,012.51
|
| Rate for Payer: Anthem Medicaid |
$1,345.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,051.63
|
| Rate for Payer: Cash Price |
$1,956.17
|
| Rate for Payer: Cigna Commercial |
$3,247.25
|
| Rate for Payer: First Health Commercial |
$3,716.73
|
| Rate for Payer: Humana Commercial |
$3,325.50
|
| Rate for Payer: Humana KY Medicaid |
$1,345.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1,359.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,208.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,887.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,173.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,372.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,442.87
|
| Rate for Payer: Ohio Health Group HMO |
$2,934.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,129.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,403.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,699.52
|
| Rate for Payer: PHCS Commercial |
$3,755.86
|
| Rate for Payer: United Healthcare All Payer |
$3,442.87
|
|
|
GRAFT HEMASHIELD 24*12MM
|
Facility
|
IP
|
$3,912.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,173.70 |
| Max. Negotiated Rate |
$3,755.86 |
| Rate for Payer: Aetna Commercial |
$3,012.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,051.63
|
| Rate for Payer: Cash Price |
$1,956.17
|
| Rate for Payer: Cigna Commercial |
$3,247.25
|
| Rate for Payer: First Health Commercial |
$3,716.73
|
| Rate for Payer: Humana Commercial |
$3,325.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,208.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,887.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,173.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,442.87
|
| Rate for Payer: Ohio Health Group HMO |
$2,934.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,129.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,403.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,699.52
|
| Rate for Payer: PHCS Commercial |
$3,755.86
|
| Rate for Payer: United Healthcare All Payer |
$3,442.87
|
|
|
GRAFT HEMASHIELD 40*6MM
|
Facility
|
IP
|
$3,856.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,156.88 |
| Max. Negotiated Rate |
$3,702.00 |
| Rate for Payer: Aetna Commercial |
$2,969.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,007.88
|
| Rate for Payer: Cash Price |
$1,928.12
|
| Rate for Payer: Cigna Commercial |
$3,200.69
|
| Rate for Payer: First Health Commercial |
$3,663.44
|
| Rate for Payer: Humana Commercial |
$3,277.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,162.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,845.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,156.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,393.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,892.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,085.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,354.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,660.81
|
| Rate for Payer: PHCS Commercial |
$3,702.00
|
| Rate for Payer: United Healthcare All Payer |
$3,393.50
|
|
|
GRAFT HEMASHIELD 40*6MM
|
Facility
|
OP
|
$3,856.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,156.88 |
| Max. Negotiated Rate |
$3,702.00 |
| Rate for Payer: Aetna Commercial |
$2,969.31
|
| Rate for Payer: Anthem Medicaid |
$1,326.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,007.88
|
| Rate for Payer: Cash Price |
$1,928.12
|
| Rate for Payer: Cigna Commercial |
$3,200.69
|
| Rate for Payer: First Health Commercial |
$3,663.44
|
| Rate for Payer: Humana Commercial |
$3,277.81
|
| Rate for Payer: Humana KY Medicaid |
$1,326.16
|
| Rate for Payer: Kentucky WC Medicaid |
$1,339.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,162.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,845.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,156.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,352.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,393.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,892.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,085.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,354.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,660.81
|
| Rate for Payer: PHCS Commercial |
$3,702.00
|
| Rate for Payer: United Healthcare All Payer |
$3,393.50
|
|
|
GRAFT HEMASHIELD 40*8MM
|
Facility
|
OP
|
$3,279.20
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$983.76 |
| Max. Negotiated Rate |
$3,148.03 |
| Rate for Payer: Aetna Commercial |
$2,524.98
|
| Rate for Payer: Anthem Medicaid |
$1,127.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,557.78
|
| Rate for Payer: Cash Price |
$1,639.60
|
| Rate for Payer: Cigna Commercial |
$2,721.74
|
| Rate for Payer: First Health Commercial |
$3,115.24
|
| Rate for Payer: Humana Commercial |
$2,787.32
|
| Rate for Payer: Humana KY Medicaid |
$1,127.72
|
| Rate for Payer: Kentucky WC Medicaid |
$1,139.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,688.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,420.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$983.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,150.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,885.70
|
| Rate for Payer: Ohio Health Group HMO |
$2,459.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,623.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,852.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,262.65
|
| Rate for Payer: PHCS Commercial |
$3,148.03
|
| Rate for Payer: United Healthcare All Payer |
$2,885.70
|
|
|
GRAFT HEMASHIELD 40*8MM
|
Facility
|
IP
|
$3,279.20
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$983.76 |
| Max. Negotiated Rate |
$3,148.03 |
| Rate for Payer: Aetna Commercial |
$2,524.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,557.78
|
| Rate for Payer: Cash Price |
$1,639.60
|
| Rate for Payer: Cigna Commercial |
$2,721.74
|
| Rate for Payer: First Health Commercial |
$3,115.24
|
| Rate for Payer: Humana Commercial |
$2,787.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,688.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,420.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$983.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,885.70
|
| Rate for Payer: Ohio Health Group HMO |
$2,459.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,623.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,852.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,262.65
|
| Rate for Payer: PHCS Commercial |
$3,148.03
|
| Rate for Payer: United Healthcare All Payer |
$2,885.70
|
|
