|
GRAFT HEMASHIELD AORTC 22M*15C
|
Facility
|
OP
|
$3,599.41
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,079.82 |
| Max. Negotiated Rate |
$3,455.43 |
| Rate for Payer: Aetna Commercial |
$2,771.55
|
| Rate for Payer: Anthem Medicaid |
$1,237.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,807.54
|
| Rate for Payer: Cash Price |
$1,799.71
|
| Rate for Payer: Cigna Commercial |
$2,987.51
|
| Rate for Payer: First Health Commercial |
$3,419.44
|
| Rate for Payer: Humana Commercial |
$3,059.50
|
| Rate for Payer: Humana KY Medicaid |
$1,237.84
|
| Rate for Payer: Kentucky WC Medicaid |
$1,250.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,951.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,656.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,079.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,262.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,167.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,699.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,879.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,131.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,483.59
|
| Rate for Payer: PHCS Commercial |
$3,455.43
|
| Rate for Payer: United Healthcare All Payer |
$3,167.48
|
|
|
GRAFT HEMASHIELD AORTC 22M*15C
|
Facility
|
IP
|
$3,599.41
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,079.82 |
| Max. Negotiated Rate |
$3,455.43 |
| Rate for Payer: Aetna Commercial |
$2,771.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,807.54
|
| Rate for Payer: Cash Price |
$1,799.71
|
| Rate for Payer: Cigna Commercial |
$2,987.51
|
| Rate for Payer: First Health Commercial |
$3,419.44
|
| Rate for Payer: Humana Commercial |
$3,059.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,951.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,656.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,079.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,167.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,699.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,879.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,131.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,483.59
|
| Rate for Payer: PHCS Commercial |
$3,455.43
|
| Rate for Payer: United Healthcare All Payer |
$3,167.48
|
|
|
GRAFT HEMASHIELD AORTC 24M*15C
|
Facility
|
OP
|
$3,023.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$907.12 |
| Max. Negotiated Rate |
$2,902.80 |
| Rate for Payer: Aetna Commercial |
$2,328.29
|
| Rate for Payer: Anthem Medicaid |
$1,039.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,358.53
|
| Rate for Payer: Cash Price |
$1,511.88
|
| Rate for Payer: Cigna Commercial |
$2,509.71
|
| Rate for Payer: First Health Commercial |
$2,872.56
|
| Rate for Payer: Humana Commercial |
$2,570.19
|
| Rate for Payer: Humana KY Medicaid |
$1,039.87
|
| Rate for Payer: Kentucky WC Medicaid |
$1,050.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,479.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,231.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$907.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,060.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,660.90
|
| Rate for Payer: Ohio Health Group HMO |
$2,267.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,419.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,630.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,086.39
|
| Rate for Payer: PHCS Commercial |
$2,902.80
|
| Rate for Payer: United Healthcare All Payer |
$2,660.90
|
|
|
GRAFT HEMASHIELD AORTC 24M*15C
|
Facility
|
IP
|
$3,023.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$907.12 |
| Max. Negotiated Rate |
$2,902.80 |
| Rate for Payer: Aetna Commercial |
$2,328.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,358.53
|
| Rate for Payer: Cash Price |
$1,511.88
|
| Rate for Payer: Cigna Commercial |
$2,509.71
|
| Rate for Payer: First Health Commercial |
$2,872.56
|
| Rate for Payer: Humana Commercial |
$2,570.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,479.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,231.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$907.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,660.90
|
| Rate for Payer: Ohio Health Group HMO |
$2,267.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,419.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,630.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,086.39
|
| Rate for Payer: PHCS Commercial |
$2,902.80
|
| Rate for Payer: United Healthcare All Payer |
$2,660.90
|
|
|
GRAFT HEMASHIELD AORTC 26M*15C
|
Facility
|
IP
|
$3,093.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$928.00 |
| Max. Negotiated Rate |
$2,969.62 |
| Rate for Payer: Aetna Commercial |
$2,381.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,412.81
|
| Rate for Payer: Cash Price |
$1,546.67
|
| Rate for Payer: Cigna Commercial |
$2,567.48
|
| Rate for Payer: First Health Commercial |
$2,938.68
|
| Rate for Payer: Humana Commercial |
$2,629.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,536.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,282.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$928.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,722.15
|
| Rate for Payer: Ohio Health Group HMO |
$2,320.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,474.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,691.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,134.41
|
| Rate for Payer: PHCS Commercial |
$2,969.62
|
| Rate for Payer: United Healthcare All Payer |
$2,722.15
|
|
|
GRAFT HEMASHIELD AORTC 26M*15C
|
Facility
|
OP
|
$3,093.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$928.00 |
| Max. Negotiated Rate |
$2,969.62 |
| Rate for Payer: Aetna Commercial |
$2,381.88
|
| Rate for Payer: Anthem Medicaid |
$1,063.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,412.81
|
| Rate for Payer: Cash Price |
$1,546.67
|
| Rate for Payer: Cigna Commercial |
$2,567.48
|
| Rate for Payer: First Health Commercial |
$2,938.68
|
| Rate for Payer: Humana Commercial |
$2,629.35
|
| Rate for Payer: Humana KY Medicaid |
$1,063.80
|
| Rate for Payer: Kentucky WC Medicaid |
$1,074.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,536.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,282.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$928.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,085.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,722.15
|
| Rate for Payer: Ohio Health Group HMO |
$2,320.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,474.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,691.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,134.41
|
| Rate for Payer: PHCS Commercial |
$2,969.62
|
| Rate for Payer: United Healthcare All Payer |
$2,722.15
|
|
|
GRAFT HEMASHIELD AORTC 28M*15C
|
Facility
|
OP
|
$3,093.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$928.00 |
| Max. Negotiated Rate |
$2,969.62 |
| Rate for Payer: Aetna Commercial |
$2,381.88
|
| Rate for Payer: Anthem Medicaid |
$1,063.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,412.81
|
| Rate for Payer: Cash Price |
$1,546.67
|
| Rate for Payer: Cigna Commercial |
$2,567.48
|
| Rate for Payer: First Health Commercial |
$2,938.68
|
| Rate for Payer: Humana Commercial |
$2,629.35
|
| Rate for Payer: Humana KY Medicaid |
$1,063.80
|
| Rate for Payer: Kentucky WC Medicaid |
$1,074.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,536.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,282.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$928.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,085.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,722.15
|
| Rate for Payer: Ohio Health Group HMO |
$2,320.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,474.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,691.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,134.41
|
| Rate for Payer: PHCS Commercial |
$2,969.62
|
| Rate for Payer: United Healthcare All Payer |
$2,722.15
|
|
|
GRAFT HEMASHIELD AORTC 28M*15C
|
Facility
|
IP
|
$3,093.35
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$928.00 |
| Max. Negotiated Rate |
$2,969.62 |
| Rate for Payer: Aetna Commercial |
$2,381.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,412.81
|
| Rate for Payer: Cash Price |
$1,546.67
|
| Rate for Payer: Cigna Commercial |
$2,567.48
|
| Rate for Payer: First Health Commercial |
$2,938.68
|
| Rate for Payer: Humana Commercial |
$2,629.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,536.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,282.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$928.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,722.15
|
| Rate for Payer: Ohio Health Group HMO |
$2,320.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,474.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,691.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,134.41
|
| Rate for Payer: PHCS Commercial |
$2,969.62
|
| Rate for Payer: United Healthcare All Payer |
$2,722.15
|
|
|
GRAFT HEMASHIELD GOLD 20*30
|
Facility
|
OP
|
$3,932.04
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,179.61 |
| Max. Negotiated Rate |
$3,774.76 |
| Rate for Payer: Aetna Commercial |
$3,027.67
|
| Rate for Payer: Anthem Medicaid |
$1,352.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,066.99
|
| Rate for Payer: Cash Price |
$1,966.02
|
| Rate for Payer: Cigna Commercial |
$3,263.59
|
| Rate for Payer: First Health Commercial |
$3,735.44
|
| Rate for Payer: Humana Commercial |
$3,342.23
|
| Rate for Payer: Humana KY Medicaid |
$1,352.23
|
| Rate for Payer: Kentucky WC Medicaid |
$1,365.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,224.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,901.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,179.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,379.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,460.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,949.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,145.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,420.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,713.11
|
| Rate for Payer: PHCS Commercial |
$3,774.76
|
| Rate for Payer: United Healthcare All Payer |
$3,460.20
|
|
|
GRAFT HEMASHIELD GOLD 20*30
|
Facility
|
IP
|
$3,932.04
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,179.61 |
| Max. Negotiated Rate |
$3,774.76 |
| Rate for Payer: Aetna Commercial |
$3,027.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,066.99
|
| Rate for Payer: Cash Price |
$1,966.02
|
| Rate for Payer: Cigna Commercial |
$3,263.59
|
| Rate for Payer: First Health Commercial |
$3,735.44
|
| Rate for Payer: Humana Commercial |
$3,342.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,224.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,901.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,179.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,460.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,949.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,145.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,420.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,713.11
|
| Rate for Payer: PHCS Commercial |
$3,774.76
|
| Rate for Payer: United Healthcare All Payer |
$3,460.20
|
|
|
GRAFT HEMASHIELD GOLD 22*30
|
Facility
|
IP
|
$3,932.04
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,179.61 |
| Max. Negotiated Rate |
$3,774.76 |
| Rate for Payer: Aetna Commercial |
$3,027.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,066.99
|
| Rate for Payer: Cash Price |
$1,966.02
|
| Rate for Payer: Cigna Commercial |
$3,263.59
|
| Rate for Payer: First Health Commercial |
$3,735.44
|
| Rate for Payer: Humana Commercial |
$3,342.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,224.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,901.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,179.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,460.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,949.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,145.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,420.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,713.11
|
| Rate for Payer: PHCS Commercial |
$3,774.76
|
| Rate for Payer: United Healthcare All Payer |
$3,460.20
|
|
|
GRAFT HEMASHIELD GOLD 22*30
|
Facility
|
OP
|
$3,932.04
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,179.61 |
| Max. Negotiated Rate |
$3,774.76 |
| Rate for Payer: Aetna Commercial |
$3,027.67
|
| Rate for Payer: Anthem Medicaid |
$1,352.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,066.99
|
| Rate for Payer: Cash Price |
$1,966.02
|
| Rate for Payer: Cigna Commercial |
$3,263.59
|
| Rate for Payer: First Health Commercial |
$3,735.44
|
| Rate for Payer: Humana Commercial |
$3,342.23
|
| Rate for Payer: Humana KY Medicaid |
$1,352.23
|
| Rate for Payer: Kentucky WC Medicaid |
$1,365.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,224.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,901.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,179.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,379.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,460.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,949.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,145.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,420.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,713.11
|
| Rate for Payer: PHCS Commercial |
$3,774.76
|
| Rate for Payer: United Healthcare All Payer |
$3,460.20
|
|
|
GRAFT HEMASHIELD GOLD 24*30
|
Facility
|
OP
|
$3,932.04
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,179.61 |
| Max. Negotiated Rate |
$3,774.76 |
| Rate for Payer: Aetna Commercial |
$3,027.67
|
| Rate for Payer: Anthem Medicaid |
$1,352.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,066.99
|
| Rate for Payer: Cash Price |
$1,966.02
|
| Rate for Payer: Cigna Commercial |
$3,263.59
|
| Rate for Payer: First Health Commercial |
$3,735.44
|
| Rate for Payer: Humana Commercial |
$3,342.23
|
| Rate for Payer: Humana KY Medicaid |
$1,352.23
|
| Rate for Payer: Kentucky WC Medicaid |
$1,365.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,224.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,901.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,179.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,379.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,460.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,949.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,145.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,420.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,713.11
|
| Rate for Payer: PHCS Commercial |
$3,774.76
|
| Rate for Payer: United Healthcare All Payer |
$3,460.20
|
|
|
GRAFT HEMASHIELD GOLD 24*30
|
Facility
|
IP
|
$3,932.04
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,179.61 |
| Max. Negotiated Rate |
$3,774.76 |
| Rate for Payer: Aetna Commercial |
$3,027.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,066.99
|
| Rate for Payer: Cash Price |
$1,966.02
|
| Rate for Payer: Cigna Commercial |
$3,263.59
|
| Rate for Payer: First Health Commercial |
$3,735.44
|
| Rate for Payer: Humana Commercial |
$3,342.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,224.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,901.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,179.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,460.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,949.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,145.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,420.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,713.11
|
| Rate for Payer: PHCS Commercial |
$3,774.76
|
| Rate for Payer: United Healthcare All Payer |
$3,460.20
|
|
|
GRAFT HEMASHIELD GOLD 6*30
|
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
|
|
|
GRAFT HEMASHIELD GOLD 6*30
|
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 GOLD 7*30
|
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
|
|
|
GRAFT HEMASHIELD GOLD 7*30
|
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 GOLD 8*30
|
Facility
|
OP
|
$3,865.62
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,159.69 |
| Max. Negotiated Rate |
$3,711.00 |
| Rate for Payer: Aetna Commercial |
$2,976.53
|
| Rate for Payer: Anthem Medicaid |
$1,329.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,015.18
|
| Rate for Payer: Cash Price |
$1,932.81
|
| Rate for Payer: Cigna Commercial |
$3,208.46
|
| Rate for Payer: First Health Commercial |
$3,672.34
|
| Rate for Payer: Humana Commercial |
$3,285.78
|
| Rate for Payer: Humana KY Medicaid |
$1,329.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,342.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,169.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,852.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,159.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,356.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,401.75
|
| Rate for Payer: Ohio Health Group HMO |
$2,899.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,092.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,363.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,667.28
|
| Rate for Payer: PHCS Commercial |
$3,711.00
|
| Rate for Payer: United Healthcare All Payer |
$3,401.75
|
|
|
GRAFT HEMASHIELD GOLD 8*30
|
Facility
|
IP
|
$3,865.62
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,159.69 |
| Max. Negotiated Rate |
$3,711.00 |
| Rate for Payer: Aetna Commercial |
$2,976.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,015.18
|
| Rate for Payer: Cash Price |
$1,932.81
|
| Rate for Payer: Cigna Commercial |
$3,208.46
|
| Rate for Payer: First Health Commercial |
$3,672.34
|
| Rate for Payer: Humana Commercial |
$3,285.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,169.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,852.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,159.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,401.75
|
| Rate for Payer: Ohio Health Group HMO |
$2,899.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,092.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,363.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,667.28
|
| Rate for Payer: PHCS Commercial |
$3,711.00
|
| Rate for Payer: United Healthcare All Payer |
$3,401.75
|
|
|
GRAFT HEMASHIELD GOLD BIFR 22*
|
Facility
|
IP
|
$4,581.24
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,374.37 |
| Max. Negotiated Rate |
$4,397.99 |
| Rate for Payer: Aetna Commercial |
$3,527.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,573.37
|
| Rate for Payer: Cash Price |
$2,290.62
|
| Rate for Payer: Cigna Commercial |
$3,802.43
|
| Rate for Payer: First Health Commercial |
$4,352.18
|
| Rate for Payer: Humana Commercial |
$3,894.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,756.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,380.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,374.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,031.49
|
| Rate for Payer: Ohio Health Group HMO |
$3,435.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,664.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,985.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,161.06
|
| Rate for Payer: PHCS Commercial |
$4,397.99
|
| Rate for Payer: United Healthcare All Payer |
$4,031.49
|
|
|
GRAFT HEMASHIELD GOLD BIFR 22*
|
Facility
|
OP
|
$4,581.24
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,374.37 |
| Max. Negotiated Rate |
$4,397.99 |
| Rate for Payer: Aetna Commercial |
$3,527.55
|
| Rate for Payer: Anthem Medicaid |
$1,575.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,573.37
|
| Rate for Payer: Cash Price |
$2,290.62
|
| Rate for Payer: Cigna Commercial |
$3,802.43
|
| Rate for Payer: First Health Commercial |
$4,352.18
|
| Rate for Payer: Humana Commercial |
$3,894.05
|
| Rate for Payer: Humana KY Medicaid |
$1,575.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1,591.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,756.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,380.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,374.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,607.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,031.49
|
| Rate for Payer: Ohio Health Group HMO |
$3,435.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,664.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,985.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,161.06
|
| Rate for Payer: PHCS Commercial |
$4,397.99
|
| Rate for Payer: United Healthcare All Payer |
$4,031.49
|
|
|
GRAFT HEMASHIELD PLAT PATCH 2.
|
Facility
|
IP
|
$1,566.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$469.90 |
| Max. Negotiated Rate |
$1,503.67 |
| Rate for Payer: Aetna Commercial |
$1,206.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,221.73
|
| Rate for Payer: Cash Price |
$783.16
|
| Rate for Payer: Cigna Commercial |
$1,300.05
|
| Rate for Payer: First Health Commercial |
$1,488.00
|
| Rate for Payer: Humana Commercial |
$1,331.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,284.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,155.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$469.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,378.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,174.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,253.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,362.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,080.76
|
| Rate for Payer: PHCS Commercial |
$1,503.67
|
| Rate for Payer: United Healthcare All Payer |
$1,378.36
|
|
|
GRAFT HEMASHIELD PLAT PATCH 2.
|
Facility
|
OP
|
$1,566.32
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$469.90 |
| Max. Negotiated Rate |
$1,503.67 |
| Rate for Payer: Aetna Commercial |
$1,206.07
|
| Rate for Payer: Anthem Medicaid |
$538.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,221.73
|
| Rate for Payer: Cash Price |
$783.16
|
| Rate for Payer: Cigna Commercial |
$1,300.05
|
| Rate for Payer: First Health Commercial |
$1,488.00
|
| Rate for Payer: Humana Commercial |
$1,331.37
|
| Rate for Payer: Humana KY Medicaid |
$538.66
|
| Rate for Payer: Kentucky WC Medicaid |
$544.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,284.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,155.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$469.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$549.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,378.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,174.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,253.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,362.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,080.76
|
| Rate for Payer: PHCS Commercial |
$1,503.67
|
| Rate for Payer: United Healthcare All Payer |
$1,378.36
|
|
|
GRAFT HEMA STR 30M*15CM PLAT
|
Facility
|
OP
|
$3,093.35
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$928.00 |
| Max. Negotiated Rate |
$2,969.62 |
| Rate for Payer: Aetna Commercial |
$2,381.88
|
| Rate for Payer: Anthem Medicaid |
$1,063.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,412.81
|
| Rate for Payer: Cash Price |
$1,546.67
|
| Rate for Payer: Cigna Commercial |
$2,567.48
|
| Rate for Payer: First Health Commercial |
$2,938.68
|
| Rate for Payer: Humana Commercial |
$2,629.35
|
| Rate for Payer: Humana KY Medicaid |
$1,063.80
|
| Rate for Payer: Kentucky WC Medicaid |
$1,074.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,536.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,282.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$928.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,085.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,722.15
|
| Rate for Payer: Ohio Health Group HMO |
$2,320.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,474.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,691.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,134.41
|
| Rate for Payer: PHCS Commercial |
$2,969.62
|
| Rate for Payer: United Healthcare All Payer |
$2,722.15
|
|
