|
GRAFT INTUITRAK BI 28-13-120BL
|
Facility
|
OP
|
$72,421.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21,726.30 |
| Max. Negotiated Rate |
$69,524.16 |
| Rate for Payer: Aetna Commercial |
$55,764.17
|
| Rate for Payer: Anthem Medicaid |
$24,905.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56,488.38
|
| Rate for Payer: Cash Price |
$36,210.50
|
| Rate for Payer: Cigna Commercial |
$60,109.43
|
| Rate for Payer: First Health Commercial |
$68,799.95
|
| Rate for Payer: Humana Commercial |
$61,557.85
|
| Rate for Payer: Humana KY Medicaid |
$24,905.58
|
| Rate for Payer: Kentucky WC Medicaid |
$25,159.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59,385.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53,446.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,726.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,405.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$63,730.48
|
| Rate for Payer: Ohio Health Group HMO |
$54,315.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57,936.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,006.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49,970.49
|
| Rate for Payer: PHCS Commercial |
$69,524.16
|
| Rate for Payer: United Healthcare All Payer |
$63,730.48
|
|
|
GRAFT INTUITRAK BI 28-13-120BL
|
Facility
|
IP
|
$72,421.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21,726.30 |
| Max. Negotiated Rate |
$69,524.16 |
| Rate for Payer: Aetna Commercial |
$55,764.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56,488.38
|
| Rate for Payer: Cash Price |
$36,210.50
|
| Rate for Payer: Cigna Commercial |
$60,109.43
|
| Rate for Payer: First Health Commercial |
$68,799.95
|
| Rate for Payer: Humana Commercial |
$61,557.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59,385.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53,446.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,726.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$63,730.48
|
| Rate for Payer: Ohio Health Group HMO |
$54,315.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57,936.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,006.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49,970.49
|
| Rate for Payer: PHCS Commercial |
$69,524.16
|
| Rate for Payer: United Healthcare All Payer |
$63,730.48
|
|
|
GRAFT INTUITRAK BI 28-16-100BL
|
Facility
|
OP
|
$70,521.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21,156.30 |
| Max. Negotiated Rate |
$67,700.16 |
| Rate for Payer: Aetna Commercial |
$54,301.17
|
| Rate for Payer: Anthem Medicaid |
$24,252.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55,006.38
|
| Rate for Payer: Cash Price |
$35,260.50
|
| Rate for Payer: Cigna Commercial |
$58,532.43
|
| Rate for Payer: First Health Commercial |
$66,994.95
|
| Rate for Payer: Humana Commercial |
$59,942.85
|
| Rate for Payer: Humana KY Medicaid |
$24,252.17
|
| Rate for Payer: Kentucky WC Medicaid |
$24,499.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57,827.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52,044.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,156.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$24,738.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$62,058.48
|
| Rate for Payer: Ohio Health Group HMO |
$52,890.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$56,416.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$61,353.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$48,659.49
|
| Rate for Payer: PHCS Commercial |
$67,700.16
|
| Rate for Payer: United Healthcare All Payer |
$62,058.48
|
|
|
GRAFT INTUITRAK BI 28-16-100BL
|
Facility
|
IP
|
$70,521.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21,156.30 |
| Max. Negotiated Rate |
$67,700.16 |
| Rate for Payer: Aetna Commercial |
$54,301.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55,006.38
|
| Rate for Payer: Cash Price |
$35,260.50
|
| Rate for Payer: Cigna Commercial |
$58,532.43
|
| Rate for Payer: First Health Commercial |
$66,994.95
|
| Rate for Payer: Humana Commercial |
$59,942.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57,827.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52,044.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,156.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$62,058.48
|
| Rate for Payer: Ohio Health Group HMO |
$52,890.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$56,416.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$61,353.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$48,659.49
|
| Rate for Payer: PHCS Commercial |
$67,700.16
|
| Rate for Payer: United Healthcare All Payer |
$62,058.48
|
|
|
GRAFT INTUITRAK BI 28-16-120BL
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
GRAFT INTUITRAK BI 28-16-120BL
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
GRAFT INTUITRAK BI 28-16-135BL
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
GRAFT INTUITRAK BI 28-16-135BL
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
GRAFTJACKET 5CM*5CM 8600-5X05
|
Facility
|
IP
|
$13,159.44
|
|
|
Service Code
|
HCPCS Q4107
|
| Hospital Charge Code |
27000117
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,947.83 |
| Max. Negotiated Rate |
$12,633.06 |
| Rate for Payer: Aetna Commercial |
$10,132.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,264.36
|
| Rate for Payer: Cash Price |
$6,579.72
|
| Rate for Payer: Cigna Commercial |
$10,922.34
|
| Rate for Payer: First Health Commercial |
$12,501.47
|
| Rate for Payer: Humana Commercial |
$11,185.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,790.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,711.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,947.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,580.31
|
| Rate for Payer: Ohio Health Group HMO |
$9,869.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,527.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,448.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,080.01
|
| Rate for Payer: PHCS Commercial |
$12,633.06
|
| Rate for Payer: United Healthcare All Payer |
$11,580.31
|
|
|
GRAFTJACKET 5CM*5CM 8600-5X05
|
Facility
|
OP
|
$13,159.44
|
|
|
Service Code
|
HCPCS Q4107
|
| Hospital Charge Code |
27000117
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,947.83 |
| Max. Negotiated Rate |
$12,633.06 |
| Rate for Payer: Aetna Commercial |
$10,132.77
|
| Rate for Payer: Anthem Medicaid |
$4,525.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,264.36
|
| Rate for Payer: Cash Price |
$6,579.72
|
| Rate for Payer: Cigna Commercial |
$10,922.34
|
| Rate for Payer: First Health Commercial |
$12,501.47
|
| Rate for Payer: Humana Commercial |
$11,185.52
|
| Rate for Payer: Humana KY Medicaid |
$4,525.53
|
| Rate for Payer: Kentucky WC Medicaid |
$4,571.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,790.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,711.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,947.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,616.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,580.31
|
| Rate for Payer: Ohio Health Group HMO |
$9,869.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,527.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,448.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,080.01
|
| Rate for Payer: PHCS Commercial |
$12,633.06
|
| Rate for Payer: United Healthcare All Payer |
$11,580.31
|
|
|
GRAFTLINK TENDON 60-80*7.5-10.
|
Facility
|
OP
|
$12,344.55
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,703.36 |
| Max. Negotiated Rate |
$11,850.77 |
| Rate for Payer: Aetna Commercial |
$9,505.30
|
| Rate for Payer: Anthem Medicaid |
$4,245.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,628.75
|
| Rate for Payer: Cash Price |
$6,172.28
|
| Rate for Payer: Cigna Commercial |
$10,245.98
|
| Rate for Payer: First Health Commercial |
$11,727.32
|
| Rate for Payer: Humana Commercial |
$10,492.87
|
| Rate for Payer: Humana KY Medicaid |
$4,245.29
|
| Rate for Payer: Kentucky WC Medicaid |
$4,288.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,122.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,110.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,703.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,330.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,863.20
|
| Rate for Payer: Ohio Health Group HMO |
$9,258.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,875.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,739.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,517.74
|
| Rate for Payer: PHCS Commercial |
$11,850.77
|
| Rate for Payer: United Healthcare All Payer |
$10,863.20
|
|
|
GRAFTLINK TENDON 60-80*7.5-10.
|
Facility
|
IP
|
$12,344.55
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,703.36 |
| Max. Negotiated Rate |
$11,850.77 |
| Rate for Payer: Aetna Commercial |
$9,505.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,628.75
|
| Rate for Payer: Cash Price |
$6,172.28
|
| Rate for Payer: Cigna Commercial |
$10,245.98
|
| Rate for Payer: First Health Commercial |
$11,727.32
|
| Rate for Payer: Humana Commercial |
$10,492.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,122.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,110.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,703.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,863.20
|
| Rate for Payer: Ohio Health Group HMO |
$9,258.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,875.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,739.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,517.74
|
| Rate for Payer: PHCS Commercial |
$11,850.77
|
| Rate for Payer: United Healthcare All Payer |
$10,863.20
|
|
|
GRAFT MAIN BDY BIFUR 28*60*13
|
Facility
|
OP
|
$72,421.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21,726.30 |
| Max. Negotiated Rate |
$69,524.16 |
| Rate for Payer: Aetna Commercial |
$55,764.17
|
| Rate for Payer: Anthem Medicaid |
$24,905.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56,488.38
|
| Rate for Payer: Cash Price |
$36,210.50
|
| Rate for Payer: Cigna Commercial |
$60,109.43
|
| Rate for Payer: First Health Commercial |
$68,799.95
|
| Rate for Payer: Humana Commercial |
$61,557.85
|
| Rate for Payer: Humana KY Medicaid |
$24,905.58
|
| Rate for Payer: Kentucky WC Medicaid |
$25,159.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59,385.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53,446.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,726.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,405.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$63,730.48
|
| Rate for Payer: Ohio Health Group HMO |
$54,315.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57,936.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,006.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49,970.49
|
| Rate for Payer: PHCS Commercial |
$69,524.16
|
| Rate for Payer: United Healthcare All Payer |
$63,730.48
|
|
|
GRAFT MAIN BDY BIFUR 28*60*13
|
Facility
|
IP
|
$72,421.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21,726.30 |
| Max. Negotiated Rate |
$69,524.16 |
| Rate for Payer: Aetna Commercial |
$55,764.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56,488.38
|
| Rate for Payer: Cash Price |
$36,210.50
|
| Rate for Payer: Cigna Commercial |
$60,109.43
|
| Rate for Payer: First Health Commercial |
$68,799.95
|
| Rate for Payer: Humana Commercial |
$61,557.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59,385.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53,446.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,726.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$63,730.48
|
| Rate for Payer: Ohio Health Group HMO |
$54,315.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57,936.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,006.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49,970.49
|
| Rate for Payer: PHCS Commercial |
$69,524.16
|
| Rate for Payer: United Healthcare All Payer |
$63,730.48
|
|
|
GRAFT MAIN BODY EXT RX1-36-54
|
Facility
|
IP
|
$24,556.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,366.88 |
| Max. Negotiated Rate |
$23,574.00 |
| Rate for Payer: Aetna Commercial |
$18,908.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,153.88
|
| Rate for Payer: Cash Price |
$12,278.12
|
| Rate for Payer: Cigna Commercial |
$20,381.69
|
| Rate for Payer: First Health Commercial |
$23,328.44
|
| Rate for Payer: Humana Commercial |
$20,872.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,136.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,122.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,366.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,609.50
|
| Rate for Payer: Ohio Health Group HMO |
$18,417.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,645.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,363.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,943.81
|
| Rate for Payer: PHCS Commercial |
$23,574.00
|
| Rate for Payer: United Healthcare All Payer |
$21,609.50
|
|
|
GRAFT MAIN BODY EXT RX1-36-54
|
Facility
|
OP
|
$24,556.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,366.88 |
| Max. Negotiated Rate |
$23,574.00 |
| Rate for Payer: Aetna Commercial |
$18,908.31
|
| Rate for Payer: Anthem Medicaid |
$8,444.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,153.88
|
| Rate for Payer: Cash Price |
$12,278.12
|
| Rate for Payer: Cigna Commercial |
$20,381.69
|
| Rate for Payer: First Health Commercial |
$23,328.44
|
| Rate for Payer: Humana Commercial |
$20,872.81
|
| Rate for Payer: Humana KY Medicaid |
$8,444.89
|
| Rate for Payer: Kentucky WC Medicaid |
$8,530.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,136.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,122.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,366.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,614.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,609.50
|
| Rate for Payer: Ohio Health Group HMO |
$18,417.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,645.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,363.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,943.81
|
| Rate for Payer: PHCS Commercial |
$23,574.00
|
| Rate for Payer: United Healthcare All Payer |
$21,609.50
|
|
|
GRAFT MARKER RADIOPAQUE
|
Facility
|
OP
|
$491.90
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$147.57 |
| Max. Negotiated Rate |
$472.22 |
| Rate for Payer: Aetna Commercial |
$378.76
|
| Rate for Payer: Anthem Medicaid |
$169.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$383.68
|
| Rate for Payer: Cash Price |
$245.95
|
| Rate for Payer: Cigna Commercial |
$408.28
|
| Rate for Payer: First Health Commercial |
$467.31
|
| Rate for Payer: Humana Commercial |
$418.12
|
| Rate for Payer: Humana KY Medicaid |
$169.16
|
| Rate for Payer: Kentucky WC Medicaid |
$170.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$403.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$363.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$172.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$432.87
|
| Rate for Payer: Ohio Health Group HMO |
$368.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$393.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$427.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$339.41
|
| Rate for Payer: PHCS Commercial |
$472.22
|
| Rate for Payer: United Healthcare All Payer |
$432.87
|
|
|
GRAFT MARKER RADIOPAQUE
|
Facility
|
IP
|
$491.90
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$147.57 |
| Max. Negotiated Rate |
$472.22 |
| Rate for Payer: Aetna Commercial |
$378.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$383.68
|
| Rate for Payer: Cash Price |
$245.95
|
| Rate for Payer: Cigna Commercial |
$408.28
|
| Rate for Payer: First Health Commercial |
$467.31
|
| Rate for Payer: Humana Commercial |
$418.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$403.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$363.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$432.87
|
| Rate for Payer: Ohio Health Group HMO |
$368.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$393.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$427.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$339.41
|
| Rate for Payer: PHCS Commercial |
$472.22
|
| Rate for Payer: United Healthcare All Payer |
$432.87
|
|
|
GRAFTMASTER 2.8*16
|
Facility
|
IP
|
$12,289.65
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,686.89 |
| Max. Negotiated Rate |
$11,798.06 |
| Rate for Payer: Aetna Commercial |
$9,463.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,585.93
|
| Rate for Payer: Cash Price |
$6,144.82
|
| Rate for Payer: Cigna Commercial |
$10,200.41
|
| Rate for Payer: First Health Commercial |
$11,675.17
|
| Rate for Payer: Humana Commercial |
$10,446.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,077.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,069.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,686.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,814.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,217.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,831.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,692.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,479.86
|
| Rate for Payer: PHCS Commercial |
$11,798.06
|
| Rate for Payer: United Healthcare All Payer |
$10,814.89
|
|
|
GRAFTMASTER 2.8*16
|
Facility
|
OP
|
$12,289.65
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,686.89 |
| Max. Negotiated Rate |
$11,798.06 |
| Rate for Payer: Aetna Commercial |
$9,463.03
|
| Rate for Payer: Anthem Medicaid |
$4,226.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,585.93
|
| Rate for Payer: Cash Price |
$6,144.82
|
| Rate for Payer: Cigna Commercial |
$10,200.41
|
| Rate for Payer: First Health Commercial |
$11,675.17
|
| Rate for Payer: Humana Commercial |
$10,446.20
|
| Rate for Payer: Humana KY Medicaid |
$4,226.41
|
| Rate for Payer: Kentucky WC Medicaid |
$4,269.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,077.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,069.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,686.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,311.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,814.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,217.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,831.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,692.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,479.86
|
| Rate for Payer: PHCS Commercial |
$11,798.06
|
| Rate for Payer: United Healthcare All Payer |
$10,814.89
|
|
|
GRAFTMASTER 3.5*16
|
Facility
|
IP
|
$12,289.65
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,686.89 |
| Max. Negotiated Rate |
$11,798.06 |
| Rate for Payer: Aetna Commercial |
$9,463.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,585.93
|
| Rate for Payer: Cash Price |
$6,144.82
|
| Rate for Payer: Cigna Commercial |
$10,200.41
|
| Rate for Payer: First Health Commercial |
$11,675.17
|
| Rate for Payer: Humana Commercial |
$10,446.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,077.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,069.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,686.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,814.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,217.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,831.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,692.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,479.86
|
| Rate for Payer: PHCS Commercial |
$11,798.06
|
| Rate for Payer: United Healthcare All Payer |
$10,814.89
|
|
|
GRAFTMASTER 3.5*16
|
Facility
|
OP
|
$12,289.65
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,686.89 |
| Max. Negotiated Rate |
$11,798.06 |
| Rate for Payer: Aetna Commercial |
$9,463.03
|
| Rate for Payer: Anthem Medicaid |
$4,226.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,585.93
|
| Rate for Payer: Cash Price |
$6,144.82
|
| Rate for Payer: Cigna Commercial |
$10,200.41
|
| Rate for Payer: First Health Commercial |
$11,675.17
|
| Rate for Payer: Humana Commercial |
$10,446.20
|
| Rate for Payer: Humana KY Medicaid |
$4,226.41
|
| Rate for Payer: Kentucky WC Medicaid |
$4,269.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,077.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,069.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,686.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,311.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,814.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,217.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,831.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,692.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,479.86
|
| Rate for Payer: PHCS Commercial |
$11,798.06
|
| Rate for Payer: United Healthcare All Payer |
$10,814.89
|
|
|
GRAFTMASTER 4.0*16
|
Facility
|
OP
|
$12,289.65
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,686.89 |
| Max. Negotiated Rate |
$11,798.06 |
| Rate for Payer: Aetna Commercial |
$9,463.03
|
| Rate for Payer: Anthem Medicaid |
$4,226.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,585.93
|
| Rate for Payer: Cash Price |
$6,144.82
|
| Rate for Payer: Cigna Commercial |
$10,200.41
|
| Rate for Payer: First Health Commercial |
$11,675.17
|
| Rate for Payer: Humana Commercial |
$10,446.20
|
| Rate for Payer: Humana KY Medicaid |
$4,226.41
|
| Rate for Payer: Kentucky WC Medicaid |
$4,269.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,077.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,069.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,686.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,311.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,814.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,217.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,831.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,692.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,479.86
|
| Rate for Payer: PHCS Commercial |
$11,798.06
|
| Rate for Payer: United Healthcare All Payer |
$10,814.89
|
|
|
GRAFTMASTER 4.0*16
|
Facility
|
IP
|
$12,289.65
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,686.89 |
| Max. Negotiated Rate |
$11,798.06 |
| Rate for Payer: Aetna Commercial |
$9,463.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,585.93
|
| Rate for Payer: Cash Price |
$6,144.82
|
| Rate for Payer: Cigna Commercial |
$10,200.41
|
| Rate for Payer: First Health Commercial |
$11,675.17
|
| Rate for Payer: Humana Commercial |
$10,446.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,077.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,069.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,686.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,814.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,217.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,831.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,692.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,479.86
|
| Rate for Payer: PHCS Commercial |
$11,798.06
|
| Rate for Payer: United Healthcare All Payer |
$10,814.89
|
|
|
GRAFTMASTER 4.8*16
|
Facility
|
OP
|
$12,289.65
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,686.89 |
| Max. Negotiated Rate |
$11,798.06 |
| Rate for Payer: Aetna Commercial |
$9,463.03
|
| Rate for Payer: Anthem Medicaid |
$4,226.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,585.93
|
| Rate for Payer: Cash Price |
$6,144.82
|
| Rate for Payer: Cigna Commercial |
$10,200.41
|
| Rate for Payer: First Health Commercial |
$11,675.17
|
| Rate for Payer: Humana Commercial |
$10,446.20
|
| Rate for Payer: Humana KY Medicaid |
$4,226.41
|
| Rate for Payer: Kentucky WC Medicaid |
$4,269.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,077.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,069.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,686.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,311.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,814.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,217.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,831.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,692.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,479.86
|
| Rate for Payer: PHCS Commercial |
$11,798.06
|
| Rate for Payer: United Healthcare All Payer |
$10,814.89
|
|
