|
GRAFTMASTER 4.8*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 RX 2.8*19
|
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 RX 2.8*19
|
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 RX 3.5*19
|
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 RX 3.5*19
|
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 RX 4.0*19
|
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 RX 4.0*19
|
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 RX 4.5*19
|
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 RX 4.5*19
|
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 RX 4.8*19
|
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 RX 4.8*19
|
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
|
|
|
GRAFT MN BDY BIFR 25*90*16*30
|
Facility
|
IP
|
$73,504.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,051.20 |
| Max. Negotiated Rate |
$70,563.84 |
| Rate for Payer: Aetna Commercial |
$56,598.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,333.12
|
| Rate for Payer: Cash Price |
$36,752.00
|
| Rate for Payer: Cigna Commercial |
$61,008.32
|
| Rate for Payer: First Health Commercial |
$69,828.80
|
| Rate for Payer: Humana Commercial |
$62,478.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,273.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,245.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,051.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,683.52
|
| Rate for Payer: Ohio Health Group HMO |
$55,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,803.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,948.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,717.76
|
| Rate for Payer: PHCS Commercial |
$70,563.84
|
| Rate for Payer: United Healthcare All Payer |
$64,683.52
|
|
|
GRAFT MN BDY BIFR 25*90*16*30
|
Facility
|
OP
|
$73,504.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,051.20 |
| Max. Negotiated Rate |
$70,563.84 |
| Rate for Payer: Aetna Commercial |
$56,598.08
|
| Rate for Payer: Anthem Medicaid |
$25,278.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,333.12
|
| Rate for Payer: Cash Price |
$36,752.00
|
| Rate for Payer: Cigna Commercial |
$61,008.32
|
| Rate for Payer: First Health Commercial |
$69,828.80
|
| Rate for Payer: Humana Commercial |
$62,478.40
|
| Rate for Payer: Humana KY Medicaid |
$25,278.03
|
| Rate for Payer: Kentucky WC Medicaid |
$25,535.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,273.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,245.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,051.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,785.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,683.52
|
| Rate for Payer: Ohio Health Group HMO |
$55,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,803.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,948.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,717.76
|
| Rate for Payer: PHCS Commercial |
$70,563.84
|
| Rate for Payer: United Healthcare All Payer |
$64,683.52
|
|
|
GRAFT PATCH 1/3 * 3
|
Facility
|
OP
|
$1,506.13
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$451.84 |
| Max. Negotiated Rate |
$1,445.88 |
| Rate for Payer: Aetna Commercial |
$1,159.72
|
| Rate for Payer: Anthem Medicaid |
$517.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,174.78
|
| Rate for Payer: Cash Price |
$753.06
|
| Rate for Payer: Cigna Commercial |
$1,250.09
|
| Rate for Payer: First Health Commercial |
$1,430.82
|
| Rate for Payer: Humana Commercial |
$1,280.21
|
| Rate for Payer: Humana KY Medicaid |
$517.96
|
| Rate for Payer: Kentucky WC Medicaid |
$523.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,235.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,111.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$451.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$528.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,325.39
|
| Rate for Payer: Ohio Health Group HMO |
$1,129.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,204.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,310.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,039.23
|
| Rate for Payer: PHCS Commercial |
$1,445.88
|
| Rate for Payer: United Healthcare All Payer |
$1,325.39
|
|
|
GRAFT PATCH 1/3 * 3
|
Facility
|
IP
|
$1,506.13
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$451.84 |
| Max. Negotiated Rate |
$1,445.88 |
| Rate for Payer: Aetna Commercial |
$1,159.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,174.78
|
| Rate for Payer: Cash Price |
$753.06
|
| Rate for Payer: Cigna Commercial |
$1,250.09
|
| Rate for Payer: First Health Commercial |
$1,430.82
|
| Rate for Payer: Humana Commercial |
$1,280.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,235.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,111.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$451.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,325.39
|
| Rate for Payer: Ohio Health Group HMO |
$1,129.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,204.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,310.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,039.23
|
| Rate for Payer: PHCS Commercial |
$1,445.88
|
| Rate for Payer: United Healthcare All Payer |
$1,325.39
|
|
|
GRAFT POSTERIOR TIBIAL ULTRA
|
Facility
|
OP
|
$10,281.75
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,084.53 |
| Max. Negotiated Rate |
$9,870.48 |
| Rate for Payer: Aetna Commercial |
$7,916.95
|
| Rate for Payer: Anthem Medicaid |
$3,535.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,019.77
|
| Rate for Payer: Cash Price |
$5,140.88
|
| Rate for Payer: Cigna Commercial |
$8,533.85
|
| Rate for Payer: First Health Commercial |
$9,767.66
|
| Rate for Payer: Humana Commercial |
$8,739.49
|
| Rate for Payer: Humana KY Medicaid |
$3,535.89
|
| Rate for Payer: Kentucky WC Medicaid |
$3,571.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,431.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,587.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,084.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,606.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,047.94
|
| Rate for Payer: Ohio Health Group HMO |
$7,711.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,225.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,945.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,094.41
|
| Rate for Payer: PHCS Commercial |
$9,870.48
|
| Rate for Payer: United Healthcare All Payer |
$9,047.94
|
|
|
GRAFT POSTERIOR TIBIAL ULTRA
|
Facility
|
IP
|
$10,281.75
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,084.53 |
| Max. Negotiated Rate |
$9,870.48 |
| Rate for Payer: Aetna Commercial |
$7,916.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,019.77
|
| Rate for Payer: Cash Price |
$5,140.88
|
| Rate for Payer: Cigna Commercial |
$8,533.85
|
| Rate for Payer: First Health Commercial |
$9,767.66
|
| Rate for Payer: Humana Commercial |
$8,739.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,431.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,587.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,084.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,047.94
|
| Rate for Payer: Ohio Health Group HMO |
$7,711.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,225.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,945.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,094.41
|
| Rate for Payer: PHCS Commercial |
$9,870.48
|
| Rate for Payer: United Healthcare All Payer |
$9,047.94
|
|
|
GRAFT PROCOL VAS BIOPROST 6*30
|
Facility
|
IP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
GRAFT PROCOL VAS BIOPROST 6*30
|
Facility
|
OP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem Medicaid |
$2,726.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Humana KY Medicaid |
$2,726.27
|
| Rate for Payer: Kentucky WC Medicaid |
$2,754.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,780.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
GRAFT PROPATEN 4-7*45
|
Facility
|
IP
|
$7,748.65
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,324.59 |
| Max. Negotiated Rate |
$7,438.70 |
| Rate for Payer: Aetna Commercial |
$5,966.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,043.95
|
| Rate for Payer: Cash Price |
$3,874.32
|
| Rate for Payer: Cigna Commercial |
$6,431.38
|
| Rate for Payer: First Health Commercial |
$7,361.22
|
| Rate for Payer: Humana Commercial |
$6,586.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,353.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,718.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,324.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,818.81
|
| Rate for Payer: Ohio Health Group HMO |
$5,811.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,198.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,741.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,346.57
|
| Rate for Payer: PHCS Commercial |
$7,438.70
|
| Rate for Payer: United Healthcare All Payer |
$6,818.81
|
|
|
GRAFT PROPATEN 4-7*45
|
Facility
|
OP
|
$7,748.65
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,324.59 |
| Max. Negotiated Rate |
$7,438.70 |
| Rate for Payer: Aetna Commercial |
$5,966.46
|
| Rate for Payer: Anthem Medicaid |
$2,664.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,043.95
|
| Rate for Payer: Cash Price |
$3,874.32
|
| Rate for Payer: Cigna Commercial |
$6,431.38
|
| Rate for Payer: First Health Commercial |
$7,361.22
|
| Rate for Payer: Humana Commercial |
$6,586.35
|
| Rate for Payer: Humana KY Medicaid |
$2,664.76
|
| Rate for Payer: Kentucky WC Medicaid |
$2,691.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,353.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,718.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,324.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,718.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,818.81
|
| Rate for Payer: Ohio Health Group HMO |
$5,811.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,198.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,741.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,346.57
|
| Rate for Payer: PHCS Commercial |
$7,438.70
|
| Rate for Payer: United Healthcare All Payer |
$6,818.81
|
|
|
GRAFT PROPATEN 6*40
|
Facility
|
IP
|
$7,423.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,227.14 |
| Max. Negotiated Rate |
$7,126.85 |
| Rate for Payer: Aetna Commercial |
$5,716.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,790.56
|
| Rate for Payer: Cash Price |
$3,711.90
|
| Rate for Payer: Cigna Commercial |
$6,161.75
|
| Rate for Payer: First Health Commercial |
$7,052.61
|
| Rate for Payer: Humana Commercial |
$6,310.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,087.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,478.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,227.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,532.94
|
| Rate for Payer: Ohio Health Group HMO |
$5,567.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,939.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,458.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,122.42
|
| Rate for Payer: PHCS Commercial |
$7,126.85
|
| Rate for Payer: United Healthcare All Payer |
$6,532.94
|
|
|
GRAFT PROPATEN 6*40
|
Facility
|
OP
|
$7,423.80
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,227.14 |
| Max. Negotiated Rate |
$7,126.85 |
| Rate for Payer: Aetna Commercial |
$5,716.33
|
| Rate for Payer: Anthem Medicaid |
$2,553.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,790.56
|
| Rate for Payer: Cash Price |
$3,711.90
|
| Rate for Payer: Cigna Commercial |
$6,161.75
|
| Rate for Payer: First Health Commercial |
$7,052.61
|
| Rate for Payer: Humana Commercial |
$6,310.23
|
| Rate for Payer: Humana KY Medicaid |
$2,553.04
|
| Rate for Payer: Kentucky WC Medicaid |
$2,579.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,087.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,478.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,227.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,604.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,532.94
|
| Rate for Payer: Ohio Health Group HMO |
$5,567.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,939.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,458.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,122.42
|
| Rate for Payer: PHCS Commercial |
$7,126.85
|
| Rate for Payer: United Healthcare All Payer |
$6,532.94
|
|
|
GRAFT PROPATEN 6*40 STD WALL
|
Facility
|
OP
|
$6,777.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,033.33 |
| Max. Negotiated Rate |
$6,506.64 |
| Rate for Payer: Aetna Commercial |
$5,218.87
|
| Rate for Payer: Anthem Medicaid |
$2,330.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,286.65
|
| Rate for Payer: Cash Price |
$3,388.88
|
| Rate for Payer: Cigna Commercial |
$5,625.53
|
| Rate for Payer: First Health Commercial |
$6,438.86
|
| Rate for Payer: Humana Commercial |
$5,761.09
|
| Rate for Payer: Humana KY Medicaid |
$2,330.87
|
| Rate for Payer: Kentucky WC Medicaid |
$2,354.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,557.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,001.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,033.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,377.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,964.42
|
| Rate for Payer: Ohio Health Group HMO |
$5,083.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,422.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,896.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,676.65
|
| Rate for Payer: PHCS Commercial |
$6,506.64
|
| Rate for Payer: United Healthcare All Payer |
$5,964.42
|
|
|
GRAFT PROPATEN 6*40 STD WALL
|
Facility
|
IP
|
$6,777.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,033.33 |
| Max. Negotiated Rate |
$6,506.64 |
| Rate for Payer: Aetna Commercial |
$5,218.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,286.65
|
| Rate for Payer: Cash Price |
$3,388.88
|
| Rate for Payer: Cigna Commercial |
$5,625.53
|
| Rate for Payer: First Health Commercial |
$6,438.86
|
| Rate for Payer: Humana Commercial |
$5,761.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,557.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,001.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,033.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,964.42
|
| Rate for Payer: Ohio Health Group HMO |
$5,083.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,422.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,896.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,676.65
|
| Rate for Payer: PHCS Commercial |
$6,506.64
|
| Rate for Payer: United Healthcare All Payer |
$5,964.42
|
|
