|
GRAFT SM REM RING 6*40
|
Facility
|
OP
|
$4,062.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.75 |
| Max. Negotiated Rate |
$3,900.00 |
| Rate for Payer: Aetna Commercial |
$3,128.12
|
| Rate for Payer: Anthem Medicaid |
$1,397.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,168.75
|
| Rate for Payer: Cash Price |
$2,031.25
|
| Rate for Payer: Cigna Commercial |
$3,371.88
|
| Rate for Payer: First Health Commercial |
$3,859.38
|
| Rate for Payer: Humana Commercial |
$3,453.12
|
| Rate for Payer: Humana KY Medicaid |
$1,397.09
|
| Rate for Payer: Kentucky WC Medicaid |
$1,411.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,331.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,998.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,218.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,425.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,575.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,046.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,534.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,803.12
|
| Rate for Payer: PHCS Commercial |
$3,900.00
|
| Rate for Payer: United Healthcare All Payer |
$3,575.00
|
|
|
GRAFT SPREADER
|
Facility
|
OP
|
$3,476.56
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,042.97 |
| Max. Negotiated Rate |
$3,337.50 |
| Rate for Payer: Aetna Commercial |
$2,676.95
|
| Rate for Payer: Anthem Medicaid |
$1,195.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,711.72
|
| Rate for Payer: Cash Price |
$1,738.28
|
| Rate for Payer: Cigna Commercial |
$2,885.54
|
| Rate for Payer: First Health Commercial |
$3,302.73
|
| Rate for Payer: Humana Commercial |
$2,955.08
|
| Rate for Payer: Humana KY Medicaid |
$1,195.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,207.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,850.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,565.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,042.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,219.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,059.37
|
| Rate for Payer: Ohio Health Group HMO |
$2,607.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,781.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,024.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,398.83
|
| Rate for Payer: PHCS Commercial |
$3,337.50
|
| Rate for Payer: United Healthcare All Payer |
$3,059.37
|
|
|
GRAFT SPREADER
|
Facility
|
IP
|
$3,476.56
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,042.97 |
| Max. Negotiated Rate |
$3,337.50 |
| Rate for Payer: Aetna Commercial |
$2,676.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,711.72
|
| Rate for Payer: Cash Price |
$1,738.28
|
| Rate for Payer: Cigna Commercial |
$2,885.54
|
| Rate for Payer: First Health Commercial |
$3,302.73
|
| Rate for Payer: Humana Commercial |
$2,955.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,850.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,565.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,042.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,059.37
|
| Rate for Payer: Ohio Health Group HMO |
$2,607.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,781.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,024.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,398.83
|
| Rate for Payer: PHCS Commercial |
$3,337.50
|
| Rate for Payer: United Healthcare All Payer |
$3,059.37
|
|
|
GRAFT STANDARD WALL 6*30CM
|
Facility
|
IP
|
$3,173.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$952.12 |
| Max. Negotiated Rate |
$3,046.80 |
| Rate for Payer: Aetna Commercial |
$2,443.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,475.53
|
| Rate for Payer: Cash Price |
$1,586.88
|
| Rate for Payer: Cigna Commercial |
$2,634.21
|
| Rate for Payer: First Health Commercial |
$3,015.06
|
| Rate for Payer: Humana Commercial |
$2,697.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,602.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,342.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$952.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,792.90
|
| Rate for Payer: Ohio Health Group HMO |
$2,380.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,539.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,761.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,189.89
|
| Rate for Payer: PHCS Commercial |
$3,046.80
|
| Rate for Payer: United Healthcare All Payer |
$2,792.90
|
|
|
GRAFT STANDARD WALL 6*30CM
|
Facility
|
OP
|
$3,173.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$952.12 |
| Max. Negotiated Rate |
$3,046.80 |
| Rate for Payer: Aetna Commercial |
$2,443.79
|
| Rate for Payer: Anthem Medicaid |
$1,091.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,475.53
|
| Rate for Payer: Cash Price |
$1,586.88
|
| Rate for Payer: Cigna Commercial |
$2,634.21
|
| Rate for Payer: First Health Commercial |
$3,015.06
|
| Rate for Payer: Humana Commercial |
$2,697.69
|
| Rate for Payer: Humana KY Medicaid |
$1,091.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1,102.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,602.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,342.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$952.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,113.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,792.90
|
| Rate for Payer: Ohio Health Group HMO |
$2,380.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,539.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,761.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,189.89
|
| Rate for Payer: PHCS Commercial |
$3,046.80
|
| Rate for Payer: United Healthcare All Payer |
$2,792.90
|
|
|
GRAFT STANDARD WALL 6*70CM
|
Facility
|
OP
|
$4,032.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,209.75 |
| Max. Negotiated Rate |
$3,871.20 |
| Rate for Payer: Aetna Commercial |
$3,105.03
|
| Rate for Payer: Anthem Medicaid |
$1,386.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,145.35
|
| Rate for Payer: Cash Price |
$2,016.25
|
| Rate for Payer: Cigna Commercial |
$3,346.97
|
| Rate for Payer: First Health Commercial |
$3,830.88
|
| Rate for Payer: Humana Commercial |
$3,427.62
|
| Rate for Payer: Humana KY Medicaid |
$1,386.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1,400.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,306.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,975.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,209.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,414.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,548.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,024.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,226.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,508.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,782.43
|
| Rate for Payer: PHCS Commercial |
$3,871.20
|
| Rate for Payer: United Healthcare All Payer |
$3,548.60
|
|
|
GRAFT STANDARD WALL 6*70CM
|
Facility
|
IP
|
$4,032.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,209.75 |
| Max. Negotiated Rate |
$3,871.20 |
| Rate for Payer: Aetna Commercial |
$3,105.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,145.35
|
| Rate for Payer: Cash Price |
$2,016.25
|
| Rate for Payer: Cigna Commercial |
$3,346.97
|
| Rate for Payer: First Health Commercial |
$3,830.88
|
| Rate for Payer: Humana Commercial |
$3,427.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,306.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,975.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,209.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,548.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,024.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,226.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,508.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,782.43
|
| Rate for Payer: PHCS Commercial |
$3,871.20
|
| Rate for Payer: United Healthcare All Payer |
$3,548.60
|
|
|
GRAFT STANDARD WALL 8*70CM
|
Facility
|
OP
|
$4,107.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,232.25 |
| Max. Negotiated Rate |
$3,943.20 |
| Rate for Payer: Aetna Commercial |
$3,162.78
|
| Rate for Payer: Anthem Medicaid |
$1,412.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,203.85
|
| Rate for Payer: Cash Price |
$2,053.75
|
| Rate for Payer: Cigna Commercial |
$3,409.22
|
| Rate for Payer: First Health Commercial |
$3,902.12
|
| Rate for Payer: Humana Commercial |
$3,491.38
|
| Rate for Payer: Humana KY Medicaid |
$1,412.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1,426.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,368.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,031.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,232.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,440.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,614.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,080.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,286.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,573.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,834.18
|
| Rate for Payer: PHCS Commercial |
$3,943.20
|
| Rate for Payer: United Healthcare All Payer |
$3,614.60
|
|
|
GRAFT STANDARD WALL 8*70CM
|
Facility
|
IP
|
$4,107.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,232.25 |
| Max. Negotiated Rate |
$3,943.20 |
| Rate for Payer: Aetna Commercial |
$3,162.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,203.85
|
| Rate for Payer: Cash Price |
$2,053.75
|
| Rate for Payer: Cigna Commercial |
$3,409.22
|
| Rate for Payer: First Health Commercial |
$3,902.12
|
| Rate for Payer: Humana Commercial |
$3,491.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,368.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,031.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,232.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,614.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,080.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,286.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,573.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,834.18
|
| Rate for Payer: PHCS Commercial |
$3,943.20
|
| Rate for Payer: United Healthcare All Payer |
$3,614.60
|
|
|
GRAFT STD WALL STRETCH 10*40CM
|
Facility
|
IP
|
$3,830.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,149.00 |
| Max. Negotiated Rate |
$3,676.80 |
| Rate for Payer: Aetna Commercial |
$2,949.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,987.40
|
| Rate for Payer: Cash Price |
$1,915.00
|
| Rate for Payer: Cigna Commercial |
$3,178.90
|
| Rate for Payer: First Health Commercial |
$3,638.50
|
| Rate for Payer: Humana Commercial |
$3,255.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,140.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,826.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,149.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,370.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,872.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,064.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,332.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,642.70
|
| Rate for Payer: PHCS Commercial |
$3,676.80
|
| Rate for Payer: United Healthcare All Payer |
$3,370.40
|
|
|
GRAFT STD WALL STRETCH 10*40CM
|
Facility
|
OP
|
$3,830.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,149.00 |
| Max. Negotiated Rate |
$3,676.80 |
| Rate for Payer: Aetna Commercial |
$2,949.10
|
| Rate for Payer: Anthem Medicaid |
$1,317.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,987.40
|
| Rate for Payer: Cash Price |
$1,915.00
|
| Rate for Payer: Cigna Commercial |
$3,178.90
|
| Rate for Payer: First Health Commercial |
$3,638.50
|
| Rate for Payer: Humana Commercial |
$3,255.50
|
| Rate for Payer: Humana KY Medicaid |
$1,317.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,330.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,140.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,826.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,149.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,343.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,370.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,872.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,064.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,332.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,642.70
|
| Rate for Payer: PHCS Commercial |
$3,676.80
|
| Rate for Payer: United Healthcare All Payer |
$3,370.40
|
|
|
GRAFT SW FEP RINGED 6*45CM
|
Facility
|
IP
|
$4,257.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,277.25 |
| Max. Negotiated Rate |
$4,087.20 |
| Rate for Payer: Aetna Commercial |
$3,278.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,320.85
|
| Rate for Payer: Cash Price |
$2,128.75
|
| Rate for Payer: Cigna Commercial |
$3,533.72
|
| Rate for Payer: First Health Commercial |
$4,044.62
|
| Rate for Payer: Humana Commercial |
$3,618.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,491.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,142.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,277.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,746.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,193.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,406.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,704.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,937.68
|
| Rate for Payer: PHCS Commercial |
$4,087.20
|
| Rate for Payer: United Healthcare All Payer |
$3,746.60
|
|
|
GRAFT SW FEP RINGED 6*45CM
|
Facility
|
OP
|
$4,257.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,277.25 |
| Max. Negotiated Rate |
$4,087.20 |
| Rate for Payer: Aetna Commercial |
$3,278.28
|
| Rate for Payer: Anthem Medicaid |
$1,464.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,320.85
|
| Rate for Payer: Cash Price |
$2,128.75
|
| Rate for Payer: Cigna Commercial |
$3,533.72
|
| Rate for Payer: First Health Commercial |
$4,044.62
|
| Rate for Payer: Humana Commercial |
$3,618.88
|
| Rate for Payer: Humana KY Medicaid |
$1,464.15
|
| Rate for Payer: Kentucky WC Medicaid |
$1,479.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,491.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,142.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,277.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,493.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,746.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,193.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,406.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,704.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,937.68
|
| Rate for Payer: PHCS Commercial |
$4,087.20
|
| Rate for Payer: United Healthcare All Payer |
$3,746.60
|
|
|
GRAFT SW RINGED 4*7MM
|
Facility
|
IP
|
$4,366.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,309.88 |
| Max. Negotiated Rate |
$4,191.60 |
| Rate for Payer: Aetna Commercial |
$3,362.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,405.68
|
| Rate for Payer: Cash Price |
$2,183.12
|
| Rate for Payer: Cigna Commercial |
$3,623.99
|
| Rate for Payer: First Health Commercial |
$4,147.94
|
| Rate for Payer: Humana Commercial |
$3,711.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,580.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,222.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,309.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,842.30
|
| Rate for Payer: Ohio Health Group HMO |
$3,274.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,493.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,798.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,012.71
|
| Rate for Payer: PHCS Commercial |
$4,191.60
|
| Rate for Payer: United Healthcare All Payer |
$3,842.30
|
|
|
GRAFT SW RINGED 4*7MM
|
Facility
|
OP
|
$4,366.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,309.88 |
| Max. Negotiated Rate |
$4,191.60 |
| Rate for Payer: Aetna Commercial |
$3,362.01
|
| Rate for Payer: Anthem Medicaid |
$1,501.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,405.68
|
| Rate for Payer: Cash Price |
$2,183.12
|
| Rate for Payer: Cigna Commercial |
$3,623.99
|
| Rate for Payer: First Health Commercial |
$4,147.94
|
| Rate for Payer: Humana Commercial |
$3,711.31
|
| Rate for Payer: Humana KY Medicaid |
$1,501.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1,516.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,580.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,222.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,309.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,531.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,842.30
|
| Rate for Payer: Ohio Health Group HMO |
$3,274.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,493.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,798.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,012.71
|
| Rate for Payer: PHCS Commercial |
$4,191.60
|
| Rate for Payer: United Healthcare All Payer |
$3,842.30
|
|
|
GRAFT TIBIA DISTAL LF LSH
|
Facility
|
IP
|
$30,477.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,143.25 |
| Max. Negotiated Rate |
$29,258.40 |
| Rate for Payer: Aetna Commercial |
$23,467.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23,772.45
|
| Rate for Payer: Cash Price |
$15,238.75
|
| Rate for Payer: Cigna Commercial |
$25,296.33
|
| Rate for Payer: First Health Commercial |
$28,953.62
|
| Rate for Payer: Humana Commercial |
$25,905.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24,991.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22,492.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,143.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$26,820.20
|
| Rate for Payer: Ohio Health Group HMO |
$22,858.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24,382.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26,515.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,029.47
|
| Rate for Payer: PHCS Commercial |
$29,258.40
|
| Rate for Payer: United Healthcare All Payer |
$26,820.20
|
|
|
GRAFT TIBIA DISTAL LF LSH
|
Facility
|
OP
|
$30,477.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,143.25 |
| Max. Negotiated Rate |
$29,258.40 |
| Rate for Payer: Aetna Commercial |
$23,467.67
|
| Rate for Payer: Anthem Medicaid |
$10,481.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23,772.45
|
| Rate for Payer: Cash Price |
$15,238.75
|
| Rate for Payer: Cigna Commercial |
$25,296.33
|
| Rate for Payer: First Health Commercial |
$28,953.62
|
| Rate for Payer: Humana Commercial |
$25,905.88
|
| Rate for Payer: Humana KY Medicaid |
$10,481.21
|
| Rate for Payer: Kentucky WC Medicaid |
$10,587.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24,991.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22,492.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,143.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,691.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$26,820.20
|
| Rate for Payer: Ohio Health Group HMO |
$22,858.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24,382.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26,515.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,029.47
|
| Rate for Payer: PHCS Commercial |
$29,258.40
|
| Rate for Payer: United Healthcare All Payer |
$26,820.20
|
|
|
GRAFT TW BIFURCATED LIMB 10*20
|
Facility
|
IP
|
$4,838.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,451.62 |
| Max. Negotiated Rate |
$4,645.20 |
| Rate for Payer: Aetna Commercial |
$3,725.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,774.22
|
| Rate for Payer: Cash Price |
$2,419.38
|
| Rate for Payer: Cigna Commercial |
$4,016.16
|
| Rate for Payer: First Health Commercial |
$4,596.81
|
| Rate for Payer: Humana Commercial |
$4,112.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,967.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,571.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,451.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,258.10
|
| Rate for Payer: Ohio Health Group HMO |
$3,629.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,871.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,209.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,338.74
|
| Rate for Payer: PHCS Commercial |
$4,645.20
|
| Rate for Payer: United Healthcare All Payer |
$4,258.10
|
|
|
GRAFT TW BIFURCATED LIMB 10*20
|
Facility
|
OP
|
$4,838.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,451.62 |
| Max. Negotiated Rate |
$4,645.20 |
| Rate for Payer: Aetna Commercial |
$3,725.84
|
| Rate for Payer: Anthem Medicaid |
$1,664.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,774.22
|
| Rate for Payer: Cash Price |
$2,419.38
|
| Rate for Payer: Cigna Commercial |
$4,016.16
|
| Rate for Payer: First Health Commercial |
$4,596.81
|
| Rate for Payer: Humana Commercial |
$4,112.94
|
| Rate for Payer: Humana KY Medicaid |
$1,664.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,680.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,967.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,571.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,451.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,697.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,258.10
|
| Rate for Payer: Ohio Health Group HMO |
$3,629.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,871.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,209.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,338.74
|
| Rate for Payer: PHCS Commercial |
$4,645.20
|
| Rate for Payer: United Healthcare All Payer |
$4,258.10
|
|
|
GRAFT TW BIFURCATED LIMB 16*8
|
Facility
|
OP
|
$4,838.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,451.62 |
| Max. Negotiated Rate |
$4,645.20 |
| Rate for Payer: Aetna Commercial |
$3,725.84
|
| Rate for Payer: Anthem Medicaid |
$1,664.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,774.22
|
| Rate for Payer: Cash Price |
$2,419.38
|
| Rate for Payer: Cigna Commercial |
$4,016.16
|
| Rate for Payer: First Health Commercial |
$4,596.81
|
| Rate for Payer: Humana Commercial |
$4,112.94
|
| Rate for Payer: Humana KY Medicaid |
$1,664.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,680.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,967.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,571.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,451.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,697.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,258.10
|
| Rate for Payer: Ohio Health Group HMO |
$3,629.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,871.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,209.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,338.74
|
| Rate for Payer: PHCS Commercial |
$4,645.20
|
| Rate for Payer: United Healthcare All Payer |
$4,258.10
|
|
|
GRAFT TW BIFURCATED LIMB 16*8
|
Facility
|
IP
|
$4,838.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,451.62 |
| Max. Negotiated Rate |
$4,645.20 |
| Rate for Payer: Aetna Commercial |
$3,725.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,774.22
|
| Rate for Payer: Cash Price |
$2,419.38
|
| Rate for Payer: Cigna Commercial |
$4,016.16
|
| Rate for Payer: First Health Commercial |
$4,596.81
|
| Rate for Payer: Humana Commercial |
$4,112.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,967.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,571.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,451.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,258.10
|
| Rate for Payer: Ohio Health Group HMO |
$3,629.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,871.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,209.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,338.74
|
| Rate for Payer: PHCS Commercial |
$4,645.20
|
| Rate for Payer: United Healthcare All Payer |
$4,258.10
|
|
|
GRAFT TW BIFURCATED LIMB 7*14
|
Facility
|
OP
|
$5,746.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,723.88 |
| Max. Negotiated Rate |
$5,516.40 |
| Rate for Payer: Aetna Commercial |
$4,424.61
|
| Rate for Payer: Anthem Medicaid |
$1,976.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,482.07
|
| Rate for Payer: Cash Price |
$2,873.12
|
| Rate for Payer: Cigna Commercial |
$4,769.39
|
| Rate for Payer: First Health Commercial |
$5,458.94
|
| Rate for Payer: Humana Commercial |
$4,884.31
|
| Rate for Payer: Humana KY Medicaid |
$1,976.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,996.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,711.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,240.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,723.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,015.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,056.70
|
| Rate for Payer: Ohio Health Group HMO |
$4,309.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,597.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,999.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,964.91
|
| Rate for Payer: PHCS Commercial |
$5,516.40
|
| Rate for Payer: United Healthcare All Payer |
$5,056.70
|
|
|
GRAFT TW BIFURCATED LIMB 7*14
|
Facility
|
IP
|
$5,746.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,723.88 |
| Max. Negotiated Rate |
$5,516.40 |
| Rate for Payer: Aetna Commercial |
$4,424.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,482.07
|
| Rate for Payer: Cash Price |
$2,873.12
|
| Rate for Payer: Cigna Commercial |
$4,769.39
|
| Rate for Payer: First Health Commercial |
$5,458.94
|
| Rate for Payer: Humana Commercial |
$4,884.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,711.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,240.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,723.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,056.70
|
| Rate for Payer: Ohio Health Group HMO |
$4,309.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,597.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,999.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,964.91
|
| Rate for Payer: PHCS Commercial |
$5,516.40
|
| Rate for Payer: United Healthcare All Payer |
$5,056.70
|
|
|
GRAFT TW BIFURCATED LIMB 9*18
|
Facility
|
OP
|
$4,838.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,451.62 |
| Max. Negotiated Rate |
$4,645.20 |
| Rate for Payer: Aetna Commercial |
$3,725.84
|
| Rate for Payer: Anthem Medicaid |
$1,664.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,774.22
|
| Rate for Payer: Cash Price |
$2,419.38
|
| Rate for Payer: Cigna Commercial |
$4,016.16
|
| Rate for Payer: First Health Commercial |
$4,596.81
|
| Rate for Payer: Humana Commercial |
$4,112.94
|
| Rate for Payer: Humana KY Medicaid |
$1,664.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,680.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,967.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,571.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,451.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,697.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,258.10
|
| Rate for Payer: Ohio Health Group HMO |
$3,629.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,871.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,209.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,338.74
|
| Rate for Payer: PHCS Commercial |
$4,645.20
|
| Rate for Payer: United Healthcare All Payer |
$4,258.10
|
|
|
GRAFT TW BIFURCATED LIMB 9*18
|
Facility
|
IP
|
$4,838.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,451.62 |
| Max. Negotiated Rate |
$4,645.20 |
| Rate for Payer: Aetna Commercial |
$3,725.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,774.22
|
| Rate for Payer: Cash Price |
$2,419.38
|
| Rate for Payer: Cigna Commercial |
$4,016.16
|
| Rate for Payer: First Health Commercial |
$4,596.81
|
| Rate for Payer: Humana Commercial |
$4,112.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,967.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,571.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,451.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,258.10
|
| Rate for Payer: Ohio Health Group HMO |
$3,629.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,871.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,209.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,338.74
|
| Rate for Payer: PHCS Commercial |
$4,645.20
|
| Rate for Payer: United Healthcare All Payer |
$4,258.10
|
|
