|
GRAFT VASC INTERING 8*40 THIN
|
Facility
|
OP
|
$4,988.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,496.62 |
| Max. Negotiated Rate |
$4,789.20 |
| Rate for Payer: Aetna Commercial |
$3,841.34
|
| Rate for Payer: Anthem Medicaid |
$1,715.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,891.22
|
| Rate for Payer: Cash Price |
$2,494.38
|
| Rate for Payer: Cigna Commercial |
$4,140.66
|
| Rate for Payer: First Health Commercial |
$4,739.31
|
| Rate for Payer: Humana Commercial |
$4,240.44
|
| Rate for Payer: Humana KY Medicaid |
$1,715.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1,733.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,090.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,681.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,496.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,750.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,390.10
|
| Rate for Payer: Ohio Health Group HMO |
$3,741.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,991.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,340.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,442.24
|
| Rate for Payer: PHCS Commercial |
$4,789.20
|
| Rate for Payer: United Healthcare All Payer |
$4,390.10
|
|
|
GRAFT VASCULAR INTERING 6*60
|
Facility
|
IP
|
$7,405.55
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,221.66 |
| Max. Negotiated Rate |
$7,109.33 |
| Rate for Payer: Aetna Commercial |
$5,702.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,776.33
|
| Rate for Payer: Cash Price |
$3,702.78
|
| Rate for Payer: Cigna Commercial |
$6,146.61
|
| Rate for Payer: First Health Commercial |
$7,035.27
|
| Rate for Payer: Humana Commercial |
$6,294.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,072.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,465.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,221.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,516.88
|
| Rate for Payer: Ohio Health Group HMO |
$5,554.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,924.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,442.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,109.83
|
| Rate for Payer: PHCS Commercial |
$7,109.33
|
| Rate for Payer: United Healthcare All Payer |
$6,516.88
|
|
|
GRAFT VASCULAR INTERING 6*60
|
Facility
|
OP
|
$7,405.55
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,221.66 |
| Max. Negotiated Rate |
$7,109.33 |
| Rate for Payer: Aetna Commercial |
$5,702.27
|
| Rate for Payer: Anthem Medicaid |
$2,546.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,776.33
|
| Rate for Payer: Cash Price |
$3,702.78
|
| Rate for Payer: Cigna Commercial |
$6,146.61
|
| Rate for Payer: First Health Commercial |
$7,035.27
|
| Rate for Payer: Humana Commercial |
$6,294.72
|
| Rate for Payer: Humana KY Medicaid |
$2,546.77
|
| Rate for Payer: Kentucky WC Medicaid |
$2,572.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,072.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,465.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,221.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,597.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,516.88
|
| Rate for Payer: Ohio Health Group HMO |
$5,554.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,924.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,442.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,109.83
|
| Rate for Payer: PHCS Commercial |
$7,109.33
|
| Rate for Payer: United Healthcare All Payer |
$6,516.88
|
|
|
GRAFT VASCULAR INTERING 8*60
|
Facility
|
OP
|
$7,401.90
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,220.57 |
| Max. Negotiated Rate |
$7,105.82 |
| Rate for Payer: Aetna Commercial |
$5,699.46
|
| Rate for Payer: Anthem Medicaid |
$2,545.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,773.48
|
| Rate for Payer: Cash Price |
$3,700.95
|
| Rate for Payer: Cigna Commercial |
$6,143.58
|
| Rate for Payer: First Health Commercial |
$7,031.81
|
| Rate for Payer: Humana Commercial |
$6,291.61
|
| Rate for Payer: Humana KY Medicaid |
$2,545.51
|
| Rate for Payer: Kentucky WC Medicaid |
$2,571.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,069.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,462.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,220.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,596.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,513.67
|
| Rate for Payer: Ohio Health Group HMO |
$5,551.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,921.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,439.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,107.31
|
| Rate for Payer: PHCS Commercial |
$7,105.82
|
| Rate for Payer: United Healthcare All Payer |
$6,513.67
|
|
|
GRAFT VASCULAR INTERING 8*60
|
Facility
|
IP
|
$7,401.90
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,220.57 |
| Max. Negotiated Rate |
$7,105.82 |
| Rate for Payer: Aetna Commercial |
$5,699.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,773.48
|
| Rate for Payer: Cash Price |
$3,700.95
|
| Rate for Payer: Cigna Commercial |
$6,143.58
|
| Rate for Payer: First Health Commercial |
$7,031.81
|
| Rate for Payer: Humana Commercial |
$6,291.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,069.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,462.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,220.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,513.67
|
| Rate for Payer: Ohio Health Group HMO |
$5,551.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,921.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,439.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,107.31
|
| Rate for Payer: PHCS Commercial |
$7,105.82
|
| Rate for Payer: United Healthcare All Payer |
$6,513.67
|
|
|
GRAFT VECTRA DIALYSIS 5MM*40CM
|
Facility
|
OP
|
$6,909.15
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,072.74 |
| Max. Negotiated Rate |
$6,632.78 |
| Rate for Payer: Aetna Commercial |
$5,320.05
|
| Rate for Payer: Anthem Medicaid |
$2,376.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,389.14
|
| Rate for Payer: Cash Price |
$3,454.57
|
| Rate for Payer: Cigna Commercial |
$5,734.59
|
| Rate for Payer: First Health Commercial |
$6,563.69
|
| Rate for Payer: Humana Commercial |
$5,872.78
|
| Rate for Payer: Humana KY Medicaid |
$2,376.06
|
| Rate for Payer: Kentucky WC Medicaid |
$2,400.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,665.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,098.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,072.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,423.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,080.05
|
| Rate for Payer: Ohio Health Group HMO |
$5,181.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,527.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,010.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,767.31
|
| Rate for Payer: PHCS Commercial |
$6,632.78
|
| Rate for Payer: United Healthcare All Payer |
$6,080.05
|
|
|
GRAFT VECTRA DIALYSIS 5MM*40CM
|
Facility
|
IP
|
$6,909.15
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,072.74 |
| Max. Negotiated Rate |
$6,632.78 |
| Rate for Payer: Aetna Commercial |
$5,320.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,389.14
|
| Rate for Payer: Cash Price |
$3,454.57
|
| Rate for Payer: Cigna Commercial |
$5,734.59
|
| Rate for Payer: First Health Commercial |
$6,563.69
|
| Rate for Payer: Humana Commercial |
$5,872.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,665.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,098.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,072.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,080.05
|
| Rate for Payer: Ohio Health Group HMO |
$5,181.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,527.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,010.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,767.31
|
| Rate for Payer: PHCS Commercial |
$6,632.78
|
| Rate for Payer: United Healthcare All Payer |
$6,080.05
|
|
|
GRAFT VECTRA DIALYSIS 6*40
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
GRAFT VECTRA DIALYSIS 6*40
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
GRAFT Z CONVERTER ZT
|
Facility
|
OP
|
$13,740.29
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,122.09 |
| Max. Negotiated Rate |
$13,190.68 |
| Rate for Payer: Aetna Commercial |
$10,580.02
|
| Rate for Payer: Anthem Medicaid |
$4,725.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,717.43
|
| Rate for Payer: Cash Price |
$6,870.15
|
| Rate for Payer: Cigna Commercial |
$11,404.44
|
| Rate for Payer: First Health Commercial |
$13,053.28
|
| Rate for Payer: Humana Commercial |
$11,679.25
|
| Rate for Payer: Humana KY Medicaid |
$4,725.29
|
| Rate for Payer: Kentucky WC Medicaid |
$4,773.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,267.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,140.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,122.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,820.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,091.46
|
| Rate for Payer: Ohio Health Group HMO |
$10,305.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,992.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,954.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,480.80
|
| Rate for Payer: PHCS Commercial |
$13,190.68
|
| Rate for Payer: United Healthcare All Payer |
$12,091.46
|
|
|
GRAFT Z CONVERTER ZT
|
Facility
|
IP
|
$13,740.29
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,122.09 |
| Max. Negotiated Rate |
$13,190.68 |
| Rate for Payer: Aetna Commercial |
$10,580.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,717.43
|
| Rate for Payer: Cash Price |
$6,870.15
|
| Rate for Payer: Cigna Commercial |
$11,404.44
|
| Rate for Payer: First Health Commercial |
$13,053.28
|
| Rate for Payer: Humana Commercial |
$11,679.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,267.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,140.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,122.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,091.46
|
| Rate for Payer: Ohio Health Group HMO |
$10,305.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,992.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,954.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,480.80
|
| Rate for Payer: PHCS Commercial |
$13,190.68
|
| Rate for Payer: United Healthcare All Payer |
$12,091.46
|
|
|
GRAFT Z CONVERTRS ESC-24-12-80
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
GRAFT Z CONVERTRS ESC-24-12-80
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem Medicaid |
$3,980.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Humana KY Medicaid |
$3,980.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,020.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,060.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
GRAFT Z CONVERTRS ESC-28-12-80
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
GRAFT Z CONVERTRS ESC-28-12-80
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem Medicaid |
$3,980.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Humana KY Medicaid |
$3,980.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,020.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,060.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
GRAFT Z CONVERTRS ESC-32-12-80
|
Facility
|
IP
|
$12,142.85
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,642.86 |
| Max. Negotiated Rate |
$11,657.14 |
| Rate for Payer: Aetna Commercial |
$9,349.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,471.42
|
| Rate for Payer: Cash Price |
$6,071.42
|
| Rate for Payer: Cigna Commercial |
$10,078.57
|
| Rate for Payer: First Health Commercial |
$11,535.71
|
| Rate for Payer: Humana Commercial |
$10,321.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,957.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,961.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,642.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,685.71
|
| Rate for Payer: Ohio Health Group HMO |
$9,107.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,714.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,564.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,378.57
|
| Rate for Payer: PHCS Commercial |
$11,657.14
|
| Rate for Payer: United Healthcare All Payer |
$10,685.71
|
|
|
GRAFT Z CONVERTRS ESC-32-12-80
|
Facility
|
OP
|
$12,142.85
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,642.86 |
| Max. Negotiated Rate |
$11,657.14 |
| Rate for Payer: Aetna Commercial |
$9,349.99
|
| Rate for Payer: Anthem Medicaid |
$4,175.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,471.42
|
| Rate for Payer: Cash Price |
$6,071.42
|
| Rate for Payer: Cigna Commercial |
$10,078.57
|
| Rate for Payer: First Health Commercial |
$11,535.71
|
| Rate for Payer: Humana Commercial |
$10,321.42
|
| Rate for Payer: Humana KY Medicaid |
$4,175.93
|
| Rate for Payer: Kentucky WC Medicaid |
$4,218.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,957.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,961.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,642.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,259.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,685.71
|
| Rate for Payer: Ohio Health Group HMO |
$9,107.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,714.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,564.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,378.57
|
| Rate for Payer: PHCS Commercial |
$11,657.14
|
| Rate for Payer: United Healthcare All Payer |
$10,685.71
|
|
|
GRAFT Z CONVRT ESC-36-12-82-ZT
|
Facility
|
OP
|
$12,142.85
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,642.86 |
| Max. Negotiated Rate |
$11,657.14 |
| Rate for Payer: Aetna Commercial |
$9,349.99
|
| Rate for Payer: Anthem Medicaid |
$4,175.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,471.42
|
| Rate for Payer: Cash Price |
$6,071.42
|
| Rate for Payer: Cigna Commercial |
$10,078.57
|
| Rate for Payer: First Health Commercial |
$11,535.71
|
| Rate for Payer: Humana Commercial |
$10,321.42
|
| Rate for Payer: Humana KY Medicaid |
$4,175.93
|
| Rate for Payer: Kentucky WC Medicaid |
$4,218.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,957.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,961.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,642.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,259.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,685.71
|
| Rate for Payer: Ohio Health Group HMO |
$9,107.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,714.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,564.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,378.57
|
| Rate for Payer: PHCS Commercial |
$11,657.14
|
| Rate for Payer: United Healthcare All Payer |
$10,685.71
|
|
|
GRAFT Z CONVRT ESC-36-12-82-ZT
|
Facility
|
IP
|
$12,142.85
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,642.86 |
| Max. Negotiated Rate |
$11,657.14 |
| Rate for Payer: Aetna Commercial |
$9,349.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,471.42
|
| Rate for Payer: Cash Price |
$6,071.42
|
| Rate for Payer: Cigna Commercial |
$10,078.57
|
| Rate for Payer: First Health Commercial |
$11,535.71
|
| Rate for Payer: Humana Commercial |
$10,321.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,957.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,961.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,642.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,685.71
|
| Rate for Payer: Ohio Health Group HMO |
$9,107.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,714.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,564.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,378.57
|
| Rate for Payer: PHCS Commercial |
$11,657.14
|
| Rate for Payer: United Healthcare All Payer |
$10,685.71
|
|
|
GRAFT ZENITH FEN DIST 12*45*76
|
Facility
|
IP
|
$18,959.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,687.85 |
| Max. Negotiated Rate |
$18,201.12 |
| Rate for Payer: Aetna Commercial |
$14,598.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,788.41
|
| Rate for Payer: Cash Price |
$9,479.75
|
| Rate for Payer: Cigna Commercial |
$15,736.39
|
| Rate for Payer: First Health Commercial |
$18,011.53
|
| Rate for Payer: Humana Commercial |
$16,115.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,546.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,992.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,687.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,684.36
|
| Rate for Payer: Ohio Health Group HMO |
$14,219.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,167.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,494.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,082.06
|
| Rate for Payer: PHCS Commercial |
$18,201.12
|
| Rate for Payer: United Healthcare All Payer |
$16,684.36
|
|
|
GRAFT ZENITH FEN DIST 12*45*76
|
Facility
|
OP
|
$18,959.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,687.85 |
| Max. Negotiated Rate |
$18,201.12 |
| Rate for Payer: Aetna Commercial |
$14,598.82
|
| Rate for Payer: Anthem Medicaid |
$6,520.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,788.41
|
| Rate for Payer: Cash Price |
$9,479.75
|
| Rate for Payer: Cigna Commercial |
$15,736.39
|
| Rate for Payer: First Health Commercial |
$18,011.53
|
| Rate for Payer: Humana Commercial |
$16,115.58
|
| Rate for Payer: Humana KY Medicaid |
$6,520.17
|
| Rate for Payer: Kentucky WC Medicaid |
$6,586.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,546.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,992.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,687.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,650.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,684.36
|
| Rate for Payer: Ohio Health Group HMO |
$14,219.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,167.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,494.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,082.06
|
| Rate for Payer: PHCS Commercial |
$18,201.12
|
| Rate for Payer: United Healthcare All Payer |
$16,684.36
|
|
|
GRAFT ZENITH FEN DISTAL 12*28*
|
Facility
|
IP
|
$18,959.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,687.85 |
| Max. Negotiated Rate |
$18,201.12 |
| Rate for Payer: Aetna Commercial |
$14,598.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,788.41
|
| Rate for Payer: Cash Price |
$9,479.75
|
| Rate for Payer: Cigna Commercial |
$15,736.39
|
| Rate for Payer: First Health Commercial |
$18,011.53
|
| Rate for Payer: Humana Commercial |
$16,115.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,546.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,992.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,687.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,684.36
|
| Rate for Payer: Ohio Health Group HMO |
$14,219.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,167.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,494.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,082.06
|
| Rate for Payer: PHCS Commercial |
$18,201.12
|
| Rate for Payer: United Healthcare All Payer |
$16,684.36
|
|
|
GRAFT ZENITH FEN DISTAL 12*28*
|
Facility
|
OP
|
$18,959.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,687.85 |
| Max. Negotiated Rate |
$18,201.12 |
| Rate for Payer: Aetna Commercial |
$14,598.82
|
| Rate for Payer: Anthem Medicaid |
$6,520.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,788.41
|
| Rate for Payer: Cash Price |
$9,479.75
|
| Rate for Payer: Cigna Commercial |
$15,736.39
|
| Rate for Payer: First Health Commercial |
$18,011.53
|
| Rate for Payer: Humana Commercial |
$16,115.58
|
| Rate for Payer: Humana KY Medicaid |
$6,520.17
|
| Rate for Payer: Kentucky WC Medicaid |
$6,586.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,546.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,992.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,687.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,650.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,684.36
|
| Rate for Payer: Ohio Health Group HMO |
$14,219.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,167.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,494.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,082.06
|
| Rate for Payer: PHCS Commercial |
$18,201.12
|
| Rate for Payer: United Healthcare All Payer |
$16,684.36
|
|
|
GRAFT ZENITH FEN PROX 2*30*109
|
Facility
|
OP
|
$73,846.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,153.80 |
| Max. Negotiated Rate |
$70,892.16 |
| Rate for Payer: Aetna Commercial |
$56,861.42
|
| Rate for Payer: Anthem Medicaid |
$25,395.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,599.88
|
| Rate for Payer: Cash Price |
$36,923.00
|
| Rate for Payer: Cigna Commercial |
$61,292.18
|
| Rate for Payer: First Health Commercial |
$70,153.70
|
| Rate for Payer: Humana Commercial |
$62,769.10
|
| Rate for Payer: Humana KY Medicaid |
$25,395.64
|
| Rate for Payer: Kentucky WC Medicaid |
$25,654.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,553.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,498.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,153.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,905.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,984.48
|
| Rate for Payer: Ohio Health Group HMO |
$55,384.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$59,076.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64,246.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,953.74
|
| Rate for Payer: PHCS Commercial |
$70,892.16
|
| Rate for Payer: United Healthcare All Payer |
$64,984.48
|
|
|
GRAFT ZENITH FEN PROX 2*30*109
|
Facility
|
IP
|
$73,846.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,153.80 |
| Max. Negotiated Rate |
$70,892.16 |
| Rate for Payer: Aetna Commercial |
$56,861.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,599.88
|
| Rate for Payer: Cash Price |
$36,923.00
|
| Rate for Payer: Cigna Commercial |
$61,292.18
|
| Rate for Payer: First Health Commercial |
$70,153.70
|
| Rate for Payer: Humana Commercial |
$62,769.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,553.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,498.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,153.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,984.48
|
| Rate for Payer: Ohio Health Group HMO |
$55,384.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$59,076.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64,246.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,953.74
|
| Rate for Payer: PHCS Commercial |
$70,892.16
|
| Rate for Payer: United Healthcare All Payer |
$64,984.48
|
|
