|
LIFESTREAM COV. STENT 6*58*135
|
Facility
|
IP
|
$17,700.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,301.00 |
| Max. Negotiated Rate |
$16,992.00 |
| Rate for Payer: Aetna Commercial |
$13,629.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,806.00
|
| Rate for Payer: Cash Price |
$8,850.00
|
| Rate for Payer: Cigna Commercial |
$14,691.00
|
| Rate for Payer: First Health Commercial |
$16,815.00
|
| Rate for Payer: Humana Commercial |
$15,045.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,514.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,062.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,310.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,576.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,301.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,487.00
|
| Rate for Payer: PHCS Commercial |
$16,992.00
|
| Rate for Payer: United Healthcare All Payer |
$15,576.00
|
|
|
LIFESTREAM COV. STENT 7*15*135
|
Facility
|
OP
|
$10,965.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,425.45 |
| Max. Negotiated Rate |
$10,526.40 |
| Rate for Payer: Aetna Commercial |
$8,443.05
|
| Rate for Payer: Anthem Medicaid |
$3,770.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,552.70
|
| Rate for Payer: Cash Price |
$5,482.50
|
| Rate for Payer: Cigna Commercial |
$9,100.95
|
| Rate for Payer: First Health Commercial |
$10,416.75
|
| Rate for Payer: Humana Commercial |
$9,320.25
|
| Rate for Payer: Humana KY Medicaid |
$3,770.86
|
| Rate for Payer: Kentucky WC Medicaid |
$3,809.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,991.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,092.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,289.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,846.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,649.20
|
| Rate for Payer: Ohio Health Group HMO |
$8,223.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,193.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,425.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,399.15
|
| Rate for Payer: PHCS Commercial |
$10,526.40
|
| Rate for Payer: United Healthcare All Payer |
$9,649.20
|
|
|
LIFESTREAM COV. STENT 7*15*135
|
Facility
|
IP
|
$10,965.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,425.45 |
| Max. Negotiated Rate |
$10,526.40 |
| Rate for Payer: Aetna Commercial |
$8,443.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,552.70
|
| Rate for Payer: Cash Price |
$5,482.50
|
| Rate for Payer: Cigna Commercial |
$9,100.95
|
| Rate for Payer: First Health Commercial |
$10,416.75
|
| Rate for Payer: Humana Commercial |
$9,320.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,991.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,092.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,289.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,649.20
|
| Rate for Payer: Ohio Health Group HMO |
$8,223.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,193.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,425.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,399.15
|
| Rate for Payer: PHCS Commercial |
$10,526.40
|
| Rate for Payer: United Healthcare All Payer |
$9,649.20
|
|
|
LIFESTREAM COV. STENT 7*26*135
|
Facility
|
IP
|
$17,700.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,301.00 |
| Max. Negotiated Rate |
$16,992.00 |
| Rate for Payer: Aetna Commercial |
$13,629.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,806.00
|
| Rate for Payer: Cash Price |
$8,850.00
|
| Rate for Payer: Cigna Commercial |
$14,691.00
|
| Rate for Payer: First Health Commercial |
$16,815.00
|
| Rate for Payer: Humana Commercial |
$15,045.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,514.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,062.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,310.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,576.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,301.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,487.00
|
| Rate for Payer: PHCS Commercial |
$16,992.00
|
| Rate for Payer: United Healthcare All Payer |
$15,576.00
|
|
|
LIFESTREAM COV. STENT 7*26*135
|
Facility
|
OP
|
$17,700.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,301.00 |
| Max. Negotiated Rate |
$16,992.00 |
| Rate for Payer: Aetna Commercial |
$13,629.00
|
| Rate for Payer: Anthem Medicaid |
$6,087.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,806.00
|
| Rate for Payer: Cash Price |
$8,850.00
|
| Rate for Payer: Cigna Commercial |
$14,691.00
|
| Rate for Payer: First Health Commercial |
$16,815.00
|
| Rate for Payer: Humana Commercial |
$15,045.00
|
| Rate for Payer: Humana KY Medicaid |
$6,087.03
|
| Rate for Payer: Kentucky WC Medicaid |
$6,148.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,514.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,062.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,310.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,209.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,576.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,301.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,487.00
|
| Rate for Payer: PHCS Commercial |
$16,992.00
|
| Rate for Payer: United Healthcare All Payer |
$15,576.00
|
|
|
LIFESTREAM COV. STENT 7*37*135
|
Facility
|
OP
|
$17,700.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,301.00 |
| Max. Negotiated Rate |
$16,992.00 |
| Rate for Payer: Aetna Commercial |
$13,629.00
|
| Rate for Payer: Anthem Medicaid |
$6,087.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,806.00
|
| Rate for Payer: Cash Price |
$8,850.00
|
| Rate for Payer: Cigna Commercial |
$14,691.00
|
| Rate for Payer: First Health Commercial |
$16,815.00
|
| Rate for Payer: Humana Commercial |
$15,045.00
|
| Rate for Payer: Humana KY Medicaid |
$6,087.03
|
| Rate for Payer: Kentucky WC Medicaid |
$6,148.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,514.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,062.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,310.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,209.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,576.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,301.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,487.00
|
| Rate for Payer: PHCS Commercial |
$16,992.00
|
| Rate for Payer: United Healthcare All Payer |
$15,576.00
|
|
|
LIFESTREAM COV. STENT 7*37*135
|
Facility
|
IP
|
$17,700.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,301.00 |
| Max. Negotiated Rate |
$16,992.00 |
| Rate for Payer: Aetna Commercial |
$13,629.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,806.00
|
| Rate for Payer: Cash Price |
$8,850.00
|
| Rate for Payer: Cigna Commercial |
$14,691.00
|
| Rate for Payer: First Health Commercial |
$16,815.00
|
| Rate for Payer: Humana Commercial |
$15,045.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,514.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,062.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,310.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,576.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,301.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,487.00
|
| Rate for Payer: PHCS Commercial |
$16,992.00
|
| Rate for Payer: United Healthcare All Payer |
$15,576.00
|
|
|
LIFESTREAM COV. STENT 7*58*135
|
Facility
|
IP
|
$17,700.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,301.00 |
| Max. Negotiated Rate |
$16,992.00 |
| Rate for Payer: Aetna Commercial |
$13,629.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,806.00
|
| Rate for Payer: Cash Price |
$8,850.00
|
| Rate for Payer: Cigna Commercial |
$14,691.00
|
| Rate for Payer: First Health Commercial |
$16,815.00
|
| Rate for Payer: Humana Commercial |
$15,045.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,514.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,062.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,310.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,576.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,301.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,487.00
|
| Rate for Payer: PHCS Commercial |
$16,992.00
|
| Rate for Payer: United Healthcare All Payer |
$15,576.00
|
|
|
LIFESTREAM COV. STENT 7*58*135
|
Facility
|
OP
|
$17,700.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,301.00 |
| Max. Negotiated Rate |
$16,992.00 |
| Rate for Payer: Aetna Commercial |
$13,629.00
|
| Rate for Payer: Anthem Medicaid |
$6,087.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,806.00
|
| Rate for Payer: Cash Price |
$8,850.00
|
| Rate for Payer: Cigna Commercial |
$14,691.00
|
| Rate for Payer: First Health Commercial |
$16,815.00
|
| Rate for Payer: Humana Commercial |
$15,045.00
|
| Rate for Payer: Humana KY Medicaid |
$6,087.03
|
| Rate for Payer: Kentucky WC Medicaid |
$6,148.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,514.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,062.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,310.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,209.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,576.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,301.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,487.00
|
| Rate for Payer: PHCS Commercial |
$16,992.00
|
| Rate for Payer: United Healthcare All Payer |
$15,576.00
|
|
|
LIFESTREAM COV. STENT 8*16*135
|
Facility
|
IP
|
$17,700.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,301.00 |
| Max. Negotiated Rate |
$16,992.00 |
| Rate for Payer: Aetna Commercial |
$13,629.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,806.00
|
| Rate for Payer: Cash Price |
$8,850.00
|
| Rate for Payer: Cigna Commercial |
$14,691.00
|
| Rate for Payer: First Health Commercial |
$16,815.00
|
| Rate for Payer: Humana Commercial |
$15,045.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,514.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,062.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,310.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,576.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,301.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,487.00
|
| Rate for Payer: PHCS Commercial |
$16,992.00
|
| Rate for Payer: United Healthcare All Payer |
$15,576.00
|
|
|
LIFESTREAM COV. STENT 8*16*135
|
Facility
|
OP
|
$17,700.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,301.00 |
| Max. Negotiated Rate |
$16,992.00 |
| Rate for Payer: Aetna Commercial |
$13,629.00
|
| Rate for Payer: Anthem Medicaid |
$6,087.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,806.00
|
| Rate for Payer: Cash Price |
$8,850.00
|
| Rate for Payer: Cigna Commercial |
$14,691.00
|
| Rate for Payer: First Health Commercial |
$16,815.00
|
| Rate for Payer: Humana Commercial |
$15,045.00
|
| Rate for Payer: Humana KY Medicaid |
$6,087.03
|
| Rate for Payer: Kentucky WC Medicaid |
$6,148.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,514.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,062.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,310.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,209.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,576.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,301.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,487.00
|
| Rate for Payer: PHCS Commercial |
$16,992.00
|
| Rate for Payer: United Healthcare All Payer |
$15,576.00
|
|
|
LIFESTREAM COV. STENT 8*26*135
|
Facility
|
OP
|
$11,330.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.90 |
| Max. Negotiated Rate |
$10,876.80 |
| Rate for Payer: Aetna Commercial |
$8,724.10
|
| Rate for Payer: Anthem Medicaid |
$3,896.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,837.40
|
| Rate for Payer: Cash Price |
$5,665.00
|
| Rate for Payer: Cigna Commercial |
$9,403.90
|
| Rate for Payer: First Health Commercial |
$10,763.50
|
| Rate for Payer: Humana Commercial |
$9,630.50
|
| Rate for Payer: Humana KY Medicaid |
$3,896.39
|
| Rate for Payer: Kentucky WC Medicaid |
$3,936.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,290.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,361.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,399.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,974.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,970.40
|
| Rate for Payer: Ohio Health Group HMO |
$8,497.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,266.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,472.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.30
|
| Rate for Payer: PHCS Commercial |
$10,876.80
|
| Rate for Payer: United Healthcare All Payer |
$9,970.40
|
|
|
LIFESTREAM COV. STENT 8*26*135
|
Facility
|
IP
|
$11,330.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.90 |
| Max. Negotiated Rate |
$10,876.80 |
| Rate for Payer: Aetna Commercial |
$8,724.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,837.40
|
| Rate for Payer: Cash Price |
$5,665.00
|
| Rate for Payer: Cigna Commercial |
$9,403.90
|
| Rate for Payer: First Health Commercial |
$10,763.50
|
| Rate for Payer: Humana Commercial |
$9,630.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,290.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,361.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,399.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,970.40
|
| Rate for Payer: Ohio Health Group HMO |
$8,497.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,266.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,472.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.30
|
| Rate for Payer: PHCS Commercial |
$10,876.80
|
| Rate for Payer: United Healthcare All Payer |
$9,970.40
|
|
|
LIFESTREAM COV. STENT 8*37*135
|
Facility
|
OP
|
$17,700.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,301.00 |
| Max. Negotiated Rate |
$16,992.00 |
| Rate for Payer: Aetna Commercial |
$13,629.00
|
| Rate for Payer: Anthem Medicaid |
$6,087.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,806.00
|
| Rate for Payer: Cash Price |
$8,850.00
|
| Rate for Payer: Cigna Commercial |
$14,691.00
|
| Rate for Payer: First Health Commercial |
$16,815.00
|
| Rate for Payer: Humana Commercial |
$15,045.00
|
| Rate for Payer: Humana KY Medicaid |
$6,087.03
|
| Rate for Payer: Kentucky WC Medicaid |
$6,148.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,514.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,062.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,310.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,209.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,576.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,301.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,487.00
|
| Rate for Payer: PHCS Commercial |
$16,992.00
|
| Rate for Payer: United Healthcare All Payer |
$15,576.00
|
|
|
LIFESTREAM COV. STENT 8*37*135
|
Facility
|
IP
|
$17,700.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,301.00 |
| Max. Negotiated Rate |
$16,992.00 |
| Rate for Payer: Aetna Commercial |
$13,629.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,806.00
|
| Rate for Payer: Cash Price |
$8,850.00
|
| Rate for Payer: Cigna Commercial |
$14,691.00
|
| Rate for Payer: First Health Commercial |
$16,815.00
|
| Rate for Payer: Humana Commercial |
$15,045.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,514.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,062.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,310.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,576.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,301.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,487.00
|
| Rate for Payer: PHCS Commercial |
$16,992.00
|
| Rate for Payer: United Healthcare All Payer |
$15,576.00
|
|
|
LIFESTREAM COV. STENT 8*58*135
|
Facility
|
IP
|
$17,700.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,301.00 |
| Max. Negotiated Rate |
$16,992.00 |
| Rate for Payer: Aetna Commercial |
$13,629.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,806.00
|
| Rate for Payer: Cash Price |
$8,850.00
|
| Rate for Payer: Cigna Commercial |
$14,691.00
|
| Rate for Payer: First Health Commercial |
$16,815.00
|
| Rate for Payer: Humana Commercial |
$15,045.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,514.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,062.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,310.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,576.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,301.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,487.00
|
| Rate for Payer: PHCS Commercial |
$16,992.00
|
| Rate for Payer: United Healthcare All Payer |
$15,576.00
|
|
|
LIFESTREAM COV. STENT 8*58*135
|
Facility
|
OP
|
$17,700.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,301.00 |
| Max. Negotiated Rate |
$16,992.00 |
| Rate for Payer: Aetna Commercial |
$13,629.00
|
| Rate for Payer: Anthem Medicaid |
$6,087.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,806.00
|
| Rate for Payer: Cash Price |
$8,850.00
|
| Rate for Payer: Cigna Commercial |
$14,691.00
|
| Rate for Payer: First Health Commercial |
$16,815.00
|
| Rate for Payer: Humana Commercial |
$15,045.00
|
| Rate for Payer: Humana KY Medicaid |
$6,087.03
|
| Rate for Payer: Kentucky WC Medicaid |
$6,148.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,514.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,062.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,310.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,209.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,576.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,301.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,487.00
|
| Rate for Payer: PHCS Commercial |
$16,992.00
|
| Rate for Payer: United Healthcare All Payer |
$15,576.00
|
|
|
LIFESTREAM COV. STENT 9*38*135
|
Facility
|
OP
|
$11,330.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.90 |
| Max. Negotiated Rate |
$10,876.80 |
| Rate for Payer: Aetna Commercial |
$8,724.10
|
| Rate for Payer: Anthem Medicaid |
$3,896.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,837.40
|
| Rate for Payer: Cash Price |
$5,665.00
|
| Rate for Payer: Cigna Commercial |
$9,403.90
|
| Rate for Payer: First Health Commercial |
$10,763.50
|
| Rate for Payer: Humana Commercial |
$9,630.50
|
| Rate for Payer: Humana KY Medicaid |
$3,896.39
|
| Rate for Payer: Kentucky WC Medicaid |
$3,936.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,290.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,361.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,399.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,974.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,970.40
|
| Rate for Payer: Ohio Health Group HMO |
$8,497.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,266.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,472.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.30
|
| Rate for Payer: PHCS Commercial |
$10,876.80
|
| Rate for Payer: United Healthcare All Payer |
$9,970.40
|
|
|
LIFESTREAM COV. STENT 9*38*135
|
Facility
|
IP
|
$11,330.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.90 |
| Max. Negotiated Rate |
$10,876.80 |
| Rate for Payer: Aetna Commercial |
$8,724.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,837.40
|
| Rate for Payer: Cash Price |
$5,665.00
|
| Rate for Payer: Cigna Commercial |
$9,403.90
|
| Rate for Payer: First Health Commercial |
$10,763.50
|
| Rate for Payer: Humana Commercial |
$9,630.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,290.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,361.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,399.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,970.40
|
| Rate for Payer: Ohio Health Group HMO |
$8,497.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,266.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,472.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.30
|
| Rate for Payer: PHCS Commercial |
$10,876.80
|
| Rate for Payer: United Healthcare All Payer |
$9,970.40
|
|
|
LIFESTREAM COV. STENT 9*58*135
|
Facility
|
OP
|
$11,330.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.90 |
| Max. Negotiated Rate |
$10,876.80 |
| Rate for Payer: Aetna Commercial |
$8,724.10
|
| Rate for Payer: Anthem Medicaid |
$3,896.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,837.40
|
| Rate for Payer: Cash Price |
$5,665.00
|
| Rate for Payer: Cigna Commercial |
$9,403.90
|
| Rate for Payer: First Health Commercial |
$10,763.50
|
| Rate for Payer: Humana Commercial |
$9,630.50
|
| Rate for Payer: Humana KY Medicaid |
$3,896.39
|
| Rate for Payer: Kentucky WC Medicaid |
$3,936.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,290.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,361.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,399.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,974.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,970.40
|
| Rate for Payer: Ohio Health Group HMO |
$8,497.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,266.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,472.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.30
|
| Rate for Payer: PHCS Commercial |
$10,876.80
|
| Rate for Payer: United Healthcare All Payer |
$9,970.40
|
|
|
LIFESTREAM COV. STENT 9*58*135
|
Facility
|
IP
|
$11,330.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.90 |
| Max. Negotiated Rate |
$10,876.80 |
| Rate for Payer: Aetna Commercial |
$8,724.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,837.40
|
| Rate for Payer: Cash Price |
$5,665.00
|
| Rate for Payer: Cigna Commercial |
$9,403.90
|
| Rate for Payer: First Health Commercial |
$10,763.50
|
| Rate for Payer: Humana Commercial |
$9,630.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,290.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,361.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,399.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,970.40
|
| Rate for Payer: Ohio Health Group HMO |
$8,497.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,266.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,472.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.30
|
| Rate for Payer: PHCS Commercial |
$10,876.80
|
| Rate for Payer: United Healthcare All Payer |
$9,970.40
|
|
|
LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR
|
Facility
|
OP
|
$8,661.10
|
|
|
Service Code
|
CPT 27427
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,186.50 |
| Max. Negotiated Rate |
$8,661.10 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,186.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,661.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,351.78
|
| Rate for Payer: Humana Medicare Advantage |
$6,186.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,423.80
|
|
|
LIGAMENT PATELLAR PRE-SHP 10MM
|
Facility
|
OP
|
$15,063.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,958.19 |
| Max. Negotiated Rate |
$14,460.48 |
| Rate for Payer: Aetna Commercial |
$11,598.51
|
| Rate for Payer: Anthem Medicaid |
$5,180.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,749.14
|
| Rate for Payer: Cash Price |
$7,531.50
|
| Rate for Payer: Cigna Commercial |
$12,502.29
|
| Rate for Payer: First Health Commercial |
$14,309.85
|
| Rate for Payer: Humana Commercial |
$12,803.55
|
| Rate for Payer: Humana KY Medicaid |
$5,180.17
|
| Rate for Payer: Kentucky WC Medicaid |
$5,232.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,351.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,116.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,518.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,284.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,255.44
|
| Rate for Payer: Ohio Health Group HMO |
$11,297.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,012.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,958.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,669.53
|
| Rate for Payer: PHCS Commercial |
$14,460.48
|
| Rate for Payer: United Healthcare All Payer |
$13,255.44
|
|
|
LIGAMENT PATELLAR PRE-SHP 10MM
|
Facility
|
IP
|
$15,063.00
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,958.19 |
| Max. Negotiated Rate |
$14,460.48 |
| Rate for Payer: Aetna Commercial |
$11,598.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,749.14
|
| Rate for Payer: Cash Price |
$7,531.50
|
| Rate for Payer: Cigna Commercial |
$12,502.29
|
| Rate for Payer: First Health Commercial |
$14,309.85
|
| Rate for Payer: Humana Commercial |
$12,803.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,351.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,116.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,518.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,255.44
|
| Rate for Payer: Ohio Health Group HMO |
$11,297.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,012.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,958.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,669.53
|
| Rate for Payer: PHCS Commercial |
$14,460.48
|
| Rate for Payer: United Healthcare All Payer |
$13,255.44
|
|
|
LIGAMENT RECON KNEE INTARTIC
|
Professional
|
Both
|
$3,535.00
|
|
|
Service Code
|
HCPCS 27428
|
| Hospital Charge Code |
76100843
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$745.89 |
| Max. Negotiated Rate |
$3,535.00 |
| Rate for Payer: Aetna Commercial |
$1,625.81
|
| Rate for Payer: Anthem Medicaid |
$745.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,535.00
|
| Rate for Payer: Cash Price |
$1,767.50
|
| Rate for Payer: Cash Price |
$1,767.50
|
| Rate for Payer: Cigna Commercial |
$1,759.85
|
| Rate for Payer: Healthspan PPO |
$1,472.63
|
| Rate for Payer: Humana Medicaid |
$745.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,382.81
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$760.81
|
| Rate for Payer: Molina Healthcare Passport |
$745.89
|
| Rate for Payer: Multiplan PHCS |
$2,121.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,474.50
|
| Rate for Payer: UHCCP Medicaid |
$1,237.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$753.35
|
|
