|
LIDO+EPI 2%-1:100K MDV 30ML VL
|
Facility
|
IP
|
$80.39
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
25004024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.12 |
| Max. Negotiated Rate |
$77.17 |
| Rate for Payer: Aetna Commercial |
$61.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.70
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$66.72
|
| Rate for Payer: First Health Commercial |
$76.37
|
| Rate for Payer: Humana Commercial |
$68.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.74
|
| Rate for Payer: Ohio Health Group HMO |
$60.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.47
|
| Rate for Payer: PHCS Commercial |
$77.17
|
| Rate for Payer: United Healthcare All Payer |
$70.74
|
|
|
LIFESTREAM COV STENT 10*38*135
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
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
|
|
|
LIFESTREAM COV STENT 10*38*135
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
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
|
|
|
LIFESTREAM COV STENT 10*58*135
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
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
|
|
|
LIFESTREAM COV STENT 10*58*135
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
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
|
|
|
LIFESTREAM COV STENT 12*38*135
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
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
|
|
|
LIFESTREAM COV STENT 12*38*135
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
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
|
|
|
LIFESTREAM COV. STENT 5*26*135
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
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
|
|
|
LIFESTREAM COV. STENT 5*26*135
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
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
|
|
|
LIFESTREAM COV. STENT 5*37*135
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
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
|
|
|
LIFESTREAM COV. STENT 5*37*135
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
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
|
|
|
LIFESTREAM COV. STENT 6*16*135
|
Facility
|
IP
|
$18,275.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,482.50 |
| Max. Negotiated Rate |
$17,544.00 |
| Rate for Payer: Aetna Commercial |
$14,071.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,254.50
|
| Rate for Payer: Cash Price |
$9,137.50
|
| Rate for Payer: Cigna Commercial |
$15,168.25
|
| Rate for Payer: First Health Commercial |
$17,361.25
|
| Rate for Payer: Humana Commercial |
$15,533.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,985.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,486.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,482.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,082.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,706.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,620.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,899.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,609.75
|
| Rate for Payer: PHCS Commercial |
$17,544.00
|
| Rate for Payer: United Healthcare All Payer |
$16,082.00
|
|
|
LIFESTREAM COV. STENT 6*16*135
|
Facility
|
OP
|
$18,275.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,482.50 |
| Max. Negotiated Rate |
$17,544.00 |
| Rate for Payer: Aetna Commercial |
$14,071.75
|
| Rate for Payer: Anthem Medicaid |
$6,284.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,254.50
|
| Rate for Payer: Cash Price |
$9,137.50
|
| Rate for Payer: Cigna Commercial |
$15,168.25
|
| Rate for Payer: First Health Commercial |
$17,361.25
|
| Rate for Payer: Humana Commercial |
$15,533.75
|
| Rate for Payer: Humana KY Medicaid |
$6,284.77
|
| Rate for Payer: Kentucky WC Medicaid |
$6,348.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,985.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,486.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,482.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,410.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,082.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,706.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,620.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,899.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,609.75
|
| Rate for Payer: PHCS Commercial |
$17,544.00
|
| Rate for Payer: United Healthcare All Payer |
$16,082.00
|
|
|
LIFESTREAM COV. STENT 6*26*135
|
Facility
|
IP
|
$18,275.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,482.50 |
| Max. Negotiated Rate |
$17,544.00 |
| Rate for Payer: Aetna Commercial |
$14,071.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,254.50
|
| Rate for Payer: Cash Price |
$9,137.50
|
| Rate for Payer: Cigna Commercial |
$15,168.25
|
| Rate for Payer: First Health Commercial |
$17,361.25
|
| Rate for Payer: Humana Commercial |
$15,533.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,985.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,486.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,482.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,082.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,706.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,620.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,899.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,609.75
|
| Rate for Payer: PHCS Commercial |
$17,544.00
|
| Rate for Payer: United Healthcare All Payer |
$16,082.00
|
|
|
LIFESTREAM COV. STENT 6*26*135
|
Facility
|
OP
|
$18,275.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,482.50 |
| Max. Negotiated Rate |
$17,544.00 |
| Rate for Payer: Aetna Commercial |
$14,071.75
|
| Rate for Payer: Anthem Medicaid |
$6,284.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,254.50
|
| Rate for Payer: Cash Price |
$9,137.50
|
| Rate for Payer: Cigna Commercial |
$15,168.25
|
| Rate for Payer: First Health Commercial |
$17,361.25
|
| Rate for Payer: Humana Commercial |
$15,533.75
|
| Rate for Payer: Humana KY Medicaid |
$6,284.77
|
| Rate for Payer: Kentucky WC Medicaid |
$6,348.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,985.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,486.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,482.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,410.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,082.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,706.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,620.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,899.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,609.75
|
| Rate for Payer: PHCS Commercial |
$17,544.00
|
| Rate for Payer: United Healthcare All Payer |
$16,082.00
|
|
|
LIFESTREAM COV. STENT 6*37*135
|
Facility
|
OP
|
$20,562.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,168.75 |
| Max. Negotiated Rate |
$19,740.00 |
| Rate for Payer: Aetna Commercial |
$15,833.12
|
| Rate for Payer: Anthem Medicaid |
$7,071.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,038.75
|
| Rate for Payer: Cash Price |
$10,281.25
|
| Rate for Payer: Cigna Commercial |
$17,066.88
|
| Rate for Payer: First Health Commercial |
$19,534.38
|
| Rate for Payer: Humana Commercial |
$17,478.12
|
| Rate for Payer: Humana KY Medicaid |
$7,071.44
|
| Rate for Payer: Kentucky WC Medicaid |
$7,143.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,861.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,175.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,168.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,213.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,095.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,421.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,889.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,188.12
|
| Rate for Payer: PHCS Commercial |
$19,740.00
|
| Rate for Payer: United Healthcare All Payer |
$18,095.00
|
|
|
LIFESTREAM COV. STENT 6*37*135
|
Facility
|
IP
|
$20,562.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,168.75 |
| Max. Negotiated Rate |
$19,740.00 |
| Rate for Payer: Aetna Commercial |
$15,833.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,038.75
|
| Rate for Payer: Cash Price |
$10,281.25
|
| Rate for Payer: Cigna Commercial |
$17,066.88
|
| Rate for Payer: First Health Commercial |
$19,534.38
|
| Rate for Payer: Humana Commercial |
$17,478.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,861.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,175.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,168.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,095.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,421.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,889.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,188.12
|
| Rate for Payer: PHCS Commercial |
$19,740.00
|
| Rate for Payer: United Healthcare All Payer |
$18,095.00
|
|
|
LIFESTREAM COV. STENT 6*58*135
|
Facility
|
IP
|
$18,275.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,482.50 |
| Max. Negotiated Rate |
$17,544.00 |
| Rate for Payer: Aetna Commercial |
$14,071.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,254.50
|
| Rate for Payer: Cash Price |
$9,137.50
|
| Rate for Payer: Cigna Commercial |
$15,168.25
|
| Rate for Payer: First Health Commercial |
$17,361.25
|
| Rate for Payer: Humana Commercial |
$15,533.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,985.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,486.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,482.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,082.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,706.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,620.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,899.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,609.75
|
| Rate for Payer: PHCS Commercial |
$17,544.00
|
| Rate for Payer: United Healthcare All Payer |
$16,082.00
|
|
|
LIFESTREAM COV. STENT 6*58*135
|
Facility
|
OP
|
$18,275.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,482.50 |
| Max. Negotiated Rate |
$17,544.00 |
| Rate for Payer: Aetna Commercial |
$14,071.75
|
| Rate for Payer: Anthem Medicaid |
$6,284.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,254.50
|
| Rate for Payer: Cash Price |
$9,137.50
|
| Rate for Payer: Cigna Commercial |
$15,168.25
|
| Rate for Payer: First Health Commercial |
$17,361.25
|
| Rate for Payer: Humana Commercial |
$15,533.75
|
| Rate for Payer: Humana KY Medicaid |
$6,284.77
|
| Rate for Payer: Kentucky WC Medicaid |
$6,348.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,985.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,486.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,482.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,410.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,082.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,706.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,620.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,899.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,609.75
|
| Rate for Payer: PHCS Commercial |
$17,544.00
|
| Rate for Payer: United Healthcare All Payer |
$16,082.00
|
|
|
LIFESTREAM COV. STENT 7*15*135
|
Facility
|
OP
|
$11,207.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,362.10 |
| Max. Negotiated Rate |
$10,758.72 |
| Rate for Payer: Aetna Commercial |
$8,629.39
|
| Rate for Payer: Anthem Medicaid |
$3,854.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,741.46
|
| Rate for Payer: Cash Price |
$5,603.50
|
| Rate for Payer: Cigna Commercial |
$9,301.81
|
| Rate for Payer: First Health Commercial |
$10,646.65
|
| Rate for Payer: Humana Commercial |
$9,525.95
|
| Rate for Payer: Humana KY Medicaid |
$3,854.09
|
| Rate for Payer: Kentucky WC Medicaid |
$3,893.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,189.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,270.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,362.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,931.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,862.16
|
| Rate for Payer: Ohio Health Group HMO |
$8,405.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,965.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,750.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,732.83
|
| Rate for Payer: PHCS Commercial |
$10,758.72
|
| Rate for Payer: United Healthcare All Payer |
$9,862.16
|
|
|
LIFESTREAM COV. STENT 7*15*135
|
Facility
|
IP
|
$11,207.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,362.10 |
| Max. Negotiated Rate |
$10,758.72 |
| Rate for Payer: Aetna Commercial |
$8,629.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,741.46
|
| Rate for Payer: Cash Price |
$5,603.50
|
| Rate for Payer: Cigna Commercial |
$9,301.81
|
| Rate for Payer: First Health Commercial |
$10,646.65
|
| Rate for Payer: Humana Commercial |
$9,525.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,189.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,270.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,362.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,862.16
|
| Rate for Payer: Ohio Health Group HMO |
$8,405.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,965.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,750.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,732.83
|
| Rate for Payer: PHCS Commercial |
$10,758.72
|
| Rate for Payer: United Healthcare All Payer |
$9,862.16
|
|
|
LIFESTREAM COV. STENT 7*26*135
|
Facility
|
IP
|
$20,562.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,168.75 |
| Max. Negotiated Rate |
$19,740.00 |
| Rate for Payer: Aetna Commercial |
$15,833.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,038.75
|
| Rate for Payer: Cash Price |
$10,281.25
|
| Rate for Payer: Cigna Commercial |
$17,066.88
|
| Rate for Payer: First Health Commercial |
$19,534.38
|
| Rate for Payer: Humana Commercial |
$17,478.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,861.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,175.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,168.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,095.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,421.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,889.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,188.12
|
| Rate for Payer: PHCS Commercial |
$19,740.00
|
| Rate for Payer: United Healthcare All Payer |
$18,095.00
|
|
|
LIFESTREAM COV. STENT 7*26*135
|
Facility
|
OP
|
$20,562.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,168.75 |
| Max. Negotiated Rate |
$19,740.00 |
| Rate for Payer: Aetna Commercial |
$15,833.12
|
| Rate for Payer: Anthem Medicaid |
$7,071.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,038.75
|
| Rate for Payer: Cash Price |
$10,281.25
|
| Rate for Payer: Cigna Commercial |
$17,066.88
|
| Rate for Payer: First Health Commercial |
$19,534.38
|
| Rate for Payer: Humana Commercial |
$17,478.12
|
| Rate for Payer: Humana KY Medicaid |
$7,071.44
|
| Rate for Payer: Kentucky WC Medicaid |
$7,143.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,861.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,175.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,168.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,213.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,095.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,421.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,889.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,188.12
|
| Rate for Payer: PHCS Commercial |
$19,740.00
|
| Rate for Payer: United Healthcare All Payer |
$18,095.00
|
|
|
LIFESTREAM COV. STENT 7*37*135
|
Facility
|
IP
|
$20,562.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,168.75 |
| Max. Negotiated Rate |
$19,740.00 |
| Rate for Payer: Aetna Commercial |
$15,833.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,038.75
|
| Rate for Payer: Cash Price |
$10,281.25
|
| Rate for Payer: Cigna Commercial |
$17,066.88
|
| Rate for Payer: First Health Commercial |
$19,534.38
|
| Rate for Payer: Humana Commercial |
$17,478.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,861.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,175.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,168.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,095.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,421.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,889.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,188.12
|
| Rate for Payer: PHCS Commercial |
$19,740.00
|
| Rate for Payer: United Healthcare All Payer |
$18,095.00
|
|
|
LIFESTREAM COV. STENT 7*37*135
|
Facility
|
OP
|
$20,562.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,168.75 |
| Max. Negotiated Rate |
$19,740.00 |
| Rate for Payer: Aetna Commercial |
$15,833.12
|
| Rate for Payer: Anthem Medicaid |
$7,071.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,038.75
|
| Rate for Payer: Cash Price |
$10,281.25
|
| Rate for Payer: Cigna Commercial |
$17,066.88
|
| Rate for Payer: First Health Commercial |
$19,534.38
|
| Rate for Payer: Humana Commercial |
$17,478.12
|
| Rate for Payer: Humana KY Medicaid |
$7,071.44
|
| Rate for Payer: Kentucky WC Medicaid |
$7,143.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,861.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,175.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,168.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,213.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,095.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,421.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,889.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,188.12
|
| Rate for Payer: PHCS Commercial |
$19,740.00
|
| Rate for Payer: United Healthcare All Payer |
$18,095.00
|
|
