|
NIRXCELL STENT 3.0*20
|
Facility
|
OP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem Medicaid |
$1,268.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Humana KY Medicaid |
$1,268.13
|
| Rate for Payer: Kentucky WC Medicaid |
$1,281.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,293.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 3.0*20
|
Facility
|
IP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 3.0*24
|
Facility
|
IP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 3.0*24
|
Facility
|
OP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem Medicaid |
$1,268.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Humana KY Medicaid |
$1,268.13
|
| Rate for Payer: Kentucky WC Medicaid |
$1,281.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,293.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 3.0*28
|
Facility
|
OP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem Medicaid |
$1,268.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Humana KY Medicaid |
$1,268.13
|
| Rate for Payer: Kentucky WC Medicaid |
$1,281.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,293.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 3.0*28
|
Facility
|
IP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 3.0*33
|
Facility
|
OP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem Medicaid |
$1,268.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Humana KY Medicaid |
$1,268.13
|
| Rate for Payer: Kentucky WC Medicaid |
$1,281.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,293.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 3.0*33
|
Facility
|
IP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 3.0*8
|
Facility
|
OP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem Medicaid |
$1,268.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Humana KY Medicaid |
$1,268.13
|
| Rate for Payer: Kentucky WC Medicaid |
$1,281.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,293.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 3.0*8
|
Facility
|
IP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 3.5*12
|
Facility
|
IP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 3.5*12
|
Facility
|
OP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem Medicaid |
$1,268.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Humana KY Medicaid |
$1,268.13
|
| Rate for Payer: Kentucky WC Medicaid |
$1,281.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,293.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 3.5*17
|
Facility
|
OP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem Medicaid |
$1,268.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Humana KY Medicaid |
$1,268.13
|
| Rate for Payer: Kentucky WC Medicaid |
$1,281.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,293.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 3.5*17
|
Facility
|
IP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 3.5*20
|
Facility
|
IP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 3.5*20
|
Facility
|
OP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem Medicaid |
$1,268.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Humana KY Medicaid |
$1,268.13
|
| Rate for Payer: Kentucky WC Medicaid |
$1,281.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,293.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 3.5*24
|
Facility
|
IP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 3.5*24
|
Facility
|
OP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem Medicaid |
$1,268.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Humana KY Medicaid |
$1,268.13
|
| Rate for Payer: Kentucky WC Medicaid |
$1,281.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,293.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 3.5*28
|
Facility
|
OP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem Medicaid |
$1,268.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Humana KY Medicaid |
$1,268.13
|
| Rate for Payer: Kentucky WC Medicaid |
$1,281.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,293.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 3.5*28
|
Facility
|
IP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 3.5*33
|
Facility
|
IP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 3.5*33
|
Facility
|
OP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem Medicaid |
$1,268.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Humana KY Medicaid |
$1,268.13
|
| Rate for Payer: Kentucky WC Medicaid |
$1,281.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,293.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 3.5*8
|
Facility
|
OP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem Medicaid |
$1,268.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Humana KY Medicaid |
$1,268.13
|
| Rate for Payer: Kentucky WC Medicaid |
$1,281.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,293.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 3.5*8
|
Facility
|
IP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
NIRXCELL STENT 4.0*12
|
Facility
|
IP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
