|
PALMAZ BLUE SLALOM 6*18*80
|
Facility
|
IP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,471.88 |
| Max. Negotiated Rate |
$4,710.00 |
| Rate for Payer: Aetna Commercial |
$3,777.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,826.88
|
| Rate for Payer: Cash Price |
$2,453.12
|
| Rate for Payer: Cigna Commercial |
$4,072.19
|
| Rate for Payer: First Health Commercial |
$4,660.94
|
| Rate for Payer: Humana Commercial |
$4,170.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,620.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,471.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,679.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,268.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.31
|
| Rate for Payer: PHCS Commercial |
$4,710.00
|
| Rate for Payer: United Healthcare All Payer |
$4,317.50
|
|
|
PALMAZ BLUE SLALOM 6*18*80
|
Facility
|
OP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,471.88 |
| Max. Negotiated Rate |
$4,710.00 |
| Rate for Payer: Aetna Commercial |
$3,777.81
|
| Rate for Payer: Anthem Medicaid |
$1,687.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,826.88
|
| Rate for Payer: Cash Price |
$2,453.12
|
| Rate for Payer: Cigna Commercial |
$4,072.19
|
| Rate for Payer: First Health Commercial |
$4,660.94
|
| Rate for Payer: Humana Commercial |
$4,170.31
|
| Rate for Payer: Humana KY Medicaid |
$1,687.26
|
| Rate for Payer: Kentucky WC Medicaid |
$1,704.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,620.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,471.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,721.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,679.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,268.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.31
|
| Rate for Payer: PHCS Commercial |
$4,710.00
|
| Rate for Payer: United Healthcare All Payer |
$4,317.50
|
|
|
PALMAZ BLUE SLALOM 6*24*135
|
Facility
|
IP
|
$5,204.15
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,561.24 |
| Max. Negotiated Rate |
$4,995.98 |
| Rate for Payer: Aetna Commercial |
$4,007.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,059.24
|
| Rate for Payer: Cash Price |
$2,602.07
|
| Rate for Payer: Cigna Commercial |
$4,319.44
|
| Rate for Payer: First Health Commercial |
$4,943.94
|
| Rate for Payer: Humana Commercial |
$4,423.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,267.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,840.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,561.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,579.65
|
| Rate for Payer: Ohio Health Group HMO |
$3,903.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,163.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,527.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,590.86
|
| Rate for Payer: PHCS Commercial |
$4,995.98
|
| Rate for Payer: United Healthcare All Payer |
$4,579.65
|
|
|
PALMAZ BLUE SLALOM 6*24*135
|
Facility
|
OP
|
$5,204.15
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,561.24 |
| Max. Negotiated Rate |
$4,995.98 |
| Rate for Payer: Aetna Commercial |
$4,007.20
|
| Rate for Payer: Anthem Medicaid |
$1,789.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,059.24
|
| Rate for Payer: Cash Price |
$2,602.07
|
| Rate for Payer: Cigna Commercial |
$4,319.44
|
| Rate for Payer: First Health Commercial |
$4,943.94
|
| Rate for Payer: Humana Commercial |
$4,423.53
|
| Rate for Payer: Humana KY Medicaid |
$1,789.71
|
| Rate for Payer: Kentucky WC Medicaid |
$1,807.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,267.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,840.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,561.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,825.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,579.65
|
| Rate for Payer: Ohio Health Group HMO |
$3,903.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,163.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,527.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,590.86
|
| Rate for Payer: PHCS Commercial |
$4,995.98
|
| Rate for Payer: United Healthcare All Payer |
$4,579.65
|
|
|
PALMAZ BLUE SLALOM 7*12*135
|
Facility
|
OP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,471.88 |
| Max. Negotiated Rate |
$4,710.00 |
| Rate for Payer: Aetna Commercial |
$3,777.81
|
| Rate for Payer: Anthem Medicaid |
$1,687.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,826.88
|
| Rate for Payer: Cash Price |
$2,453.12
|
| Rate for Payer: Cigna Commercial |
$4,072.19
|
| Rate for Payer: First Health Commercial |
$4,660.94
|
| Rate for Payer: Humana Commercial |
$4,170.31
|
| Rate for Payer: Humana KY Medicaid |
$1,687.26
|
| Rate for Payer: Kentucky WC Medicaid |
$1,704.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,620.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,471.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,721.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,679.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,268.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.31
|
| Rate for Payer: PHCS Commercial |
$4,710.00
|
| Rate for Payer: United Healthcare All Payer |
$4,317.50
|
|
|
PALMAZ BLUE SLALOM 7*12*135
|
Facility
|
IP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,471.88 |
| Max. Negotiated Rate |
$4,710.00 |
| Rate for Payer: Aetna Commercial |
$3,777.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,826.88
|
| Rate for Payer: Cash Price |
$2,453.12
|
| Rate for Payer: Cigna Commercial |
$4,072.19
|
| Rate for Payer: First Health Commercial |
$4,660.94
|
| Rate for Payer: Humana Commercial |
$4,170.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,620.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,471.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,679.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,268.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.31
|
| Rate for Payer: PHCS Commercial |
$4,710.00
|
| Rate for Payer: United Healthcare All Payer |
$4,317.50
|
|
|
PALMAZ BLUE SLALOM 7*12*80
|
Facility
|
IP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,471.88 |
| Max. Negotiated Rate |
$4,710.00 |
| Rate for Payer: Aetna Commercial |
$3,777.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,826.88
|
| Rate for Payer: Cash Price |
$2,453.12
|
| Rate for Payer: Cigna Commercial |
$4,072.19
|
| Rate for Payer: First Health Commercial |
$4,660.94
|
| Rate for Payer: Humana Commercial |
$4,170.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,620.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,471.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,679.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,268.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.31
|
| Rate for Payer: PHCS Commercial |
$4,710.00
|
| Rate for Payer: United Healthcare All Payer |
$4,317.50
|
|
|
PALMAZ BLUE SLALOM 7*12*80
|
Facility
|
OP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,471.88 |
| Max. Negotiated Rate |
$4,710.00 |
| Rate for Payer: Aetna Commercial |
$3,777.81
|
| Rate for Payer: Anthem Medicaid |
$1,687.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,826.88
|
| Rate for Payer: Cash Price |
$2,453.12
|
| Rate for Payer: Cigna Commercial |
$4,072.19
|
| Rate for Payer: First Health Commercial |
$4,660.94
|
| Rate for Payer: Humana Commercial |
$4,170.31
|
| Rate for Payer: Humana KY Medicaid |
$1,687.26
|
| Rate for Payer: Kentucky WC Medicaid |
$1,704.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,620.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,471.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,721.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,679.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,268.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.31
|
| Rate for Payer: PHCS Commercial |
$4,710.00
|
| Rate for Payer: United Healthcare All Payer |
$4,317.50
|
|
|
PALMAZ BLUE SLALOM 7*14*135
|
Facility
|
OP
|
$5,204.15
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,561.24 |
| Max. Negotiated Rate |
$4,995.98 |
| Rate for Payer: Aetna Commercial |
$4,007.20
|
| Rate for Payer: Anthem Medicaid |
$1,789.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,059.24
|
| Rate for Payer: Cash Price |
$2,602.07
|
| Rate for Payer: Cigna Commercial |
$4,319.44
|
| Rate for Payer: First Health Commercial |
$4,943.94
|
| Rate for Payer: Humana Commercial |
$4,423.53
|
| Rate for Payer: Humana KY Medicaid |
$1,789.71
|
| Rate for Payer: Kentucky WC Medicaid |
$1,807.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,267.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,840.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,561.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,825.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,579.65
|
| Rate for Payer: Ohio Health Group HMO |
$3,903.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,163.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,527.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,590.86
|
| Rate for Payer: PHCS Commercial |
$4,995.98
|
| Rate for Payer: United Healthcare All Payer |
$4,579.65
|
|
|
PALMAZ BLUE SLALOM 7*14*135
|
Facility
|
IP
|
$5,204.15
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,561.24 |
| Max. Negotiated Rate |
$4,995.98 |
| Rate for Payer: Aetna Commercial |
$4,007.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,059.24
|
| Rate for Payer: Cash Price |
$2,602.07
|
| Rate for Payer: Cigna Commercial |
$4,319.44
|
| Rate for Payer: First Health Commercial |
$4,943.94
|
| Rate for Payer: Humana Commercial |
$4,423.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,267.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,840.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,561.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,579.65
|
| Rate for Payer: Ohio Health Group HMO |
$3,903.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,163.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,527.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,590.86
|
| Rate for Payer: PHCS Commercial |
$4,995.98
|
| Rate for Payer: United Healthcare All Payer |
$4,579.65
|
|
|
PALMAZ BLUE SLALOM 7*14*80
|
Facility
|
IP
|
$5,204.15
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,561.24 |
| Max. Negotiated Rate |
$4,995.98 |
| Rate for Payer: Aetna Commercial |
$4,007.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,059.24
|
| Rate for Payer: Cash Price |
$2,602.07
|
| Rate for Payer: Cigna Commercial |
$4,319.44
|
| Rate for Payer: First Health Commercial |
$4,943.94
|
| Rate for Payer: Humana Commercial |
$4,423.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,267.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,840.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,561.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,579.65
|
| Rate for Payer: Ohio Health Group HMO |
$3,903.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,163.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,527.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,590.86
|
| Rate for Payer: PHCS Commercial |
$4,995.98
|
| Rate for Payer: United Healthcare All Payer |
$4,579.65
|
|
|
PALMAZ BLUE SLALOM 7*14*80
|
Facility
|
OP
|
$5,204.15
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,561.24 |
| Max. Negotiated Rate |
$4,995.98 |
| Rate for Payer: Aetna Commercial |
$4,007.20
|
| Rate for Payer: Anthem Medicaid |
$1,789.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,059.24
|
| Rate for Payer: Cash Price |
$2,602.07
|
| Rate for Payer: Cigna Commercial |
$4,319.44
|
| Rate for Payer: First Health Commercial |
$4,943.94
|
| Rate for Payer: Humana Commercial |
$4,423.53
|
| Rate for Payer: Humana KY Medicaid |
$1,789.71
|
| Rate for Payer: Kentucky WC Medicaid |
$1,807.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,267.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,840.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,561.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,825.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,579.65
|
| Rate for Payer: Ohio Health Group HMO |
$3,903.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,163.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,527.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,590.86
|
| Rate for Payer: PHCS Commercial |
$4,995.98
|
| Rate for Payer: United Healthcare All Payer |
$4,579.65
|
|
|
PALMAZ BLUE SLALOM 7*18*135
|
Facility
|
OP
|
$5,204.15
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,561.24 |
| Max. Negotiated Rate |
$4,995.98 |
| Rate for Payer: Aetna Commercial |
$4,007.20
|
| Rate for Payer: Anthem Medicaid |
$1,789.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,059.24
|
| Rate for Payer: Cash Price |
$2,602.07
|
| Rate for Payer: Cigna Commercial |
$4,319.44
|
| Rate for Payer: First Health Commercial |
$4,943.94
|
| Rate for Payer: Humana Commercial |
$4,423.53
|
| Rate for Payer: Humana KY Medicaid |
$1,789.71
|
| Rate for Payer: Kentucky WC Medicaid |
$1,807.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,267.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,840.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,561.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,825.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,579.65
|
| Rate for Payer: Ohio Health Group HMO |
$3,903.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,163.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,527.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,590.86
|
| Rate for Payer: PHCS Commercial |
$4,995.98
|
| Rate for Payer: United Healthcare All Payer |
$4,579.65
|
|
|
PALMAZ BLUE SLALOM 7*18*135
|
Facility
|
IP
|
$5,204.15
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,561.24 |
| Max. Negotiated Rate |
$4,995.98 |
| Rate for Payer: Aetna Commercial |
$4,007.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,059.24
|
| Rate for Payer: Cash Price |
$2,602.07
|
| Rate for Payer: Cigna Commercial |
$4,319.44
|
| Rate for Payer: First Health Commercial |
$4,943.94
|
| Rate for Payer: Humana Commercial |
$4,423.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,267.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,840.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,561.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,579.65
|
| Rate for Payer: Ohio Health Group HMO |
$3,903.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,163.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,527.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,590.86
|
| Rate for Payer: PHCS Commercial |
$4,995.98
|
| Rate for Payer: United Healthcare All Payer |
$4,579.65
|
|
|
PALMAZ BLUE SLALOM 7*18*80
|
Facility
|
IP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,471.88 |
| Max. Negotiated Rate |
$4,710.00 |
| Rate for Payer: Aetna Commercial |
$3,777.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,826.88
|
| Rate for Payer: Cash Price |
$2,453.12
|
| Rate for Payer: Cigna Commercial |
$4,072.19
|
| Rate for Payer: First Health Commercial |
$4,660.94
|
| Rate for Payer: Humana Commercial |
$4,170.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,620.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,471.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,679.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,268.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.31
|
| Rate for Payer: PHCS Commercial |
$4,710.00
|
| Rate for Payer: United Healthcare All Payer |
$4,317.50
|
|
|
PALMAZ BLUE SLALOM 7*18*80
|
Facility
|
OP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,471.88 |
| Max. Negotiated Rate |
$4,710.00 |
| Rate for Payer: Aetna Commercial |
$3,777.81
|
| Rate for Payer: Anthem Medicaid |
$1,687.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,826.88
|
| Rate for Payer: Cash Price |
$2,453.12
|
| Rate for Payer: Cigna Commercial |
$4,072.19
|
| Rate for Payer: First Health Commercial |
$4,660.94
|
| Rate for Payer: Humana Commercial |
$4,170.31
|
| Rate for Payer: Humana KY Medicaid |
$1,687.26
|
| Rate for Payer: Kentucky WC Medicaid |
$1,704.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,620.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,471.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,721.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,679.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,268.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.31
|
| Rate for Payer: PHCS Commercial |
$4,710.00
|
| Rate for Payer: United Healthcare All Payer |
$4,317.50
|
|
|
PALMAZ BLUE SLALOM 7*24*135
|
Facility
|
OP
|
$5,204.15
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,561.24 |
| Max. Negotiated Rate |
$4,995.98 |
| Rate for Payer: Aetna Commercial |
$4,007.20
|
| Rate for Payer: Anthem Medicaid |
$1,789.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,059.24
|
| Rate for Payer: Cash Price |
$2,602.07
|
| Rate for Payer: Cigna Commercial |
$4,319.44
|
| Rate for Payer: First Health Commercial |
$4,943.94
|
| Rate for Payer: Humana Commercial |
$4,423.53
|
| Rate for Payer: Humana KY Medicaid |
$1,789.71
|
| Rate for Payer: Kentucky WC Medicaid |
$1,807.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,267.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,840.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,561.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,825.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,579.65
|
| Rate for Payer: Ohio Health Group HMO |
$3,903.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,163.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,527.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,590.86
|
| Rate for Payer: PHCS Commercial |
$4,995.98
|
| Rate for Payer: United Healthcare All Payer |
$4,579.65
|
|
|
PALMAZ BLUE SLALOM 7*24*135
|
Facility
|
IP
|
$5,204.15
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,561.24 |
| Max. Negotiated Rate |
$4,995.98 |
| Rate for Payer: Aetna Commercial |
$4,007.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,059.24
|
| Rate for Payer: Cash Price |
$2,602.07
|
| Rate for Payer: Cigna Commercial |
$4,319.44
|
| Rate for Payer: First Health Commercial |
$4,943.94
|
| Rate for Payer: Humana Commercial |
$4,423.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,267.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,840.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,561.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,579.65
|
| Rate for Payer: Ohio Health Group HMO |
$3,903.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,163.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,527.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,590.86
|
| Rate for Payer: PHCS Commercial |
$4,995.98
|
| Rate for Payer: United Healthcare All Payer |
$4,579.65
|
|
|
PALMAZ GENESIS STENT 12*40*80
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
PALMAZ GENESIS STENT 12*40*80
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
PALMAZ GENESIS STENT 12*50*80
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
PALMAZ GENESIS STENT 12*50*80
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
PALMAZ GENESIS STENT 12*60*80
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
PALMAZ GENESIS STENT 12*60*80
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
PALMAZ GENESIS STENT 12*70*80
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
