|
PROTEGE EF STENT LONG 6*150*12
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
PROTEGE EF STENT LONG 7*150*12
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
PROTEGE EF STENT LONG 7*150*12
|
Facility
|
IP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
PROTEGE EF STENT LONG 8*100*12
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
PROTEGE EF STENT LONG 8*100*12
|
Facility
|
IP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
PROTEGE EVERFLEX STENT 6*20*12
|
Facility
|
OP
|
$9,643.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,253.69 |
| Max. Negotiated Rate |
$9,258.00 |
| Rate for Payer: Aetna Commercial |
$7,425.69
|
| Rate for Payer: Anthem Medicaid |
$3,316.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,522.12
|
| Rate for Payer: Cash Price |
$4,821.88
|
| Rate for Payer: Cigna Commercial |
$8,004.31
|
| Rate for Payer: First Health Commercial |
$9,161.56
|
| Rate for Payer: Humana Commercial |
$8,197.19
|
| Rate for Payer: Humana KY Medicaid |
$3,316.49
|
| Rate for Payer: Kentucky WC Medicaid |
$3,350.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,907.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,117.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,893.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,383.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,486.50
|
| Rate for Payer: Ohio Health Group HMO |
$7,232.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,928.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,253.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,989.56
|
| Rate for Payer: PHCS Commercial |
$9,258.00
|
| Rate for Payer: United Healthcare All Payer |
$8,486.50
|
|
|
PROTEGE EVERFLEX STENT 6*20*12
|
Facility
|
IP
|
$9,643.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,253.69 |
| Max. Negotiated Rate |
$9,258.00 |
| Rate for Payer: Aetna Commercial |
$7,425.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,522.12
|
| Rate for Payer: Cash Price |
$4,821.88
|
| Rate for Payer: Cigna Commercial |
$8,004.31
|
| Rate for Payer: First Health Commercial |
$9,161.56
|
| Rate for Payer: Humana Commercial |
$8,197.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,907.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,117.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,893.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,486.50
|
| Rate for Payer: Ohio Health Group HMO |
$7,232.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,928.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,253.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,989.56
|
| Rate for Payer: PHCS Commercial |
$9,258.00
|
| Rate for Payer: United Healthcare All Payer |
$8,486.50
|
|
|
PROTEGE EVERFLEX STENT 6*30*12
|
Facility
|
IP
|
$9,643.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,253.69 |
| Max. Negotiated Rate |
$9,258.00 |
| Rate for Payer: Aetna Commercial |
$7,425.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,522.12
|
| Rate for Payer: Cash Price |
$4,821.88
|
| Rate for Payer: Cigna Commercial |
$8,004.31
|
| Rate for Payer: First Health Commercial |
$9,161.56
|
| Rate for Payer: Humana Commercial |
$8,197.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,907.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,117.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,893.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,486.50
|
| Rate for Payer: Ohio Health Group HMO |
$7,232.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,928.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,253.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,989.56
|
| Rate for Payer: PHCS Commercial |
$9,258.00
|
| Rate for Payer: United Healthcare All Payer |
$8,486.50
|
|
|
PROTEGE EVERFLEX STENT 6*30*12
|
Facility
|
OP
|
$9,643.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,253.69 |
| Max. Negotiated Rate |
$9,258.00 |
| Rate for Payer: Aetna Commercial |
$7,425.69
|
| Rate for Payer: Anthem Medicaid |
$3,316.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,522.12
|
| Rate for Payer: Cash Price |
$4,821.88
|
| Rate for Payer: Cigna Commercial |
$8,004.31
|
| Rate for Payer: First Health Commercial |
$9,161.56
|
| Rate for Payer: Humana Commercial |
$8,197.19
|
| Rate for Payer: Humana KY Medicaid |
$3,316.49
|
| Rate for Payer: Kentucky WC Medicaid |
$3,350.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,907.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,117.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,893.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,383.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,486.50
|
| Rate for Payer: Ohio Health Group HMO |
$7,232.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,928.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,253.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,989.56
|
| Rate for Payer: PHCS Commercial |
$9,258.00
|
| Rate for Payer: United Healthcare All Payer |
$8,486.50
|
|
|
PROTEGE EVERFLEX STENT 6*40*12
|
Facility
|
IP
|
$9,643.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,253.69 |
| Max. Negotiated Rate |
$9,258.00 |
| Rate for Payer: Aetna Commercial |
$7,425.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,522.12
|
| Rate for Payer: Cash Price |
$4,821.88
|
| Rate for Payer: Cigna Commercial |
$8,004.31
|
| Rate for Payer: First Health Commercial |
$9,161.56
|
| Rate for Payer: Humana Commercial |
$8,197.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,907.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,117.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,893.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,486.50
|
| Rate for Payer: Ohio Health Group HMO |
$7,232.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,928.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,253.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,989.56
|
| Rate for Payer: PHCS Commercial |
$9,258.00
|
| Rate for Payer: United Healthcare All Payer |
$8,486.50
|
|
|
PROTEGE EVERFLEX STENT 6*40*12
|
Facility
|
OP
|
$9,643.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,253.69 |
| Max. Negotiated Rate |
$9,258.00 |
| Rate for Payer: Aetna Commercial |
$7,425.69
|
| Rate for Payer: Anthem Medicaid |
$3,316.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,522.12
|
| Rate for Payer: Cash Price |
$4,821.88
|
| Rate for Payer: Cigna Commercial |
$8,004.31
|
| Rate for Payer: First Health Commercial |
$9,161.56
|
| Rate for Payer: Humana Commercial |
$8,197.19
|
| Rate for Payer: Humana KY Medicaid |
$3,316.49
|
| Rate for Payer: Kentucky WC Medicaid |
$3,350.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,907.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,117.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,893.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,383.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,486.50
|
| Rate for Payer: Ohio Health Group HMO |
$7,232.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,928.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,253.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,989.56
|
| Rate for Payer: PHCS Commercial |
$9,258.00
|
| Rate for Payer: United Healthcare All Payer |
$8,486.50
|
|
|
PROTEGE EVERFLEX STENT 6*60*12
|
Facility
|
IP
|
$9,643.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,253.69 |
| Max. Negotiated Rate |
$9,258.00 |
| Rate for Payer: Aetna Commercial |
$7,425.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,522.12
|
| Rate for Payer: Cash Price |
$4,821.88
|
| Rate for Payer: Cigna Commercial |
$8,004.31
|
| Rate for Payer: First Health Commercial |
$9,161.56
|
| Rate for Payer: Humana Commercial |
$8,197.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,907.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,117.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,893.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,486.50
|
| Rate for Payer: Ohio Health Group HMO |
$7,232.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,928.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,253.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,989.56
|
| Rate for Payer: PHCS Commercial |
$9,258.00
|
| Rate for Payer: United Healthcare All Payer |
$8,486.50
|
|
|
PROTEGE EVERFLEX STENT 6*60*12
|
Facility
|
OP
|
$9,643.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,253.69 |
| Max. Negotiated Rate |
$9,258.00 |
| Rate for Payer: Aetna Commercial |
$7,425.69
|
| Rate for Payer: Anthem Medicaid |
$3,316.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,522.12
|
| Rate for Payer: Cash Price |
$4,821.88
|
| Rate for Payer: Cigna Commercial |
$8,004.31
|
| Rate for Payer: First Health Commercial |
$9,161.56
|
| Rate for Payer: Humana Commercial |
$8,197.19
|
| Rate for Payer: Humana KY Medicaid |
$3,316.49
|
| Rate for Payer: Kentucky WC Medicaid |
$3,350.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,907.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,117.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,893.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,383.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,486.50
|
| Rate for Payer: Ohio Health Group HMO |
$7,232.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,928.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,253.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,989.56
|
| Rate for Payer: PHCS Commercial |
$9,258.00
|
| Rate for Payer: United Healthcare All Payer |
$8,486.50
|
|
|
PROTEGE EVERFLEX STENT 6*80*12
|
Facility
|
IP
|
$10,873.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,413.59 |
| Max. Negotiated Rate |
$10,438.80 |
| Rate for Payer: Aetna Commercial |
$8,372.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,481.52
|
| Rate for Payer: Cash Price |
$5,436.88
|
| Rate for Payer: Cigna Commercial |
$9,025.21
|
| Rate for Payer: First Health Commercial |
$10,330.06
|
| Rate for Payer: Humana Commercial |
$9,242.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,916.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,024.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,262.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,568.90
|
| Rate for Payer: Ohio Health Group HMO |
$8,155.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,174.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,413.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,370.86
|
| Rate for Payer: PHCS Commercial |
$10,438.80
|
| Rate for Payer: United Healthcare All Payer |
$9,568.90
|
|
|
PROTEGE EVERFLEX STENT 6*80*12
|
Facility
|
OP
|
$10,873.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,413.59 |
| Max. Negotiated Rate |
$10,438.80 |
| Rate for Payer: Aetna Commercial |
$8,372.79
|
| Rate for Payer: Anthem Medicaid |
$3,739.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,481.52
|
| Rate for Payer: Cash Price |
$5,436.88
|
| Rate for Payer: Cigna Commercial |
$9,025.21
|
| Rate for Payer: First Health Commercial |
$10,330.06
|
| Rate for Payer: Humana Commercial |
$9,242.69
|
| Rate for Payer: Humana KY Medicaid |
$3,739.48
|
| Rate for Payer: Kentucky WC Medicaid |
$3,777.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,916.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,024.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,262.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,814.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,568.90
|
| Rate for Payer: Ohio Health Group HMO |
$8,155.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,174.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,413.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,370.86
|
| Rate for Payer: PHCS Commercial |
$10,438.80
|
| Rate for Payer: United Healthcare All Payer |
$9,568.90
|
|
|
PROTEGE EVERFLEX STENT 7*20*12
|
Facility
|
OP
|
$4,912.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$638.62 |
| Max. Negotiated Rate |
$4,716.00 |
| Rate for Payer: Aetna Commercial |
$3,782.62
|
| Rate for Payer: Anthem Medicaid |
$1,689.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,831.75
|
| Rate for Payer: Cash Price |
$2,456.25
|
| Rate for Payer: Cigna Commercial |
$4,077.38
|
| Rate for Payer: First Health Commercial |
$4,666.88
|
| Rate for Payer: Humana Commercial |
$4,175.62
|
| Rate for Payer: Humana KY Medicaid |
$1,689.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1,706.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,028.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,625.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,723.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,323.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,684.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$982.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$638.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,522.88
|
| Rate for Payer: PHCS Commercial |
$4,716.00
|
| Rate for Payer: United Healthcare All Payer |
$4,323.00
|
|
|
PROTEGE EVERFLEX STENT 7*20*12
|
Facility
|
IP
|
$4,912.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$638.62 |
| Max. Negotiated Rate |
$4,716.00 |
| Rate for Payer: Aetna Commercial |
$3,782.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,831.75
|
| Rate for Payer: Cash Price |
$2,456.25
|
| Rate for Payer: Cigna Commercial |
$4,077.38
|
| Rate for Payer: First Health Commercial |
$4,666.88
|
| Rate for Payer: Humana Commercial |
$4,175.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,028.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,625.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,323.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,684.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$982.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$638.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,522.88
|
| Rate for Payer: PHCS Commercial |
$4,716.00
|
| Rate for Payer: United Healthcare All Payer |
$4,323.00
|
|
|
PROTEGE EVERFLEX STENT 7*20*80
|
Facility
|
IP
|
$7,855.25
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,021.18 |
| Max. Negotiated Rate |
$7,541.04 |
| Rate for Payer: Aetna Commercial |
$6,048.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,127.10
|
| Rate for Payer: Cash Price |
$3,927.62
|
| Rate for Payer: Cigna Commercial |
$6,519.86
|
| Rate for Payer: First Health Commercial |
$7,462.49
|
| Rate for Payer: Humana Commercial |
$6,676.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,441.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,797.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,356.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,912.62
|
| Rate for Payer: Ohio Health Group HMO |
$5,891.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,571.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,021.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,435.13
|
| Rate for Payer: PHCS Commercial |
$7,541.04
|
| Rate for Payer: United Healthcare All Payer |
$6,912.62
|
|
|
PROTEGE EVERFLEX STENT 7*20*80
|
Facility
|
OP
|
$7,855.25
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,021.18 |
| Max. Negotiated Rate |
$7,541.04 |
| Rate for Payer: Aetna Commercial |
$6,048.54
|
| Rate for Payer: Anthem Medicaid |
$2,701.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,127.10
|
| Rate for Payer: Cash Price |
$3,927.62
|
| Rate for Payer: Cigna Commercial |
$6,519.86
|
| Rate for Payer: First Health Commercial |
$7,462.49
|
| Rate for Payer: Humana Commercial |
$6,676.96
|
| Rate for Payer: Humana KY Medicaid |
$2,701.42
|
| Rate for Payer: Kentucky WC Medicaid |
$2,728.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,441.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,797.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,356.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,755.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,912.62
|
| Rate for Payer: Ohio Health Group HMO |
$5,891.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,571.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,021.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,435.13
|
| Rate for Payer: PHCS Commercial |
$7,541.04
|
| Rate for Payer: United Healthcare All Payer |
$6,912.62
|
|
|
PROTEGE EVERFLEX STENT 7*30*12
|
Facility
|
IP
|
$4,912.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$638.62 |
| Max. Negotiated Rate |
$4,716.00 |
| Rate for Payer: Aetna Commercial |
$3,782.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,831.75
|
| Rate for Payer: Cash Price |
$2,456.25
|
| Rate for Payer: Cigna Commercial |
$4,077.38
|
| Rate for Payer: First Health Commercial |
$4,666.88
|
| Rate for Payer: Humana Commercial |
$4,175.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,028.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,625.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,323.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,684.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$982.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$638.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,522.88
|
| Rate for Payer: PHCS Commercial |
$4,716.00
|
| Rate for Payer: United Healthcare All Payer |
$4,323.00
|
|
|
PROTEGE EVERFLEX STENT 7*30*12
|
Facility
|
OP
|
$4,912.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$638.62 |
| Max. Negotiated Rate |
$4,716.00 |
| Rate for Payer: Aetna Commercial |
$3,782.62
|
| Rate for Payer: Anthem Medicaid |
$1,689.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,831.75
|
| Rate for Payer: Cash Price |
$2,456.25
|
| Rate for Payer: Cigna Commercial |
$4,077.38
|
| Rate for Payer: First Health Commercial |
$4,666.88
|
| Rate for Payer: Humana Commercial |
$4,175.62
|
| Rate for Payer: Humana KY Medicaid |
$1,689.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1,706.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,028.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,625.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,723.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,323.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,684.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$982.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$638.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,522.88
|
| Rate for Payer: PHCS Commercial |
$4,716.00
|
| Rate for Payer: United Healthcare All Payer |
$4,323.00
|
|
|
PROTEGE EVERFLEX STENT 7*40*12
|
Facility
|
OP
|
$9,643.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,253.69 |
| Max. Negotiated Rate |
$9,258.00 |
| Rate for Payer: Aetna Commercial |
$7,425.69
|
| Rate for Payer: Anthem Medicaid |
$3,316.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,522.12
|
| Rate for Payer: Cash Price |
$4,821.88
|
| Rate for Payer: Cigna Commercial |
$8,004.31
|
| Rate for Payer: First Health Commercial |
$9,161.56
|
| Rate for Payer: Humana Commercial |
$8,197.19
|
| Rate for Payer: Humana KY Medicaid |
$3,316.49
|
| Rate for Payer: Kentucky WC Medicaid |
$3,350.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,907.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,117.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,893.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,383.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,486.50
|
| Rate for Payer: Ohio Health Group HMO |
$7,232.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,928.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,253.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,989.56
|
| Rate for Payer: PHCS Commercial |
$9,258.00
|
| Rate for Payer: United Healthcare All Payer |
$8,486.50
|
|
|
PROTEGE EVERFLEX STENT 7*40*12
|
Facility
|
IP
|
$9,643.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,253.69 |
| Max. Negotiated Rate |
$9,258.00 |
| Rate for Payer: Aetna Commercial |
$7,425.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,522.12
|
| Rate for Payer: Cash Price |
$4,821.88
|
| Rate for Payer: Cigna Commercial |
$8,004.31
|
| Rate for Payer: First Health Commercial |
$9,161.56
|
| Rate for Payer: Humana Commercial |
$8,197.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,907.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,117.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,893.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,486.50
|
| Rate for Payer: Ohio Health Group HMO |
$7,232.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,928.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,253.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,989.56
|
| Rate for Payer: PHCS Commercial |
$9,258.00
|
| Rate for Payer: United Healthcare All Payer |
$8,486.50
|
|
|
PROTEGE EVERFLEX STENT 7*40*80
|
Facility
|
IP
|
$4,912.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$638.62 |
| Max. Negotiated Rate |
$4,716.00 |
| Rate for Payer: Aetna Commercial |
$3,782.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,831.75
|
| Rate for Payer: Cash Price |
$2,456.25
|
| Rate for Payer: Cigna Commercial |
$4,077.38
|
| Rate for Payer: First Health Commercial |
$4,666.88
|
| Rate for Payer: Humana Commercial |
$4,175.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,028.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,625.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,323.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,684.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$982.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$638.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,522.88
|
| Rate for Payer: PHCS Commercial |
$4,716.00
|
| Rate for Payer: United Healthcare All Payer |
$4,323.00
|
|
|
PROTEGE EVERFLEX STENT 7*40*80
|
Facility
|
OP
|
$4,912.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$638.62 |
| Max. Negotiated Rate |
$4,716.00 |
| Rate for Payer: Aetna Commercial |
$3,782.62
|
| Rate for Payer: Anthem Medicaid |
$1,689.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,831.75
|
| Rate for Payer: Cash Price |
$2,456.25
|
| Rate for Payer: Cigna Commercial |
$4,077.38
|
| Rate for Payer: First Health Commercial |
$4,666.88
|
| Rate for Payer: Humana Commercial |
$4,175.62
|
| Rate for Payer: Humana KY Medicaid |
$1,689.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1,706.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,028.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,625.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,723.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,323.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,684.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$982.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$638.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,522.88
|
| Rate for Payer: PHCS Commercial |
$4,716.00
|
| Rate for Payer: United Healthcare All Payer |
$4,323.00
|
|
