|
PROTECT&SERVE UNTINTED 30 SPF
|
Facility
|
OP
|
$65.00
|
|
| Hospital Charge Code |
22200139
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem Medicaid |
$22.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.70
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Humana KY Medicaid |
$22.35
|
| Rate for Payer: Kentucky WC Medicaid |
$22.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$56.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.85
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
PROTECT&SERVE UNTINTED 30 SPF
|
Professional
|
Both
|
$65.00
|
|
| Hospital Charge Code |
22200139
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$45.50 |
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Multiplan PHCS |
$39.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$45.50
|
| Rate for Payer: UHCCP Medicaid |
$22.75
|
|
|
PROTECT&SERVE UNTINTED 30 SPF
|
Facility
|
IP
|
$65.00
|
|
| Hospital Charge Code |
22200139
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.70
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$56.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.85
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
PROTEGE 6*200
|
Facility
|
OP
|
$8,110.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,433.00 |
| Max. Negotiated Rate |
$7,785.60 |
| Rate for Payer: Aetna Commercial |
$6,244.70
|
| Rate for Payer: Anthem Medicaid |
$2,789.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,325.80
|
| Rate for Payer: Cash Price |
$4,055.00
|
| Rate for Payer: Cigna Commercial |
$6,731.30
|
| Rate for Payer: First Health Commercial |
$7,704.50
|
| Rate for Payer: Humana Commercial |
$6,893.50
|
| Rate for Payer: Humana KY Medicaid |
$2,789.03
|
| Rate for Payer: Kentucky WC Medicaid |
$2,817.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,650.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,985.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,433.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,844.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,136.80
|
| Rate for Payer: Ohio Health Group HMO |
$6,082.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,488.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,055.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,595.90
|
| Rate for Payer: PHCS Commercial |
$7,785.60
|
| Rate for Payer: United Healthcare All Payer |
$7,136.80
|
|
|
PROTEGE 6*200
|
Facility
|
IP
|
$8,110.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,433.00 |
| Max. Negotiated Rate |
$7,785.60 |
| Rate for Payer: Aetna Commercial |
$6,244.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,325.80
|
| Rate for Payer: Cash Price |
$4,055.00
|
| Rate for Payer: Cigna Commercial |
$6,731.30
|
| Rate for Payer: First Health Commercial |
$7,704.50
|
| Rate for Payer: Humana Commercial |
$6,893.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,650.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,985.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,433.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,136.80
|
| Rate for Payer: Ohio Health Group HMO |
$6,082.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,488.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,055.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,595.90
|
| Rate for Payer: PHCS Commercial |
$7,785.60
|
| Rate for Payer: United Healthcare All Payer |
$7,136.80
|
|
|
PROTEGE 7*200
|
Facility
|
IP
|
$8,110.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,433.00 |
| Max. Negotiated Rate |
$7,785.60 |
| Rate for Payer: Aetna Commercial |
$6,244.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,325.80
|
| Rate for Payer: Cash Price |
$4,055.00
|
| Rate for Payer: Cigna Commercial |
$6,731.30
|
| Rate for Payer: First Health Commercial |
$7,704.50
|
| Rate for Payer: Humana Commercial |
$6,893.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,650.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,985.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,433.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,136.80
|
| Rate for Payer: Ohio Health Group HMO |
$6,082.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,488.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,055.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,595.90
|
| Rate for Payer: PHCS Commercial |
$7,785.60
|
| Rate for Payer: United Healthcare All Payer |
$7,136.80
|
|
|
PROTEGE 7*200
|
Facility
|
OP
|
$8,110.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,433.00 |
| Max. Negotiated Rate |
$7,785.60 |
| Rate for Payer: Aetna Commercial |
$6,244.70
|
| Rate for Payer: Anthem Medicaid |
$2,789.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,325.80
|
| Rate for Payer: Cash Price |
$4,055.00
|
| Rate for Payer: Cigna Commercial |
$6,731.30
|
| Rate for Payer: First Health Commercial |
$7,704.50
|
| Rate for Payer: Humana Commercial |
$6,893.50
|
| Rate for Payer: Humana KY Medicaid |
$2,789.03
|
| Rate for Payer: Kentucky WC Medicaid |
$2,817.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,650.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,985.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,433.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,844.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,136.80
|
| Rate for Payer: Ohio Health Group HMO |
$6,082.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,488.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,055.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,595.90
|
| Rate for Payer: PHCS Commercial |
$7,785.60
|
| Rate for Payer: United Healthcare All Payer |
$7,136.80
|
|
|
PROTEGE EF STENT LNG 6*120*120
|
Facility
|
IP
|
$9,022.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,706.75 |
| Max. Negotiated Rate |
$8,661.60 |
| Rate for Payer: Aetna Commercial |
$6,947.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,037.55
|
| Rate for Payer: Cash Price |
$4,511.25
|
| Rate for Payer: Cigna Commercial |
$7,488.68
|
| Rate for Payer: First Health Commercial |
$8,571.38
|
| Rate for Payer: Humana Commercial |
$7,669.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,398.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,658.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,706.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,939.80
|
| Rate for Payer: Ohio Health Group HMO |
$6,766.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,218.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,849.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,225.52
|
| Rate for Payer: PHCS Commercial |
$8,661.60
|
| Rate for Payer: United Healthcare All Payer |
$7,939.80
|
|
|
PROTEGE EF STENT LNG 6*120*120
|
Facility
|
OP
|
$9,022.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,706.75 |
| Max. Negotiated Rate |
$8,661.60 |
| Rate for Payer: Aetna Commercial |
$6,947.32
|
| Rate for Payer: Anthem Medicaid |
$3,102.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,037.55
|
| Rate for Payer: Cash Price |
$4,511.25
|
| Rate for Payer: Cigna Commercial |
$7,488.68
|
| Rate for Payer: First Health Commercial |
$8,571.38
|
| Rate for Payer: Humana Commercial |
$7,669.12
|
| Rate for Payer: Humana KY Medicaid |
$3,102.84
|
| Rate for Payer: Kentucky WC Medicaid |
$3,134.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,398.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,658.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,706.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,165.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,939.80
|
| Rate for Payer: Ohio Health Group HMO |
$6,766.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,218.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,849.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,225.52
|
| Rate for Payer: PHCS Commercial |
$8,661.60
|
| Rate for Payer: United Healthcare All Payer |
$7,939.80
|
|
|
PROTEGE EF STENT LNG 7*100*120
|
Facility
|
IP
|
$5,562.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
PROTEGE EF STENT LNG 7*100*120
|
Facility
|
OP
|
$5,562.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem Medicaid |
$1,912.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Humana KY Medicaid |
$1,912.94
|
| Rate for Payer: Kentucky WC Medicaid |
$1,932.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,951.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
PROTEGE EF STENT LNG 7*120*120
|
Facility
|
IP
|
$8,825.40
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,647.62 |
| Max. Negotiated Rate |
$8,472.38 |
| Rate for Payer: Aetna Commercial |
$6,795.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,883.81
|
| Rate for Payer: Cash Price |
$4,412.70
|
| Rate for Payer: Cigna Commercial |
$7,325.08
|
| Rate for Payer: First Health Commercial |
$8,384.13
|
| Rate for Payer: Humana Commercial |
$7,501.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,236.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,513.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,647.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,766.35
|
| Rate for Payer: Ohio Health Group HMO |
$6,619.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,060.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,678.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,089.53
|
| Rate for Payer: PHCS Commercial |
$8,472.38
|
| Rate for Payer: United Healthcare All Payer |
$7,766.35
|
|
|
PROTEGE EF STENT LNG 7*120*120
|
Facility
|
OP
|
$8,825.40
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,647.62 |
| Max. Negotiated Rate |
$8,472.38 |
| Rate for Payer: Aetna Commercial |
$6,795.56
|
| Rate for Payer: Anthem Medicaid |
$3,035.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,883.81
|
| Rate for Payer: Cash Price |
$4,412.70
|
| Rate for Payer: Cigna Commercial |
$7,325.08
|
| Rate for Payer: First Health Commercial |
$8,384.13
|
| Rate for Payer: Humana Commercial |
$7,501.59
|
| Rate for Payer: Humana KY Medicaid |
$3,035.06
|
| Rate for Payer: Kentucky WC Medicaid |
$3,065.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,236.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,513.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,647.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,095.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,766.35
|
| Rate for Payer: Ohio Health Group HMO |
$6,619.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,060.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,678.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,089.53
|
| Rate for Payer: PHCS Commercial |
$8,472.38
|
| Rate for Payer: United Healthcare All Payer |
$7,766.35
|
|
|
PROTEGE EF STENT LNG 8*120*120
|
Facility
|
OP
|
$5,562.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem Medicaid |
$1,912.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Humana KY Medicaid |
$1,912.94
|
| Rate for Payer: Kentucky WC Medicaid |
$1,932.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,951.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
PROTEGE EF STENT LNG 8*120*120
|
Facility
|
IP
|
$5,562.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
PROTEGE EF STENT LNG 8*150*120
|
Facility
|
IP
|
$5,562.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
PROTEGE EF STENT LNG 8*150*120
|
Facility
|
OP
|
$5,562.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem Medicaid |
$1,912.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Humana KY Medicaid |
$1,912.94
|
| Rate for Payer: Kentucky WC Medicaid |
$1,932.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,951.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
PROTEGE EF STENT LONG 6*100*12
|
Facility
|
IP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
|
PROTEGE EF STENT LONG 6*100*12
|
Facility
|
OP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem Medicaid |
$1,461.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Humana KY Medicaid |
$1,461.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1,476.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,490.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
|
PROTEGE EF STENT LONG 6*150*12
|
Facility
|
OP
|
$9,570.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,871.00 |
| Max. Negotiated Rate |
$9,187.20 |
| Rate for Payer: Aetna Commercial |
$7,368.90
|
| Rate for Payer: Anthem Medicaid |
$3,291.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,464.60
|
| Rate for Payer: Cash Price |
$4,785.00
|
| Rate for Payer: Cigna Commercial |
$7,943.10
|
| Rate for Payer: First Health Commercial |
$9,091.50
|
| Rate for Payer: Humana Commercial |
$8,134.50
|
| Rate for Payer: Humana KY Medicaid |
$3,291.12
|
| Rate for Payer: Kentucky WC Medicaid |
$3,324.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,847.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,062.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,871.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,357.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,421.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,177.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,325.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,603.30
|
| Rate for Payer: PHCS Commercial |
$9,187.20
|
| Rate for Payer: United Healthcare All Payer |
$8,421.60
|
|
|
PROTEGE EF STENT LONG 6*150*12
|
Facility
|
IP
|
$9,570.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,871.00 |
| Max. Negotiated Rate |
$9,187.20 |
| Rate for Payer: Aetna Commercial |
$7,368.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,464.60
|
| Rate for Payer: Cash Price |
$4,785.00
|
| Rate for Payer: Cigna Commercial |
$7,943.10
|
| Rate for Payer: First Health Commercial |
$9,091.50
|
| Rate for Payer: Humana Commercial |
$8,134.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,847.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,062.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,871.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,421.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,177.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,325.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,603.30
|
| Rate for Payer: PHCS Commercial |
$9,187.20
|
| Rate for Payer: United Healthcare All Payer |
$8,421.60
|
|
|
PROTEGE EF STENT LONG 7*150*12
|
Facility
|
IP
|
$12,216.25
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,664.88 |
| Max. Negotiated Rate |
$11,727.60 |
| Rate for Payer: Aetna Commercial |
$9,406.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,528.67
|
| Rate for Payer: Cash Price |
$6,108.12
|
| Rate for Payer: Cigna Commercial |
$10,139.49
|
| Rate for Payer: First Health Commercial |
$11,605.44
|
| Rate for Payer: Humana Commercial |
$10,383.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,017.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,015.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,664.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,750.30
|
| Rate for Payer: Ohio Health Group HMO |
$9,162.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,773.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,628.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,429.21
|
| Rate for Payer: PHCS Commercial |
$11,727.60
|
| Rate for Payer: United Healthcare All Payer |
$10,750.30
|
|
|
PROTEGE EF STENT LONG 7*150*12
|
Facility
|
OP
|
$12,216.25
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,664.88 |
| Max. Negotiated Rate |
$11,727.60 |
| Rate for Payer: Aetna Commercial |
$9,406.51
|
| Rate for Payer: Anthem Medicaid |
$4,201.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,528.67
|
| Rate for Payer: Cash Price |
$6,108.12
|
| Rate for Payer: Cigna Commercial |
$10,139.49
|
| Rate for Payer: First Health Commercial |
$11,605.44
|
| Rate for Payer: Humana Commercial |
$10,383.81
|
| Rate for Payer: Humana KY Medicaid |
$4,201.17
|
| Rate for Payer: Kentucky WC Medicaid |
$4,243.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,017.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,015.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,664.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,285.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,750.30
|
| Rate for Payer: Ohio Health Group HMO |
$9,162.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,773.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,628.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,429.21
|
| Rate for Payer: PHCS Commercial |
$11,727.60
|
| Rate for Payer: United Healthcare All Payer |
$10,750.30
|
|
|
PROTEGE EF STENT LONG 8*100*12
|
Facility
|
OP
|
$9,168.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,750.55 |
| Max. Negotiated Rate |
$8,801.76 |
| Rate for Payer: Aetna Commercial |
$7,059.74
|
| Rate for Payer: Anthem Medicaid |
$3,153.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,151.43
|
| Rate for Payer: Cash Price |
$4,584.25
|
| Rate for Payer: Cigna Commercial |
$7,609.85
|
| Rate for Payer: First Health Commercial |
$8,710.08
|
| Rate for Payer: Humana Commercial |
$7,793.23
|
| Rate for Payer: Humana KY Medicaid |
$3,153.05
|
| Rate for Payer: Kentucky WC Medicaid |
$3,185.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,518.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,766.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,750.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,216.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,068.28
|
| Rate for Payer: Ohio Health Group HMO |
$6,876.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,334.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,976.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,326.27
|
| Rate for Payer: PHCS Commercial |
$8,801.76
|
| Rate for Payer: United Healthcare All Payer |
$8,068.28
|
|
|
PROTEGE EF STENT LONG 8*100*12
|
Facility
|
IP
|
$9,168.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,750.55 |
| Max. Negotiated Rate |
$8,801.76 |
| Rate for Payer: Aetna Commercial |
$7,059.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,151.43
|
| Rate for Payer: Cash Price |
$4,584.25
|
| Rate for Payer: Cigna Commercial |
$7,609.85
|
| Rate for Payer: First Health Commercial |
$8,710.08
|
| Rate for Payer: Humana Commercial |
$7,793.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,518.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,766.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,750.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,068.28
|
| Rate for Payer: Ohio Health Group HMO |
$6,876.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,334.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,976.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,326.27
|
| Rate for Payer: PHCS Commercial |
$8,801.76
|
| Rate for Payer: United Healthcare All Payer |
$8,068.28
|
|
