|
PROTEGE EVERFLEX STENT 6*20*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 EVERFLEX STENT 6*20*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 EVERFLEX STENT 6*30*12
|
Facility
|
OP
|
$9,843.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,953.12 |
| Max. Negotiated Rate |
$9,450.00 |
| Rate for Payer: Aetna Commercial |
$7,579.69
|
| Rate for Payer: Anthem Medicaid |
$3,385.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,678.12
|
| Rate for Payer: Cash Price |
$4,921.88
|
| Rate for Payer: Cigna Commercial |
$8,170.31
|
| Rate for Payer: First Health Commercial |
$9,351.56
|
| Rate for Payer: Humana Commercial |
$8,367.19
|
| Rate for Payer: Humana KY Medicaid |
$3,385.27
|
| Rate for Payer: Kentucky WC Medicaid |
$3,419.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,071.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,264.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,953.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,453.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,662.50
|
| Rate for Payer: Ohio Health Group HMO |
$7,382.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,875.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,564.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,792.19
|
| Rate for Payer: PHCS Commercial |
$9,450.00
|
| Rate for Payer: United Healthcare All Payer |
$8,662.50
|
|
|
PROTEGE EVERFLEX STENT 6*30*12
|
Facility
|
IP
|
$9,843.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,953.12 |
| Max. Negotiated Rate |
$9,450.00 |
| Rate for Payer: Aetna Commercial |
$7,579.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,678.12
|
| Rate for Payer: Cash Price |
$4,921.88
|
| Rate for Payer: Cigna Commercial |
$8,170.31
|
| Rate for Payer: First Health Commercial |
$9,351.56
|
| Rate for Payer: Humana Commercial |
$8,367.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,071.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,264.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,953.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,662.50
|
| Rate for Payer: Ohio Health Group HMO |
$7,382.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,875.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,564.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,792.19
|
| Rate for Payer: PHCS Commercial |
$9,450.00
|
| Rate for Payer: United Healthcare All Payer |
$8,662.50
|
|
|
PROTEGE EVERFLEX STENT 6*40*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 EVERFLEX STENT 6*40*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 EVERFLEX STENT 6*60*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 EVERFLEX STENT 6*60*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 EVERFLEX STENT 6*80*12
|
Facility
|
OP
|
$11,115.25
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,334.57 |
| Max. Negotiated Rate |
$10,670.64 |
| Rate for Payer: Aetna Commercial |
$8,558.74
|
| Rate for Payer: Anthem Medicaid |
$3,822.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,669.90
|
| Rate for Payer: Cash Price |
$5,557.62
|
| Rate for Payer: Cigna Commercial |
$9,225.66
|
| Rate for Payer: First Health Commercial |
$10,559.49
|
| Rate for Payer: Humana Commercial |
$9,447.96
|
| Rate for Payer: Humana KY Medicaid |
$3,822.53
|
| Rate for Payer: Kentucky WC Medicaid |
$3,861.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,114.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,203.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,334.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,899.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,781.42
|
| Rate for Payer: Ohio Health Group HMO |
$8,336.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,892.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,670.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,669.52
|
| Rate for Payer: PHCS Commercial |
$10,670.64
|
| Rate for Payer: United Healthcare All Payer |
$9,781.42
|
|
|
PROTEGE EVERFLEX STENT 6*80*12
|
Facility
|
IP
|
$11,115.25
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,334.57 |
| Max. Negotiated Rate |
$10,670.64 |
| Rate for Payer: Aetna Commercial |
$8,558.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,669.90
|
| Rate for Payer: Cash Price |
$5,557.62
|
| Rate for Payer: Cigna Commercial |
$9,225.66
|
| Rate for Payer: First Health Commercial |
$10,559.49
|
| Rate for Payer: Humana Commercial |
$9,447.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,114.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,203.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,334.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,781.42
|
| Rate for Payer: Ohio Health Group HMO |
$8,336.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,892.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,670.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,669.52
|
| Rate for Payer: PHCS Commercial |
$10,670.64
|
| Rate for Payer: United Healthcare All Payer |
$9,781.42
|
|
|
PROTEGE EVERFLEX STENT 7*20*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 EVERFLEX STENT 7*20*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 EVERFLEX STENT 7*20*80
|
Facility
|
OP
|
$8,055.25
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,416.57 |
| Max. Negotiated Rate |
$7,733.04 |
| Rate for Payer: Aetna Commercial |
$6,202.54
|
| Rate for Payer: Anthem Medicaid |
$2,770.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,283.10
|
| Rate for Payer: Cash Price |
$4,027.62
|
| Rate for Payer: Cigna Commercial |
$6,685.86
|
| Rate for Payer: First Health Commercial |
$7,652.49
|
| Rate for Payer: Humana Commercial |
$6,846.96
|
| Rate for Payer: Humana KY Medicaid |
$2,770.20
|
| Rate for Payer: Kentucky WC Medicaid |
$2,798.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,605.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,944.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,416.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,825.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,088.62
|
| Rate for Payer: Ohio Health Group HMO |
$6,041.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,444.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,008.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,558.12
|
| Rate for Payer: PHCS Commercial |
$7,733.04
|
| Rate for Payer: United Healthcare All Payer |
$7,088.62
|
|
|
PROTEGE EVERFLEX STENT 7*20*80
|
Facility
|
IP
|
$8,055.25
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,416.57 |
| Max. Negotiated Rate |
$7,733.04 |
| Rate for Payer: Aetna Commercial |
$6,202.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,283.10
|
| Rate for Payer: Cash Price |
$4,027.62
|
| Rate for Payer: Cigna Commercial |
$6,685.86
|
| Rate for Payer: First Health Commercial |
$7,652.49
|
| Rate for Payer: Humana Commercial |
$6,846.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,605.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,944.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,416.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,088.62
|
| Rate for Payer: Ohio Health Group HMO |
$6,041.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,444.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,008.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,558.12
|
| Rate for Payer: PHCS Commercial |
$7,733.04
|
| Rate for Payer: United Healthcare All Payer |
$7,088.62
|
|
|
PROTEGE EVERFLEX STENT 7*30*12
|
Facility
|
IP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
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
|
|
|
PROTEGE EVERFLEX STENT 7*30*12
|
Facility
|
OP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
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
|
|
|
PROTEGE EVERFLEX STENT 7*40*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 EVERFLEX STENT 7*40*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 EVERFLEX STENT 7*40*80
|
Facility
|
OP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
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
|
|
|
PROTEGE EVERFLEX STENT 7*40*80
|
Facility
|
IP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
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
|
|
|
PROTEGE EVERFLEX STENT 7*60*12
|
Facility
|
IP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
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
|
|
|
PROTEGE EVERFLEX STENT 7*60*12
|
Facility
|
OP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
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
|
|
|
PROTEGE EVERFLEX STENT 7*60*80
|
Facility
|
IP
|
$7,058.80
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,117.64 |
| Max. Negotiated Rate |
$6,776.45 |
| Rate for Payer: Aetna Commercial |
$5,435.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,505.86
|
| Rate for Payer: Cash Price |
$3,529.40
|
| Rate for Payer: Cigna Commercial |
$5,858.80
|
| Rate for Payer: First Health Commercial |
$6,705.86
|
| Rate for Payer: Humana Commercial |
$5,999.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,788.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,209.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,117.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,211.74
|
| Rate for Payer: Ohio Health Group HMO |
$5,294.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,647.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,141.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,870.57
|
| Rate for Payer: PHCS Commercial |
$6,776.45
|
| Rate for Payer: United Healthcare All Payer |
$6,211.74
|
|
|
PROTEGE EVERFLEX STENT 7*60*80
|
Facility
|
OP
|
$7,058.80
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,117.64 |
| Max. Negotiated Rate |
$6,776.45 |
| Rate for Payer: Aetna Commercial |
$5,435.28
|
| Rate for Payer: Anthem Medicaid |
$2,427.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,505.86
|
| Rate for Payer: Cash Price |
$3,529.40
|
| Rate for Payer: Cigna Commercial |
$5,858.80
|
| Rate for Payer: First Health Commercial |
$6,705.86
|
| Rate for Payer: Humana Commercial |
$5,999.98
|
| Rate for Payer: Humana KY Medicaid |
$2,427.52
|
| Rate for Payer: Kentucky WC Medicaid |
$2,452.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,788.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,209.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,117.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,476.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,211.74
|
| Rate for Payer: Ohio Health Group HMO |
$5,294.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,647.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,141.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,870.57
|
| Rate for Payer: PHCS Commercial |
$6,776.45
|
| Rate for Payer: United Healthcare All Payer |
$6,211.74
|
|
|
PROTEGE EVERFLEX STENT 7*80*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
|
|
