|
STENT GFT AAA ILIAC EXT 5.5*16
|
Facility
|
IP
|
$10,691.25
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,389.86 |
| Max. Negotiated Rate |
$10,263.60 |
| Rate for Payer: Aetna Commercial |
$8,232.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,339.18
|
| Rate for Payer: Cash Price |
$5,345.62
|
| Rate for Payer: Cigna Commercial |
$8,873.74
|
| Rate for Payer: First Health Commercial |
$10,156.69
|
| Rate for Payer: Humana Commercial |
$9,087.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,766.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,890.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,207.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,408.30
|
| Rate for Payer: Ohio Health Group HMO |
$8,018.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,138.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,389.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,314.29
|
| Rate for Payer: PHCS Commercial |
$10,263.60
|
| Rate for Payer: United Healthcare All Payer |
$9,408.30
|
|
|
STENT GFT AAA ILIAC EXT 5.5*16
|
Facility
|
OP
|
$10,691.25
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,389.86 |
| Max. Negotiated Rate |
$10,263.60 |
| Rate for Payer: Aetna Commercial |
$8,232.26
|
| Rate for Payer: Anthem Medicaid |
$3,676.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,339.18
|
| Rate for Payer: Cash Price |
$5,345.62
|
| Rate for Payer: Cigna Commercial |
$8,873.74
|
| Rate for Payer: First Health Commercial |
$10,156.69
|
| Rate for Payer: Humana Commercial |
$9,087.56
|
| Rate for Payer: Humana KY Medicaid |
$3,676.72
|
| Rate for Payer: Kentucky WC Medicaid |
$3,714.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,766.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,890.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,207.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,750.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,408.30
|
| Rate for Payer: Ohio Health Group HMO |
$8,018.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,138.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,389.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,314.29
|
| Rate for Payer: PHCS Commercial |
$10,263.60
|
| Rate for Payer: United Healthcare All Payer |
$9,408.30
|
|
|
STENT GRAFT AAA BIF 13.5*20*12
|
Facility
|
IP
|
$31,262.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,064.12 |
| Max. Negotiated Rate |
$30,012.00 |
| Rate for Payer: Aetna Commercial |
$24,072.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24,384.75
|
| Rate for Payer: Cash Price |
$15,631.25
|
| Rate for Payer: Cigna Commercial |
$25,947.88
|
| Rate for Payer: First Health Commercial |
$29,699.38
|
| Rate for Payer: Humana Commercial |
$26,573.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25,635.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,071.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,378.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$27,511.00
|
| Rate for Payer: Ohio Health Group HMO |
$23,446.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,252.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,064.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,691.38
|
| Rate for Payer: PHCS Commercial |
$30,012.00
|
| Rate for Payer: United Healthcare All Payer |
$27,511.00
|
|
|
STENT GRAFT AAA BIF 13.5*20*12
|
Facility
|
OP
|
$31,262.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,064.12 |
| Max. Negotiated Rate |
$30,012.00 |
| Rate for Payer: Aetna Commercial |
$24,072.12
|
| Rate for Payer: Anthem Medicaid |
$10,751.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24,384.75
|
| Rate for Payer: Cash Price |
$15,631.25
|
| Rate for Payer: Cigna Commercial |
$25,947.88
|
| Rate for Payer: First Health Commercial |
$29,699.38
|
| Rate for Payer: Humana Commercial |
$26,573.12
|
| Rate for Payer: Humana KY Medicaid |
$10,751.17
|
| Rate for Payer: Kentucky WC Medicaid |
$10,860.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25,635.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,071.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,378.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,966.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$27,511.00
|
| Rate for Payer: Ohio Health Group HMO |
$23,446.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,252.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,064.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,691.38
|
| Rate for Payer: PHCS Commercial |
$30,012.00
|
| Rate for Payer: United Healthcare All Payer |
$27,511.00
|
|
|
STENT GRAFT AAA BIF 13.5*22*13
|
Facility
|
IP
|
$31,262.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,064.12 |
| Max. Negotiated Rate |
$30,012.00 |
| Rate for Payer: Aetna Commercial |
$24,072.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24,384.75
|
| Rate for Payer: Cash Price |
$15,631.25
|
| Rate for Payer: Cigna Commercial |
$25,947.88
|
| Rate for Payer: First Health Commercial |
$29,699.38
|
| Rate for Payer: Humana Commercial |
$26,573.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25,635.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,071.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,378.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$27,511.00
|
| Rate for Payer: Ohio Health Group HMO |
$23,446.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,252.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,064.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,691.38
|
| Rate for Payer: PHCS Commercial |
$30,012.00
|
| Rate for Payer: United Healthcare All Payer |
$27,511.00
|
|
|
STENT GRAFT AAA BIF 13.5*22*13
|
Facility
|
OP
|
$31,262.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,064.12 |
| Max. Negotiated Rate |
$30,012.00 |
| Rate for Payer: Aetna Commercial |
$24,072.12
|
| Rate for Payer: Anthem Medicaid |
$10,751.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24,384.75
|
| Rate for Payer: Cash Price |
$15,631.25
|
| Rate for Payer: Cigna Commercial |
$25,947.88
|
| Rate for Payer: First Health Commercial |
$29,699.38
|
| Rate for Payer: Humana Commercial |
$26,573.12
|
| Rate for Payer: Humana KY Medicaid |
$10,751.17
|
| Rate for Payer: Kentucky WC Medicaid |
$10,860.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25,635.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,071.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,378.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,966.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$27,511.00
|
| Rate for Payer: Ohio Health Group HMO |
$23,446.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,252.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,064.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,691.38
|
| Rate for Payer: PHCS Commercial |
$30,012.00
|
| Rate for Payer: United Healthcare All Payer |
$27,511.00
|
|
|
STENT GRAFT AAA BIF 13.5*26*15
|
Facility
|
IP
|
$31,262.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,064.12 |
| Max. Negotiated Rate |
$30,012.00 |
| Rate for Payer: Aetna Commercial |
$24,072.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24,384.75
|
| Rate for Payer: Cash Price |
$15,631.25
|
| Rate for Payer: Cigna Commercial |
$25,947.88
|
| Rate for Payer: First Health Commercial |
$29,699.38
|
| Rate for Payer: Humana Commercial |
$26,573.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25,635.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,071.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,378.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$27,511.00
|
| Rate for Payer: Ohio Health Group HMO |
$23,446.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,252.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,064.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,691.38
|
| Rate for Payer: PHCS Commercial |
$30,012.00
|
| Rate for Payer: United Healthcare All Payer |
$27,511.00
|
|
|
STENT GRAFT AAA BIF 13.5*26*15
|
Facility
|
OP
|
$31,262.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,064.12 |
| Max. Negotiated Rate |
$30,012.00 |
| Rate for Payer: Aetna Commercial |
$24,072.12
|
| Rate for Payer: Anthem Medicaid |
$10,751.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24,384.75
|
| Rate for Payer: Cash Price |
$15,631.25
|
| Rate for Payer: Cigna Commercial |
$25,947.88
|
| Rate for Payer: First Health Commercial |
$29,699.38
|
| Rate for Payer: Humana Commercial |
$26,573.12
|
| Rate for Payer: Humana KY Medicaid |
$10,751.17
|
| Rate for Payer: Kentucky WC Medicaid |
$10,860.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25,635.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,071.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,378.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,966.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$27,511.00
|
| Rate for Payer: Ohio Health Group HMO |
$23,446.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,252.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,064.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,691.38
|
| Rate for Payer: PHCS Commercial |
$30,012.00
|
| Rate for Payer: United Healthcare All Payer |
$27,511.00
|
|
|
STENT GRAFT AAA BIF 16.5*20*12
|
Facility
|
OP
|
$32,357.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,206.48 |
| Max. Negotiated Rate |
$31,063.20 |
| Rate for Payer: Aetna Commercial |
$24,915.28
|
| Rate for Payer: Anthem Medicaid |
$11,127.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,238.85
|
| Rate for Payer: Cash Price |
$16,178.75
|
| Rate for Payer: Cigna Commercial |
$26,856.72
|
| Rate for Payer: First Health Commercial |
$30,739.62
|
| Rate for Payer: Humana Commercial |
$27,503.88
|
| Rate for Payer: Humana KY Medicaid |
$11,127.74
|
| Rate for Payer: Kentucky WC Medicaid |
$11,241.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26,533.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,879.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,707.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,351.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$28,474.60
|
| Rate for Payer: Ohio Health Group HMO |
$24,268.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,471.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,206.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,030.82
|
| Rate for Payer: PHCS Commercial |
$31,063.20
|
| Rate for Payer: United Healthcare All Payer |
$28,474.60
|
|
|
STENT GRAFT AAA BIF 16.5*20*12
|
Facility
|
IP
|
$32,357.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,206.48 |
| Max. Negotiated Rate |
$31,063.20 |
| Rate for Payer: Aetna Commercial |
$24,915.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,238.85
|
| Rate for Payer: Cash Price |
$16,178.75
|
| Rate for Payer: Cigna Commercial |
$26,856.72
|
| Rate for Payer: First Health Commercial |
$30,739.62
|
| Rate for Payer: Humana Commercial |
$27,503.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26,533.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,879.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,707.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$28,474.60
|
| Rate for Payer: Ohio Health Group HMO |
$24,268.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,471.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,206.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,030.82
|
| Rate for Payer: PHCS Commercial |
$31,063.20
|
| Rate for Payer: United Healthcare All Payer |
$28,474.60
|
|
|
STENT GRAFT AAA BIF 16.5*22*13
|
Facility
|
IP
|
$32,357.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,206.48 |
| Max. Negotiated Rate |
$31,063.20 |
| Rate for Payer: Aetna Commercial |
$24,915.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,238.85
|
| Rate for Payer: Cash Price |
$16,178.75
|
| Rate for Payer: Cigna Commercial |
$26,856.72
|
| Rate for Payer: First Health Commercial |
$30,739.62
|
| Rate for Payer: Humana Commercial |
$27,503.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26,533.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,879.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,707.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$28,474.60
|
| Rate for Payer: Ohio Health Group HMO |
$24,268.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,471.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,206.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,030.82
|
| Rate for Payer: PHCS Commercial |
$31,063.20
|
| Rate for Payer: United Healthcare All Payer |
$28,474.60
|
|
|
STENT GRAFT AAA BIF 16.5*22*13
|
Facility
|
OP
|
$32,357.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,206.48 |
| Max. Negotiated Rate |
$31,063.20 |
| Rate for Payer: Aetna Commercial |
$24,915.28
|
| Rate for Payer: Anthem Medicaid |
$11,127.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,238.85
|
| Rate for Payer: Cash Price |
$16,178.75
|
| Rate for Payer: Cigna Commercial |
$26,856.72
|
| Rate for Payer: First Health Commercial |
$30,739.62
|
| Rate for Payer: Humana Commercial |
$27,503.88
|
| Rate for Payer: Humana KY Medicaid |
$11,127.74
|
| Rate for Payer: Kentucky WC Medicaid |
$11,241.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26,533.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,879.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,707.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,351.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$28,474.60
|
| Rate for Payer: Ohio Health Group HMO |
$24,268.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,471.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,206.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,030.82
|
| Rate for Payer: PHCS Commercial |
$31,063.20
|
| Rate for Payer: United Healthcare All Payer |
$28,474.60
|
|
|
STENT GRAFT AAA BIF 16.5*24*14
|
Facility
|
OP
|
$32,357.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,206.48 |
| Max. Negotiated Rate |
$31,063.20 |
| Rate for Payer: Aetna Commercial |
$24,915.28
|
| Rate for Payer: Anthem Medicaid |
$11,127.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,238.85
|
| Rate for Payer: Cash Price |
$16,178.75
|
| Rate for Payer: Cigna Commercial |
$26,856.72
|
| Rate for Payer: First Health Commercial |
$30,739.62
|
| Rate for Payer: Humana Commercial |
$27,503.88
|
| Rate for Payer: Humana KY Medicaid |
$11,127.74
|
| Rate for Payer: Kentucky WC Medicaid |
$11,241.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26,533.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,879.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,707.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,351.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$28,474.60
|
| Rate for Payer: Ohio Health Group HMO |
$24,268.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,471.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,206.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,030.82
|
| Rate for Payer: PHCS Commercial |
$31,063.20
|
| Rate for Payer: United Healthcare All Payer |
$28,474.60
|
|
|
STENT GRAFT AAA BIF 16.5*24*14
|
Facility
|
IP
|
$32,357.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,206.48 |
| Max. Negotiated Rate |
$31,063.20 |
| Rate for Payer: Aetna Commercial |
$24,915.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,238.85
|
| Rate for Payer: Cash Price |
$16,178.75
|
| Rate for Payer: Cigna Commercial |
$26,856.72
|
| Rate for Payer: First Health Commercial |
$30,739.62
|
| Rate for Payer: Humana Commercial |
$27,503.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26,533.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,879.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,707.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$28,474.60
|
| Rate for Payer: Ohio Health Group HMO |
$24,268.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,471.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,206.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,030.82
|
| Rate for Payer: PHCS Commercial |
$31,063.20
|
| Rate for Payer: United Healthcare All Payer |
$28,474.60
|
|
|
STENT GRAFT AAA BIF 16.5*26*15
|
Facility
|
IP
|
$32,357.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,206.48 |
| Max. Negotiated Rate |
$31,063.20 |
| Rate for Payer: Aetna Commercial |
$24,915.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,238.85
|
| Rate for Payer: Cash Price |
$16,178.75
|
| Rate for Payer: Cigna Commercial |
$26,856.72
|
| Rate for Payer: First Health Commercial |
$30,739.62
|
| Rate for Payer: Humana Commercial |
$27,503.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26,533.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,879.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,707.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$28,474.60
|
| Rate for Payer: Ohio Health Group HMO |
$24,268.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,471.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,206.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,030.82
|
| Rate for Payer: PHCS Commercial |
$31,063.20
|
| Rate for Payer: United Healthcare All Payer |
$28,474.60
|
|
|
STENT GRAFT AAA BIF 16.5*26*15
|
Facility
|
OP
|
$32,357.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,206.48 |
| Max. Negotiated Rate |
$31,063.20 |
| Rate for Payer: Aetna Commercial |
$24,915.28
|
| Rate for Payer: Anthem Medicaid |
$11,127.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,238.85
|
| Rate for Payer: Cash Price |
$16,178.75
|
| Rate for Payer: Cigna Commercial |
$26,856.72
|
| Rate for Payer: First Health Commercial |
$30,739.62
|
| Rate for Payer: Humana Commercial |
$27,503.88
|
| Rate for Payer: Humana KY Medicaid |
$11,127.74
|
| Rate for Payer: Kentucky WC Medicaid |
$11,241.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26,533.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,879.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,707.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,351.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$28,474.60
|
| Rate for Payer: Ohio Health Group HMO |
$24,268.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,471.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,206.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,030.82
|
| Rate for Payer: PHCS Commercial |
$31,063.20
|
| Rate for Payer: United Healthcare All Payer |
$28,474.60
|
|
|
STENT GRAFT AAA BIF 16.5*28*16
|
Facility
|
OP
|
$32,357.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,206.48 |
| Max. Negotiated Rate |
$31,063.20 |
| Rate for Payer: Aetna Commercial |
$24,915.28
|
| Rate for Payer: Anthem Medicaid |
$11,127.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,238.85
|
| Rate for Payer: Cash Price |
$16,178.75
|
| Rate for Payer: Cigna Commercial |
$26,856.72
|
| Rate for Payer: First Health Commercial |
$30,739.62
|
| Rate for Payer: Humana Commercial |
$27,503.88
|
| Rate for Payer: Humana KY Medicaid |
$11,127.74
|
| Rate for Payer: Kentucky WC Medicaid |
$11,241.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26,533.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,879.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,707.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,351.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$28,474.60
|
| Rate for Payer: Ohio Health Group HMO |
$24,268.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,471.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,206.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,030.82
|
| Rate for Payer: PHCS Commercial |
$31,063.20
|
| Rate for Payer: United Healthcare All Payer |
$28,474.60
|
|
|
STENT GRAFT AAA BIF 16.5*28*16
|
Facility
|
IP
|
$32,357.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,206.48 |
| Max. Negotiated Rate |
$31,063.20 |
| Rate for Payer: Aetna Commercial |
$24,915.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,238.85
|
| Rate for Payer: Cash Price |
$16,178.75
|
| Rate for Payer: Cigna Commercial |
$26,856.72
|
| Rate for Payer: First Health Commercial |
$30,739.62
|
| Rate for Payer: Humana Commercial |
$27,503.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26,533.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,879.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,707.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$28,474.60
|
| Rate for Payer: Ohio Health Group HMO |
$24,268.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,471.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,206.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,030.82
|
| Rate for Payer: PHCS Commercial |
$31,063.20
|
| Rate for Payer: United Healthcare All Payer |
$28,474.60
|
|
|
STENT GRAFT AAA ILIAC 11.5*12
|
Facility
|
OP
|
$12,151.25
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,579.66 |
| Max. Negotiated Rate |
$11,665.20 |
| Rate for Payer: Aetna Commercial |
$9,356.46
|
| Rate for Payer: Anthem Medicaid |
$4,178.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,477.98
|
| Rate for Payer: Cash Price |
$6,075.62
|
| Rate for Payer: Cigna Commercial |
$10,085.54
|
| Rate for Payer: First Health Commercial |
$11,543.69
|
| Rate for Payer: Humana Commercial |
$10,328.56
|
| Rate for Payer: Humana KY Medicaid |
$4,178.81
|
| Rate for Payer: Kentucky WC Medicaid |
$4,221.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,964.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,967.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,645.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,693.10
|
| Rate for Payer: Ohio Health Group HMO |
$9,113.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,430.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,579.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,766.89
|
| Rate for Payer: PHCS Commercial |
$11,665.20
|
| Rate for Payer: United Healthcare All Payer |
$10,693.10
|
|
|
STENT GRAFT AAA ILIAC 11.5*12
|
Facility
|
IP
|
$12,151.25
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,579.66 |
| Max. Negotiated Rate |
$11,665.20 |
| Rate for Payer: Aetna Commercial |
$9,356.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,477.98
|
| Rate for Payer: Cash Price |
$6,075.62
|
| Rate for Payer: Cigna Commercial |
$10,085.54
|
| Rate for Payer: First Health Commercial |
$11,543.69
|
| Rate for Payer: Humana Commercial |
$10,328.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,964.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,967.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,645.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,693.10
|
| Rate for Payer: Ohio Health Group HMO |
$9,113.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,430.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,579.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,766.89
|
| Rate for Payer: PHCS Commercial |
$11,665.20
|
| Rate for Payer: United Healthcare All Payer |
$10,693.10
|
|
|
STENT GRAFT AAA ILIAC 11.5*13
|
Facility
|
IP
|
$12,151.25
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,579.66 |
| Max. Negotiated Rate |
$11,665.20 |
| Rate for Payer: Aetna Commercial |
$9,356.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,477.98
|
| Rate for Payer: Cash Price |
$6,075.62
|
| Rate for Payer: Cigna Commercial |
$10,085.54
|
| Rate for Payer: First Health Commercial |
$11,543.69
|
| Rate for Payer: Humana Commercial |
$10,328.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,964.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,967.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,645.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,693.10
|
| Rate for Payer: Ohio Health Group HMO |
$9,113.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,430.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,579.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,766.89
|
| Rate for Payer: PHCS Commercial |
$11,665.20
|
| Rate for Payer: United Healthcare All Payer |
$10,693.10
|
|
|
STENT GRAFT AAA ILIAC 11.5*13
|
Facility
|
OP
|
$12,151.25
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,579.66 |
| Max. Negotiated Rate |
$11,665.20 |
| Rate for Payer: Aetna Commercial |
$9,356.46
|
| Rate for Payer: Anthem Medicaid |
$4,178.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,477.98
|
| Rate for Payer: Cash Price |
$6,075.62
|
| Rate for Payer: Cigna Commercial |
$10,085.54
|
| Rate for Payer: First Health Commercial |
$11,543.69
|
| Rate for Payer: Humana Commercial |
$10,328.56
|
| Rate for Payer: Humana KY Medicaid |
$4,178.81
|
| Rate for Payer: Kentucky WC Medicaid |
$4,221.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,964.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,967.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,645.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,693.10
|
| Rate for Payer: Ohio Health Group HMO |
$9,113.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,430.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,579.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,766.89
|
| Rate for Payer: PHCS Commercial |
$11,665.20
|
| Rate for Payer: United Healthcare All Payer |
$10,693.10
|
|
|
STENT GRAFT AAA ILIAC 11.5*15
|
Facility
|
OP
|
$12,151.25
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,579.66 |
| Max. Negotiated Rate |
$11,665.20 |
| Rate for Payer: Aetna Commercial |
$9,356.46
|
| Rate for Payer: Anthem Medicaid |
$4,178.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,477.98
|
| Rate for Payer: Cash Price |
$6,075.62
|
| Rate for Payer: Cigna Commercial |
$10,085.54
|
| Rate for Payer: First Health Commercial |
$11,543.69
|
| Rate for Payer: Humana Commercial |
$10,328.56
|
| Rate for Payer: Humana KY Medicaid |
$4,178.81
|
| Rate for Payer: Kentucky WC Medicaid |
$4,221.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,964.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,967.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,645.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,693.10
|
| Rate for Payer: Ohio Health Group HMO |
$9,113.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,430.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,579.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,766.89
|
| Rate for Payer: PHCS Commercial |
$11,665.20
|
| Rate for Payer: United Healthcare All Payer |
$10,693.10
|
|
|
STENT GRAFT AAA ILIAC 11.5*15
|
Facility
|
IP
|
$12,151.25
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,579.66 |
| Max. Negotiated Rate |
$11,665.20 |
| Rate for Payer: Aetna Commercial |
$9,356.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,477.98
|
| Rate for Payer: Cash Price |
$6,075.62
|
| Rate for Payer: Cigna Commercial |
$10,085.54
|
| Rate for Payer: First Health Commercial |
$11,543.69
|
| Rate for Payer: Humana Commercial |
$10,328.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,964.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,967.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,645.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,693.10
|
| Rate for Payer: Ohio Health Group HMO |
$9,113.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,430.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,579.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,766.89
|
| Rate for Payer: PHCS Commercial |
$11,665.20
|
| Rate for Payer: United Healthcare All Payer |
$10,693.10
|
|
|
STENT GRAFT AAA ILIAC 8.5*12
|
Facility
|
IP
|
$11,421.25
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,484.76 |
| Max. Negotiated Rate |
$10,964.40 |
| Rate for Payer: Aetna Commercial |
$8,794.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,908.58
|
| Rate for Payer: Cash Price |
$5,710.62
|
| Rate for Payer: Cigna Commercial |
$9,479.64
|
| Rate for Payer: First Health Commercial |
$10,850.19
|
| Rate for Payer: Humana Commercial |
$9,708.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,365.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,428.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,426.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,050.70
|
| Rate for Payer: Ohio Health Group HMO |
$8,565.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,284.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,484.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,540.59
|
| Rate for Payer: PHCS Commercial |
$10,964.40
|
| Rate for Payer: United Healthcare All Payer |
$10,050.70
|
|
