|
STENT WALLGRAFT 12*30 COVERED
|
Facility
|
OP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem Medicaid |
$3,410.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Humana KY Medicaid |
$3,410.63
|
| Rate for Payer: Kentucky WC Medicaid |
$3,445.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,479.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
STENT WALLGRAFT 12*30 COVERED
|
Facility
|
IP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
STENT WALLGRAFT 14*50 COVERED
|
Facility
|
IP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
STENT WALLGRAFT 14*50 COVERED
|
Facility
|
OP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem Medicaid |
$3,410.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Humana KY Medicaid |
$3,410.63
|
| Rate for Payer: Kentucky WC Medicaid |
$3,445.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,479.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
STENT WALLGRAFT 6*50 COVERED
|
Facility
|
OP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem Medicaid |
$3,410.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Humana KY Medicaid |
$3,410.63
|
| Rate for Payer: Kentucky WC Medicaid |
$3,445.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,479.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
STENT WALLGRAFT 6*50 COVERED
|
Facility
|
IP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
STENT WALLGRAFT 6*70 COVERED
|
Facility
|
IP
|
$11,512.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,496.62 |
| Max. Negotiated Rate |
$11,052.00 |
| Rate for Payer: Aetna Commercial |
$8,864.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,979.75
|
| Rate for Payer: Cash Price |
$5,756.25
|
| Rate for Payer: Cigna Commercial |
$9,555.38
|
| Rate for Payer: First Health Commercial |
$10,936.88
|
| Rate for Payer: Humana Commercial |
$9,785.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,440.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,496.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,453.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,131.00
|
| Rate for Payer: Ohio Health Group HMO |
$8,634.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,302.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,496.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,568.88
|
| Rate for Payer: PHCS Commercial |
$11,052.00
|
| Rate for Payer: United Healthcare All Payer |
$10,131.00
|
|
|
STENT WALLGRAFT 6*70 COVERED
|
Facility
|
OP
|
$11,512.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,496.62 |
| Max. Negotiated Rate |
$11,052.00 |
| Rate for Payer: Aetna Commercial |
$8,864.62
|
| Rate for Payer: Anthem Medicaid |
$3,959.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,979.75
|
| Rate for Payer: Cash Price |
$5,756.25
|
| Rate for Payer: Cigna Commercial |
$9,555.38
|
| Rate for Payer: First Health Commercial |
$10,936.88
|
| Rate for Payer: Humana Commercial |
$9,785.62
|
| Rate for Payer: Humana KY Medicaid |
$3,959.15
|
| Rate for Payer: Kentucky WC Medicaid |
$3,999.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,440.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,496.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,453.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,038.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,131.00
|
| Rate for Payer: Ohio Health Group HMO |
$8,634.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,302.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,496.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,568.88
|
| Rate for Payer: PHCS Commercial |
$11,052.00
|
| Rate for Payer: United Healthcare All Payer |
$10,131.00
|
|
|
STENT WALLGRAFT 8*20 COVERED
|
Facility
|
IP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
STENT WALLGRAFT 8*20 COVERED
|
Facility
|
OP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem Medicaid |
$3,410.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Humana KY Medicaid |
$3,410.63
|
| Rate for Payer: Kentucky WC Medicaid |
$3,445.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,479.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
STENT WALLGRAFT 8*30 COVERED
|
Facility
|
OP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem Medicaid |
$3,410.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Humana KY Medicaid |
$3,410.63
|
| Rate for Payer: Kentucky WC Medicaid |
$3,445.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,479.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
STENT WALLGRAFT 8*30 COVERED
|
Facility
|
IP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
STENT ZIMMON ENDO BILI 7*10
|
Facility
|
IP
|
$1,766.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$229.64 |
| Max. Negotiated Rate |
$1,695.84 |
| Rate for Payer: Aetna Commercial |
$1,360.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,377.87
|
| Rate for Payer: Cash Price |
$883.25
|
| Rate for Payer: Cigna Commercial |
$1,466.20
|
| Rate for Payer: First Health Commercial |
$1,678.18
|
| Rate for Payer: Humana Commercial |
$1,501.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,448.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,303.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$529.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,554.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,324.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$353.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$229.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$547.62
|
| Rate for Payer: PHCS Commercial |
$1,695.84
|
| Rate for Payer: United Healthcare All Payer |
$1,554.52
|
|
|
STENT ZIMMON ENDO BILI 7*10
|
Facility
|
OP
|
$1,766.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$229.64 |
| Max. Negotiated Rate |
$1,695.84 |
| Rate for Payer: Aetna Commercial |
$1,360.20
|
| Rate for Payer: Anthem Medicaid |
$607.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,377.87
|
| Rate for Payer: Cash Price |
$883.25
|
| Rate for Payer: Cigna Commercial |
$1,466.20
|
| Rate for Payer: First Health Commercial |
$1,678.18
|
| Rate for Payer: Humana Commercial |
$1,501.52
|
| Rate for Payer: Humana KY Medicaid |
$607.50
|
| Rate for Payer: Kentucky WC Medicaid |
$613.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,448.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,303.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$529.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$619.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,554.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,324.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$353.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$229.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$547.62
|
| Rate for Payer: PHCS Commercial |
$1,695.84
|
| Rate for Payer: United Healthcare All Payer |
$1,554.52
|
|
|
STENT ZIMMON ENDO BILI 7*4
|
Facility
|
IP
|
$1,707.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$221.91 |
| Max. Negotiated Rate |
$1,638.72 |
| Rate for Payer: Aetna Commercial |
$1,314.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,331.46
|
| Rate for Payer: Cash Price |
$853.50
|
| Rate for Payer: Cigna Commercial |
$1,416.81
|
| Rate for Payer: First Health Commercial |
$1,621.65
|
| Rate for Payer: Humana Commercial |
$1,450.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,399.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,259.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$512.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,502.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,280.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$341.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$221.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$529.17
|
| Rate for Payer: PHCS Commercial |
$1,638.72
|
| Rate for Payer: United Healthcare All Payer |
$1,502.16
|
|
|
STENT ZIMMON ENDO BILI 7*4
|
Facility
|
OP
|
$1,707.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$221.91 |
| Max. Negotiated Rate |
$1,638.72 |
| Rate for Payer: Aetna Commercial |
$1,314.39
|
| Rate for Payer: Anthem Medicaid |
$587.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,331.46
|
| Rate for Payer: Cash Price |
$853.50
|
| Rate for Payer: Cigna Commercial |
$1,416.81
|
| Rate for Payer: First Health Commercial |
$1,621.65
|
| Rate for Payer: Humana Commercial |
$1,450.95
|
| Rate for Payer: Humana KY Medicaid |
$587.04
|
| Rate for Payer: Kentucky WC Medicaid |
$593.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,399.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,259.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$512.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$598.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,502.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,280.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$341.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$221.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$529.17
|
| Rate for Payer: PHCS Commercial |
$1,638.72
|
| Rate for Payer: United Healthcare All Payer |
$1,502.16
|
|
|
STENT ZIMMON ENDO BILI 7*7
|
Facility
|
IP
|
$1,717.50
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$223.28 |
| Max. Negotiated Rate |
$1,648.80 |
| Rate for Payer: Aetna Commercial |
$1,322.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,339.65
|
| Rate for Payer: Cash Price |
$858.75
|
| Rate for Payer: Cigna Commercial |
$1,425.52
|
| Rate for Payer: First Health Commercial |
$1,631.62
|
| Rate for Payer: Humana Commercial |
$1,459.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,408.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,267.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$515.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,511.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,288.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$343.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$223.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$532.42
|
| Rate for Payer: PHCS Commercial |
$1,648.80
|
| Rate for Payer: United Healthcare All Payer |
$1,511.40
|
|
|
STENT ZIMMON ENDO BILI 7*7
|
Facility
|
OP
|
$1,717.50
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$223.28 |
| Max. Negotiated Rate |
$1,648.80 |
| Rate for Payer: Aetna Commercial |
$1,322.48
|
| Rate for Payer: Anthem Medicaid |
$590.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,339.65
|
| Rate for Payer: Cash Price |
$858.75
|
| Rate for Payer: Cigna Commercial |
$1,425.52
|
| Rate for Payer: First Health Commercial |
$1,631.62
|
| Rate for Payer: Humana Commercial |
$1,459.88
|
| Rate for Payer: Humana KY Medicaid |
$590.65
|
| Rate for Payer: Kentucky WC Medicaid |
$596.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,408.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,267.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$515.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$602.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,511.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,288.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$343.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$223.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$532.42
|
| Rate for Payer: PHCS Commercial |
$1,648.80
|
| Rate for Payer: United Healthcare All Payer |
$1,511.40
|
|
|
STENT ZIMMON PANCREATIC 5.0*4C
|
Facility
|
OP
|
$1,523.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$197.99 |
| Max. Negotiated Rate |
$1,462.08 |
| Rate for Payer: Aetna Commercial |
$1,172.71
|
| Rate for Payer: Anthem Medicaid |
$523.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,187.94
|
| Rate for Payer: Cash Price |
$761.50
|
| Rate for Payer: Cigna Commercial |
$1,264.09
|
| Rate for Payer: First Health Commercial |
$1,446.85
|
| Rate for Payer: Humana Commercial |
$1,294.55
|
| Rate for Payer: Humana KY Medicaid |
$523.76
|
| Rate for Payer: Kentucky WC Medicaid |
$529.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,248.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,123.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$456.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$534.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,340.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,142.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$304.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$197.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$472.13
|
| Rate for Payer: PHCS Commercial |
$1,462.08
|
| Rate for Payer: United Healthcare All Payer |
$1,340.24
|
|
|
STENT ZIMMON PANCREATIC 5.0*4C
|
Facility
|
IP
|
$1,523.00
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$197.99 |
| Max. Negotiated Rate |
$1,462.08 |
| Rate for Payer: Aetna Commercial |
$1,172.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,187.94
|
| Rate for Payer: Cash Price |
$761.50
|
| Rate for Payer: Cigna Commercial |
$1,264.09
|
| Rate for Payer: First Health Commercial |
$1,446.85
|
| Rate for Payer: Humana Commercial |
$1,294.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,248.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,123.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$456.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,340.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,142.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$304.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$197.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$472.13
|
| Rate for Payer: PHCS Commercial |
$1,462.08
|
| Rate for Payer: United Healthcare All Payer |
$1,340.24
|
|
|
STENT ZIMMON PANC W/O FLAP 3.0
|
Facility
|
IP
|
$1,155.30
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$150.19 |
| Max. Negotiated Rate |
$1,109.09 |
| Rate for Payer: Aetna Commercial |
$889.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$901.13
|
| Rate for Payer: Cash Price |
$577.65
|
| Rate for Payer: Cigna Commercial |
$958.90
|
| Rate for Payer: First Health Commercial |
$1,097.54
|
| Rate for Payer: Humana Commercial |
$982.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$947.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$852.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$346.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,016.66
|
| Rate for Payer: Ohio Health Group HMO |
$866.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$231.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$150.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$358.14
|
| Rate for Payer: PHCS Commercial |
$1,109.09
|
| Rate for Payer: United Healthcare All Payer |
$1,016.66
|
|
|
STENT ZIMMON PANC W/O FLAP 3.0
|
Facility
|
OP
|
$1,155.30
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$150.19 |
| Max. Negotiated Rate |
$1,109.09 |
| Rate for Payer: Aetna Commercial |
$889.58
|
| Rate for Payer: Anthem Medicaid |
$397.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$901.13
|
| Rate for Payer: Cash Price |
$577.65
|
| Rate for Payer: Cigna Commercial |
$958.90
|
| Rate for Payer: First Health Commercial |
$1,097.54
|
| Rate for Payer: Humana Commercial |
$982.00
|
| Rate for Payer: Humana KY Medicaid |
$397.31
|
| Rate for Payer: Kentucky WC Medicaid |
$401.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$947.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$852.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$346.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$405.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,016.66
|
| Rate for Payer: Ohio Health Group HMO |
$866.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$231.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$150.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$358.14
|
| Rate for Payer: PHCS Commercial |
$1,109.09
|
| Rate for Payer: United Healthcare All Payer |
$1,016.66
|
|
|
STEREO RAD TREATMENT
|
Facility
|
OP
|
$1,300.00
|
|
|
Service Code
|
HCPCS 77432
|
| Hospital Charge Code |
33300039
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$169.00 |
| Max. Negotiated Rate |
$1,248.00 |
| Rate for Payer: Aetna Commercial |
$1,001.00
|
| Rate for Payer: Anthem Medicaid |
$447.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,014.00
|
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Cigna Commercial |
$1,079.00
|
| Rate for Payer: First Health Commercial |
$1,235.00
|
| Rate for Payer: Humana Commercial |
$1,105.00
|
| Rate for Payer: Humana KY Medicaid |
$447.07
|
| Rate for Payer: Kentucky WC Medicaid |
$451.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,066.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$959.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$390.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$456.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,144.00
|
| Rate for Payer: Ohio Health Group HMO |
$975.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$260.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$169.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$403.00
|
| Rate for Payer: PHCS Commercial |
$1,248.00
|
| Rate for Payer: United Healthcare All Payer |
$1,144.00
|
|
|
STEREO RAD TREATMENT
|
Facility
|
IP
|
$1,300.00
|
|
|
Service Code
|
HCPCS 77432
|
| Hospital Charge Code |
33300039
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$169.00 |
| Max. Negotiated Rate |
$1,248.00 |
| Rate for Payer: Aetna Commercial |
$1,001.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,014.00
|
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Cigna Commercial |
$1,079.00
|
| Rate for Payer: First Health Commercial |
$1,235.00
|
| Rate for Payer: Humana Commercial |
$1,105.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,066.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$959.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$390.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,144.00
|
| Rate for Payer: Ohio Health Group HMO |
$975.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$260.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$169.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$403.00
|
| Rate for Payer: PHCS Commercial |
$1,248.00
|
| Rate for Payer: United Healthcare All Payer |
$1,144.00
|
|
|
STEREOTACTIC SBRT 1-5 FRACTION
|
Facility
|
OP
|
$19,885.00
|
|
|
Service Code
|
HCPCS 77373
|
| Hospital Charge Code |
33300020
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$1,543.03 |
| Max. Negotiated Rate |
$19,089.60 |
| Rate for Payer: Aetna Commercial |
$15,311.45
|
| Rate for Payer: Anthem Medicaid |
$6,838.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,543.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,510.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,160.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,083.09
|
| Rate for Payer: Cash Price |
$9,942.50
|
| Rate for Payer: Cash Price |
$9,942.50
|
| Rate for Payer: Cigna Commercial |
$16,504.55
|
| Rate for Payer: First Health Commercial |
$18,890.75
|
| Rate for Payer: Humana Commercial |
$16,902.25
|
| Rate for Payer: Humana KY Medicaid |
$6,838.45
|
| Rate for Payer: Humana Medicare Advantage |
$1,543.03
|
| Rate for Payer: Kentucky WC Medicaid |
$6,908.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,305.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,675.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,851.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,975.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,498.80
|
| Rate for Payer: Ohio Health Group HMO |
$14,913.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,977.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,585.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,164.35
|
| Rate for Payer: PHCS Commercial |
$19,089.60
|
| Rate for Payer: United Healthcare All Payer |
$17,498.80
|
|
