|
SUMMIT CEM STEM STD OFFST SZ 6
|
Facility
|
IP
|
$15,406.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,002.79 |
| Max. Negotiated Rate |
$14,789.84 |
| Rate for Payer: Aetna Commercial |
$11,862.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,016.74
|
| Rate for Payer: Cash Price |
$7,703.04
|
| Rate for Payer: Cigna Commercial |
$12,787.05
|
| Rate for Payer: First Health Commercial |
$14,635.78
|
| Rate for Payer: Humana Commercial |
$13,095.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,632.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,369.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,621.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,557.35
|
| Rate for Payer: Ohio Health Group HMO |
$11,554.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,081.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,002.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,775.88
|
| Rate for Payer: PHCS Commercial |
$14,789.84
|
| Rate for Payer: United Healthcare All Payer |
$13,557.35
|
|
|
SUMMIT CEM STEM STD OFFST SZ 7
|
Facility
|
OP
|
$15,406.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,002.79 |
| Max. Negotiated Rate |
$14,789.84 |
| Rate for Payer: Aetna Commercial |
$11,862.68
|
| Rate for Payer: Anthem Medicaid |
$5,298.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,016.74
|
| Rate for Payer: Cash Price |
$7,703.04
|
| Rate for Payer: Cigna Commercial |
$12,787.05
|
| Rate for Payer: First Health Commercial |
$14,635.78
|
| Rate for Payer: Humana Commercial |
$13,095.17
|
| Rate for Payer: Humana KY Medicaid |
$5,298.15
|
| Rate for Payer: Kentucky WC Medicaid |
$5,352.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,632.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,369.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,621.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,404.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,557.35
|
| Rate for Payer: Ohio Health Group HMO |
$11,554.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,081.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,002.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,775.88
|
| Rate for Payer: PHCS Commercial |
$14,789.84
|
| Rate for Payer: United Healthcare All Payer |
$13,557.35
|
|
|
SUMMIT CEM STEM STD OFFST SZ 7
|
Facility
|
IP
|
$15,406.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,002.79 |
| Max. Negotiated Rate |
$14,789.84 |
| Rate for Payer: Aetna Commercial |
$11,862.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,016.74
|
| Rate for Payer: Cash Price |
$7,703.04
|
| Rate for Payer: Cigna Commercial |
$12,787.05
|
| Rate for Payer: First Health Commercial |
$14,635.78
|
| Rate for Payer: Humana Commercial |
$13,095.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,632.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,369.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,621.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,557.35
|
| Rate for Payer: Ohio Health Group HMO |
$11,554.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,081.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,002.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,775.88
|
| Rate for Payer: PHCS Commercial |
$14,789.84
|
| Rate for Payer: United Healthcare All Payer |
$13,557.35
|
|
|
SUMMIT CEM STEM STD OFFST SZ 8
|
Facility
|
OP
|
$15,406.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,002.79 |
| Max. Negotiated Rate |
$14,789.84 |
| Rate for Payer: Aetna Commercial |
$11,862.68
|
| Rate for Payer: Anthem Medicaid |
$5,298.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,016.74
|
| Rate for Payer: Cash Price |
$7,703.04
|
| Rate for Payer: Cigna Commercial |
$12,787.05
|
| Rate for Payer: First Health Commercial |
$14,635.78
|
| Rate for Payer: Humana Commercial |
$13,095.17
|
| Rate for Payer: Humana KY Medicaid |
$5,298.15
|
| Rate for Payer: Kentucky WC Medicaid |
$5,352.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,632.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,369.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,621.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,404.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,557.35
|
| Rate for Payer: Ohio Health Group HMO |
$11,554.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,081.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,002.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,775.88
|
| Rate for Payer: PHCS Commercial |
$14,789.84
|
| Rate for Payer: United Healthcare All Payer |
$13,557.35
|
|
|
SUMMIT CEM STEM STD OFFST SZ 8
|
Facility
|
IP
|
$15,406.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,002.79 |
| Max. Negotiated Rate |
$14,789.84 |
| Rate for Payer: Aetna Commercial |
$11,862.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,016.74
|
| Rate for Payer: Cash Price |
$7,703.04
|
| Rate for Payer: Cigna Commercial |
$12,787.05
|
| Rate for Payer: First Health Commercial |
$14,635.78
|
| Rate for Payer: Humana Commercial |
$13,095.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,632.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,369.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,621.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,557.35
|
| Rate for Payer: Ohio Health Group HMO |
$11,554.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,081.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,002.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,775.88
|
| Rate for Payer: PHCS Commercial |
$14,789.84
|
| Rate for Payer: United Healthcare All Payer |
$13,557.35
|
|
|
SUNSCREEN/PRIMER SPF30 30ML
|
Professional
|
Both
|
$65.00
|
|
| Hospital Charge Code |
22200150
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$65.00
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Multiplan PHCS |
$39.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$45.50
|
| Rate for Payer: UHCCP Medicaid |
$22.75
|
|
|
SUNSCRN+PWDR BD-SPCTM SPF40 DP
|
Professional
|
Both
|
$65.00
|
|
| Hospital Charge Code |
22200360
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$65.00
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Multiplan PHCS |
$39.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$45.50
|
| Rate for Payer: UHCCP Medicaid |
$22.75
|
|
|
SUNSCRN+PWDR BD-SPCTM SPF40 L
|
Professional
|
Both
|
$65.00
|
|
| Hospital Charge Code |
22200358
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$65.00
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Multiplan PHCS |
$39.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$45.50
|
| Rate for Payer: UHCCP Medicaid |
$22.75
|
|
|
SUNSCRN+PWDR BD-SPCTM SPF40 M
|
Professional
|
Both
|
$65.00
|
|
| Hospital Charge Code |
22200359
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$65.00
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Multiplan PHCS |
$39.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$45.50
|
| Rate for Payer: UHCCP Medicaid |
$22.75
|
|
|
SUPARTZFX 2.5ML SYR
|
Facility
|
OP
|
$1,245.35
|
|
|
Service Code
|
HCPCS J7321
|
| Hospital Charge Code |
63600120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$161.90 |
| Max. Negotiated Rate |
$1,195.54 |
| Rate for Payer: Aetna Commercial |
$958.92
|
| Rate for Payer: Anthem Medicaid |
$428.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$971.37
|
| Rate for Payer: Cash Price |
$622.68
|
| Rate for Payer: Cigna Commercial |
$1,033.64
|
| Rate for Payer: First Health Commercial |
$1,183.08
|
| Rate for Payer: Humana Commercial |
$1,058.55
|
| Rate for Payer: Humana KY Medicaid |
$428.28
|
| Rate for Payer: Kentucky WC Medicaid |
$432.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,021.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$919.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$373.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$436.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,095.91
|
| Rate for Payer: Ohio Health Group HMO |
$934.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$249.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$161.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$386.06
|
| Rate for Payer: PHCS Commercial |
$1,195.54
|
| Rate for Payer: United Healthcare All Payer |
$1,095.91
|
|
|
SUPARTZFX 2.5ML SYR
|
Facility
|
IP
|
$1,245.35
|
|
|
Service Code
|
HCPCS J7321
|
| Hospital Charge Code |
636T0120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$161.90 |
| Max. Negotiated Rate |
$1,195.54 |
| Rate for Payer: Aetna Commercial |
$958.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$971.37
|
| Rate for Payer: Cash Price |
$622.68
|
| Rate for Payer: Cigna Commercial |
$1,033.64
|
| Rate for Payer: First Health Commercial |
$1,183.08
|
| Rate for Payer: Humana Commercial |
$1,058.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,021.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$919.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$373.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,095.91
|
| Rate for Payer: Ohio Health Group HMO |
$934.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$249.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$161.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$386.06
|
| Rate for Payer: PHCS Commercial |
$1,195.54
|
| Rate for Payer: United Healthcare All Payer |
$1,095.91
|
|
|
SUPARTZFX 2.5ML SYR
|
Facility
|
IP
|
$1,245.35
|
|
|
Service Code
|
HCPCS J7321
|
| Hospital Charge Code |
63600120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$161.90 |
| Max. Negotiated Rate |
$1,195.54 |
| Rate for Payer: Aetna Commercial |
$958.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$971.37
|
| Rate for Payer: Cash Price |
$622.68
|
| Rate for Payer: Cigna Commercial |
$1,033.64
|
| Rate for Payer: First Health Commercial |
$1,183.08
|
| Rate for Payer: Humana Commercial |
$1,058.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,021.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$919.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$373.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,095.91
|
| Rate for Payer: Ohio Health Group HMO |
$934.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$249.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$161.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$386.06
|
| Rate for Payer: PHCS Commercial |
$1,195.54
|
| Rate for Payer: United Healthcare All Payer |
$1,095.91
|
|
|
SUPARTZFX 2.5ML SYR
|
Professional
|
Both
|
$1,245.35
|
|
|
Service Code
|
HCPCS J7321
|
| Hospital Charge Code |
63600120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1,245.35 |
| Rate for Payer: Aetna Commercial |
$105.65
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,245.35
|
| Rate for Payer: Cash Price |
$622.68
|
| Rate for Payer: Cash Price |
$622.68
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$107.80
|
| Rate for Payer: Multiplan PHCS |
$747.21
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$871.74
|
| Rate for Payer: UHCCP Medicaid |
$435.87
|
|
|
SUPARTZFX 2.5ML SYR
|
Facility
|
IP
|
$1,292.79
|
|
|
Service Code
|
HCPCS J7321
|
| Hospital Charge Code |
25004016
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$168.06 |
| Max. Negotiated Rate |
$1,241.08 |
| Rate for Payer: Aetna Commercial |
$995.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,008.38
|
| Rate for Payer: Cash Price |
$646.40
|
| Rate for Payer: Cigna Commercial |
$1,073.02
|
| Rate for Payer: First Health Commercial |
$1,228.15
|
| Rate for Payer: Humana Commercial |
$1,098.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,060.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$954.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$387.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,137.66
|
| Rate for Payer: Ohio Health Group HMO |
$969.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$258.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$168.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$400.76
|
| Rate for Payer: PHCS Commercial |
$1,241.08
|
| Rate for Payer: United Healthcare All Payer |
$1,137.66
|
|
|
SUPARTZFX 2.5ML SYR
|
Facility
|
OP
|
$1,292.79
|
|
|
Service Code
|
HCPCS J7321
|
| Hospital Charge Code |
25004016
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$168.06 |
| Max. Negotiated Rate |
$1,241.08 |
| Rate for Payer: Aetna Commercial |
$995.45
|
| Rate for Payer: Anthem Medicaid |
$444.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,008.38
|
| Rate for Payer: Cash Price |
$646.40
|
| Rate for Payer: Cigna Commercial |
$1,073.02
|
| Rate for Payer: First Health Commercial |
$1,228.15
|
| Rate for Payer: Humana Commercial |
$1,098.87
|
| Rate for Payer: Humana KY Medicaid |
$444.59
|
| Rate for Payer: Kentucky WC Medicaid |
$449.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,060.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$954.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$387.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$453.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,137.66
|
| Rate for Payer: Ohio Health Group HMO |
$969.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$258.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$168.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$400.76
|
| Rate for Payer: PHCS Commercial |
$1,241.08
|
| Rate for Payer: United Healthcare All Payer |
$1,137.66
|
|
|
SUPARTZFX 2.5ML SYR
|
Facility
|
OP
|
$1,245.35
|
|
|
Service Code
|
HCPCS J7321
|
| Hospital Charge Code |
636T0120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$161.90 |
| Max. Negotiated Rate |
$1,195.54 |
| Rate for Payer: Aetna Commercial |
$958.92
|
| Rate for Payer: Anthem Medicaid |
$428.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$971.37
|
| Rate for Payer: Cash Price |
$622.68
|
| Rate for Payer: Cigna Commercial |
$1,033.64
|
| Rate for Payer: First Health Commercial |
$1,183.08
|
| Rate for Payer: Humana Commercial |
$1,058.55
|
| Rate for Payer: Humana KY Medicaid |
$428.28
|
| Rate for Payer: Kentucky WC Medicaid |
$432.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,021.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$919.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$373.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$436.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,095.91
|
| Rate for Payer: Ohio Health Group HMO |
$934.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$249.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$161.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$386.06
|
| Rate for Payer: PHCS Commercial |
$1,195.54
|
| Rate for Payer: United Healthcare All Payer |
$1,095.91
|
|
|
SUPERA PERIPH. STENT 5*100*120
|
Facility
|
IP
|
$5,087.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$661.38 |
| Max. Negotiated Rate |
$4,884.00 |
| Rate for Payer: Aetna Commercial |
$3,917.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,968.25
|
| Rate for Payer: Cash Price |
$2,543.75
|
| Rate for Payer: Cigna Commercial |
$4,222.62
|
| Rate for Payer: First Health Commercial |
$4,833.12
|
| Rate for Payer: Humana Commercial |
$4,324.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,171.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,754.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,526.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,477.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,815.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,017.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$661.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,577.12
|
| Rate for Payer: PHCS Commercial |
$4,884.00
|
| Rate for Payer: United Healthcare All Payer |
$4,477.00
|
|
|
SUPERA PERIPH. STENT 5*100*120
|
Facility
|
OP
|
$5,087.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$661.38 |
| Max. Negotiated Rate |
$4,884.00 |
| Rate for Payer: Aetna Commercial |
$3,917.38
|
| Rate for Payer: Anthem Medicaid |
$1,749.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,968.25
|
| Rate for Payer: Cash Price |
$2,543.75
|
| Rate for Payer: Cigna Commercial |
$4,222.62
|
| Rate for Payer: First Health Commercial |
$4,833.12
|
| Rate for Payer: Humana Commercial |
$4,324.38
|
| Rate for Payer: Humana KY Medicaid |
$1,749.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,767.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,171.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,754.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,526.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,784.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,477.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,815.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,017.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$661.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,577.12
|
| Rate for Payer: PHCS Commercial |
$4,884.00
|
| Rate for Payer: United Healthcare All Payer |
$4,477.00
|
|
|
SUPERA PERIPH. STENT 5*120*120
|
Facility
|
OP
|
$5,087.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$661.38 |
| Max. Negotiated Rate |
$4,884.00 |
| Rate for Payer: Aetna Commercial |
$3,917.38
|
| Rate for Payer: Anthem Medicaid |
$1,749.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,968.25
|
| Rate for Payer: Cash Price |
$2,543.75
|
| Rate for Payer: Cigna Commercial |
$4,222.62
|
| Rate for Payer: First Health Commercial |
$4,833.12
|
| Rate for Payer: Humana Commercial |
$4,324.38
|
| Rate for Payer: Humana KY Medicaid |
$1,749.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,767.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,171.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,754.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,526.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,784.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,477.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,815.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,017.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$661.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,577.12
|
| Rate for Payer: PHCS Commercial |
$4,884.00
|
| Rate for Payer: United Healthcare All Payer |
$4,477.00
|
|
|
SUPERA PERIPH. STENT 5*120*120
|
Facility
|
IP
|
$5,087.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$661.38 |
| Max. Negotiated Rate |
$4,884.00 |
| Rate for Payer: Aetna Commercial |
$3,917.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,968.25
|
| Rate for Payer: Cash Price |
$2,543.75
|
| Rate for Payer: Cigna Commercial |
$4,222.62
|
| Rate for Payer: First Health Commercial |
$4,833.12
|
| Rate for Payer: Humana Commercial |
$4,324.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,171.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,754.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,526.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,477.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,815.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,017.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$661.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,577.12
|
| Rate for Payer: PHCS Commercial |
$4,884.00
|
| Rate for Payer: United Healthcare All Payer |
$4,477.00
|
|
|
SUPERA PERIPH STNT 4.5*100*120
|
Facility
|
OP
|
$7,545.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$980.85 |
| Max. Negotiated Rate |
$7,243.20 |
| Rate for Payer: Aetna Commercial |
$5,809.65
|
| Rate for Payer: Anthem Medicaid |
$2,594.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,885.10
|
| Rate for Payer: Cash Price |
$3,772.50
|
| Rate for Payer: Cigna Commercial |
$6,262.35
|
| Rate for Payer: First Health Commercial |
$7,167.75
|
| Rate for Payer: Humana Commercial |
$6,413.25
|
| Rate for Payer: Humana KY Medicaid |
$2,594.73
|
| Rate for Payer: Kentucky WC Medicaid |
$2,621.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,186.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,568.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,263.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,646.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,639.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,658.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,509.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$980.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,338.95
|
| Rate for Payer: PHCS Commercial |
$7,243.20
|
| Rate for Payer: United Healthcare All Payer |
$6,639.60
|
|
|
SUPERA PERIPH STNT 4.5*100*120
|
Facility
|
IP
|
$7,545.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$980.85 |
| Max. Negotiated Rate |
$7,243.20 |
| Rate for Payer: Aetna Commercial |
$5,809.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,885.10
|
| Rate for Payer: Cash Price |
$3,772.50
|
| Rate for Payer: Cigna Commercial |
$6,262.35
|
| Rate for Payer: First Health Commercial |
$7,167.75
|
| Rate for Payer: Humana Commercial |
$6,413.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,186.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,568.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,263.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,639.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,658.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,509.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$980.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,338.95
|
| Rate for Payer: PHCS Commercial |
$7,243.20
|
| Rate for Payer: United Healthcare All Payer |
$6,639.60
|
|
|
SUPERA PERIPH STNT 4.5*120*120
|
Facility
|
OP
|
$5,087.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$661.38 |
| Max. Negotiated Rate |
$4,884.00 |
| Rate for Payer: Aetna Commercial |
$3,917.38
|
| Rate for Payer: Anthem Medicaid |
$1,749.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,968.25
|
| Rate for Payer: Cash Price |
$2,543.75
|
| Rate for Payer: Cigna Commercial |
$4,222.62
|
| Rate for Payer: First Health Commercial |
$4,833.12
|
| Rate for Payer: Humana Commercial |
$4,324.38
|
| Rate for Payer: Humana KY Medicaid |
$1,749.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,767.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,171.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,754.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,526.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,784.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,477.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,815.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,017.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$661.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,577.12
|
| Rate for Payer: PHCS Commercial |
$4,884.00
|
| Rate for Payer: United Healthcare All Payer |
$4,477.00
|
|
|
SUPERA PERIPH STNT 4.5*120*120
|
Facility
|
IP
|
$5,087.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$661.38 |
| Max. Negotiated Rate |
$4,884.00 |
| Rate for Payer: Aetna Commercial |
$3,917.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,968.25
|
| Rate for Payer: Cash Price |
$2,543.75
|
| Rate for Payer: Cigna Commercial |
$4,222.62
|
| Rate for Payer: First Health Commercial |
$4,833.12
|
| Rate for Payer: Humana Commercial |
$4,324.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,171.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,754.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,526.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,477.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,815.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,017.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$661.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,577.12
|
| Rate for Payer: PHCS Commercial |
$4,884.00
|
| Rate for Payer: United Healthcare All Payer |
$4,477.00
|
|
|
SUPERA PERIPH STNT 5.5*100*120
|
Facility
|
OP
|
$7,545.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$980.85 |
| Max. Negotiated Rate |
$7,243.20 |
| Rate for Payer: Aetna Commercial |
$5,809.65
|
| Rate for Payer: Anthem Medicaid |
$2,594.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,885.10
|
| Rate for Payer: Cash Price |
$3,772.50
|
| Rate for Payer: Cigna Commercial |
$6,262.35
|
| Rate for Payer: First Health Commercial |
$7,167.75
|
| Rate for Payer: Humana Commercial |
$6,413.25
|
| Rate for Payer: Humana KY Medicaid |
$2,594.73
|
| Rate for Payer: Kentucky WC Medicaid |
$2,621.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,186.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,568.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,263.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,646.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,639.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,658.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,509.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$980.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,338.95
|
| Rate for Payer: PHCS Commercial |
$7,243.20
|
| Rate for Payer: United Healthcare All Payer |
$6,639.60
|
|
