|
STENT G FLEX PIGTAIL 10F*5CM
|
Facility
|
OP
|
$1,714.20
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$514.26 |
| Max. Negotiated Rate |
$1,645.63 |
| Rate for Payer: Aetna Commercial |
$1,319.93
|
| Rate for Payer: Anthem Medicaid |
$589.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,337.08
|
| Rate for Payer: Cash Price |
$857.10
|
| Rate for Payer: Cigna Commercial |
$1,422.79
|
| Rate for Payer: First Health Commercial |
$1,628.49
|
| Rate for Payer: Humana Commercial |
$1,457.07
|
| Rate for Payer: Humana KY Medicaid |
$589.51
|
| Rate for Payer: Kentucky WC Medicaid |
$595.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,405.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,265.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$514.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$601.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,508.50
|
| Rate for Payer: Ohio Health Group HMO |
$1,285.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,371.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,491.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,182.80
|
| Rate for Payer: PHCS Commercial |
$1,645.63
|
| Rate for Payer: United Healthcare All Payer |
$1,508.50
|
|
|
STENT GFT AAA AORT EXT 3.75*20
|
Facility
|
OP
|
$10,931.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,279.53 |
| Max. Negotiated Rate |
$10,494.48 |
| Rate for Payer: Aetna Commercial |
$8,417.45
|
| Rate for Payer: Anthem Medicaid |
$3,759.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,526.76
|
| Rate for Payer: Cash Price |
$5,465.88
|
| Rate for Payer: Cigna Commercial |
$9,073.35
|
| Rate for Payer: First Health Commercial |
$10,385.16
|
| Rate for Payer: Humana Commercial |
$9,291.99
|
| Rate for Payer: Humana KY Medicaid |
$3,759.43
|
| Rate for Payer: Kentucky WC Medicaid |
$3,797.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,964.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,067.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,279.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,834.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,619.94
|
| Rate for Payer: Ohio Health Group HMO |
$8,198.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,745.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,510.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,542.91
|
| Rate for Payer: PHCS Commercial |
$10,494.48
|
| Rate for Payer: United Healthcare All Payer |
$9,619.94
|
|
|
STENT GFT AAA AORT EXT 3.75*20
|
Facility
|
IP
|
$10,931.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,279.53 |
| Max. Negotiated Rate |
$10,494.48 |
| Rate for Payer: Aetna Commercial |
$8,417.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,526.76
|
| Rate for Payer: Cash Price |
$5,465.88
|
| Rate for Payer: Cigna Commercial |
$9,073.35
|
| Rate for Payer: First Health Commercial |
$10,385.16
|
| Rate for Payer: Humana Commercial |
$9,291.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,964.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,067.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,279.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,619.94
|
| Rate for Payer: Ohio Health Group HMO |
$8,198.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,745.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,510.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,542.91
|
| Rate for Payer: PHCS Commercial |
$10,494.48
|
| Rate for Payer: United Healthcare All Payer |
$9,619.94
|
|
|
STENT GFT AAA AORT EXT 3.75*26
|
Facility
|
IP
|
$10,931.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,279.53 |
| Max. Negotiated Rate |
$10,494.48 |
| Rate for Payer: Aetna Commercial |
$8,417.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,526.76
|
| Rate for Payer: Cash Price |
$5,465.88
|
| Rate for Payer: Cigna Commercial |
$9,073.35
|
| Rate for Payer: First Health Commercial |
$10,385.16
|
| Rate for Payer: Humana Commercial |
$9,291.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,964.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,067.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,279.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,619.94
|
| Rate for Payer: Ohio Health Group HMO |
$8,198.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,745.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,510.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,542.91
|
| Rate for Payer: PHCS Commercial |
$10,494.48
|
| Rate for Payer: United Healthcare All Payer |
$9,619.94
|
|
|
STENT GFT AAA AORT EXT 3.75*26
|
Facility
|
OP
|
$10,931.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,279.53 |
| Max. Negotiated Rate |
$10,494.48 |
| Rate for Payer: Aetna Commercial |
$8,417.45
|
| Rate for Payer: Anthem Medicaid |
$3,759.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,526.76
|
| Rate for Payer: Cash Price |
$5,465.88
|
| Rate for Payer: Cigna Commercial |
$9,073.35
|
| Rate for Payer: First Health Commercial |
$10,385.16
|
| Rate for Payer: Humana Commercial |
$9,291.99
|
| Rate for Payer: Humana KY Medicaid |
$3,759.43
|
| Rate for Payer: Kentucky WC Medicaid |
$3,797.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,964.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,067.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,279.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,834.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,619.94
|
| Rate for Payer: Ohio Health Group HMO |
$8,198.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,745.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,510.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,542.91
|
| Rate for Payer: PHCS Commercial |
$10,494.48
|
| Rate for Payer: United Healthcare All Payer |
$9,619.94
|
|
|
STENT GFT AAA ILIAC EXT 5.5*12
|
Facility
|
OP
|
$10,931.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,279.53 |
| Max. Negotiated Rate |
$10,494.48 |
| Rate for Payer: Aetna Commercial |
$8,417.45
|
| Rate for Payer: Anthem Medicaid |
$3,759.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,526.76
|
| Rate for Payer: Cash Price |
$5,465.88
|
| Rate for Payer: Cigna Commercial |
$9,073.35
|
| Rate for Payer: First Health Commercial |
$10,385.16
|
| Rate for Payer: Humana Commercial |
$9,291.99
|
| Rate for Payer: Humana KY Medicaid |
$3,759.43
|
| Rate for Payer: Kentucky WC Medicaid |
$3,797.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,964.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,067.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,279.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,834.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,619.94
|
| Rate for Payer: Ohio Health Group HMO |
$8,198.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,745.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,510.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,542.91
|
| Rate for Payer: PHCS Commercial |
$10,494.48
|
| Rate for Payer: United Healthcare All Payer |
$9,619.94
|
|
|
STENT GFT AAA ILIAC EXT 5.5*12
|
Facility
|
IP
|
$10,931.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,279.53 |
| Max. Negotiated Rate |
$10,494.48 |
| Rate for Payer: Aetna Commercial |
$8,417.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,526.76
|
| Rate for Payer: Cash Price |
$5,465.88
|
| Rate for Payer: Cigna Commercial |
$9,073.35
|
| Rate for Payer: First Health Commercial |
$10,385.16
|
| Rate for Payer: Humana Commercial |
$9,291.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,964.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,067.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,279.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,619.94
|
| Rate for Payer: Ohio Health Group HMO |
$8,198.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,745.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,510.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,542.91
|
| Rate for Payer: PHCS Commercial |
$10,494.48
|
| Rate for Payer: United Healthcare All Payer |
$9,619.94
|
|
|
STENT GFT AAA ILIAC EXT 5.5*13
|
Facility
|
OP
|
$10,931.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,279.53 |
| Max. Negotiated Rate |
$10,494.48 |
| Rate for Payer: Aetna Commercial |
$8,417.45
|
| Rate for Payer: Anthem Medicaid |
$3,759.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,526.76
|
| Rate for Payer: Cash Price |
$5,465.88
|
| Rate for Payer: Cigna Commercial |
$9,073.35
|
| Rate for Payer: First Health Commercial |
$10,385.16
|
| Rate for Payer: Humana Commercial |
$9,291.99
|
| Rate for Payer: Humana KY Medicaid |
$3,759.43
|
| Rate for Payer: Kentucky WC Medicaid |
$3,797.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,964.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,067.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,279.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,834.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,619.94
|
| Rate for Payer: Ohio Health Group HMO |
$8,198.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,745.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,510.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,542.91
|
| Rate for Payer: PHCS Commercial |
$10,494.48
|
| Rate for Payer: United Healthcare All Payer |
$9,619.94
|
|
|
STENT GFT AAA ILIAC EXT 5.5*13
|
Facility
|
IP
|
$10,931.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,279.53 |
| Max. Negotiated Rate |
$10,494.48 |
| Rate for Payer: Aetna Commercial |
$8,417.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,526.76
|
| Rate for Payer: Cash Price |
$5,465.88
|
| Rate for Payer: Cigna Commercial |
$9,073.35
|
| Rate for Payer: First Health Commercial |
$10,385.16
|
| Rate for Payer: Humana Commercial |
$9,291.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,964.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,067.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,279.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,619.94
|
| Rate for Payer: Ohio Health Group HMO |
$8,198.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,745.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,510.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,542.91
|
| Rate for Payer: PHCS Commercial |
$10,494.48
|
| Rate for Payer: United Healthcare All Payer |
$9,619.94
|
|
|
STENT GFT AAA ILIAC EXT 5.5*14
|
Facility
|
IP
|
$10,931.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,279.53 |
| Max. Negotiated Rate |
$10,494.48 |
| Rate for Payer: Aetna Commercial |
$8,417.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,526.76
|
| Rate for Payer: Cash Price |
$5,465.88
|
| Rate for Payer: Cigna Commercial |
$9,073.35
|
| Rate for Payer: First Health Commercial |
$10,385.16
|
| Rate for Payer: Humana Commercial |
$9,291.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,964.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,067.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,279.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,619.94
|
| Rate for Payer: Ohio Health Group HMO |
$8,198.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,745.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,510.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,542.91
|
| Rate for Payer: PHCS Commercial |
$10,494.48
|
| Rate for Payer: United Healthcare All Payer |
$9,619.94
|
|
|
STENT GFT AAA ILIAC EXT 5.5*14
|
Facility
|
OP
|
$10,931.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,279.53 |
| Max. Negotiated Rate |
$10,494.48 |
| Rate for Payer: Aetna Commercial |
$8,417.45
|
| Rate for Payer: Anthem Medicaid |
$3,759.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,526.76
|
| Rate for Payer: Cash Price |
$5,465.88
|
| Rate for Payer: Cigna Commercial |
$9,073.35
|
| Rate for Payer: First Health Commercial |
$10,385.16
|
| Rate for Payer: Humana Commercial |
$9,291.99
|
| Rate for Payer: Humana KY Medicaid |
$3,759.43
|
| Rate for Payer: Kentucky WC Medicaid |
$3,797.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,964.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,067.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,279.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,834.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,619.94
|
| Rate for Payer: Ohio Health Group HMO |
$8,198.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,745.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,510.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,542.91
|
| Rate for Payer: PHCS Commercial |
$10,494.48
|
| Rate for Payer: United Healthcare All Payer |
$9,619.94
|
|
|
STENT GFT AAA ILIAC EXT 5.5*15
|
Facility
|
OP
|
$10,931.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,279.53 |
| Max. Negotiated Rate |
$10,494.48 |
| Rate for Payer: Aetna Commercial |
$8,417.45
|
| Rate for Payer: Anthem Medicaid |
$3,759.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,526.76
|
| Rate for Payer: Cash Price |
$5,465.88
|
| Rate for Payer: Cigna Commercial |
$9,073.35
|
| Rate for Payer: First Health Commercial |
$10,385.16
|
| Rate for Payer: Humana Commercial |
$9,291.99
|
| Rate for Payer: Humana KY Medicaid |
$3,759.43
|
| Rate for Payer: Kentucky WC Medicaid |
$3,797.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,964.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,067.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,279.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,834.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,619.94
|
| Rate for Payer: Ohio Health Group HMO |
$8,198.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,745.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,510.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,542.91
|
| Rate for Payer: PHCS Commercial |
$10,494.48
|
| Rate for Payer: United Healthcare All Payer |
$9,619.94
|
|
|
STENT GFT AAA ILIAC EXT 5.5*15
|
Facility
|
IP
|
$10,931.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,279.53 |
| Max. Negotiated Rate |
$10,494.48 |
| Rate for Payer: Aetna Commercial |
$8,417.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,526.76
|
| Rate for Payer: Cash Price |
$5,465.88
|
| Rate for Payer: Cigna Commercial |
$9,073.35
|
| Rate for Payer: First Health Commercial |
$10,385.16
|
| Rate for Payer: Humana Commercial |
$9,291.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,964.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,067.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,279.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,619.94
|
| Rate for Payer: Ohio Health Group HMO |
$8,198.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,745.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,510.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,542.91
|
| Rate for Payer: PHCS Commercial |
$10,494.48
|
| Rate for Payer: United Healthcare All Payer |
$9,619.94
|
|
|
STENT GFT AAA ILIAC EXT 5.5*16
|
Facility
|
IP
|
$10,931.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,279.53 |
| Max. Negotiated Rate |
$10,494.48 |
| Rate for Payer: Aetna Commercial |
$8,417.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,526.76
|
| Rate for Payer: Cash Price |
$5,465.88
|
| Rate for Payer: Cigna Commercial |
$9,073.35
|
| Rate for Payer: First Health Commercial |
$10,385.16
|
| Rate for Payer: Humana Commercial |
$9,291.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,964.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,067.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,279.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,619.94
|
| Rate for Payer: Ohio Health Group HMO |
$8,198.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,745.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,510.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,542.91
|
| Rate for Payer: PHCS Commercial |
$10,494.48
|
| Rate for Payer: United Healthcare All Payer |
$9,619.94
|
|
|
STENT GFT AAA ILIAC EXT 5.5*16
|
Facility
|
OP
|
$10,931.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,279.53 |
| Max. Negotiated Rate |
$10,494.48 |
| Rate for Payer: Aetna Commercial |
$8,417.45
|
| Rate for Payer: Anthem Medicaid |
$3,759.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,526.76
|
| Rate for Payer: Cash Price |
$5,465.88
|
| Rate for Payer: Cigna Commercial |
$9,073.35
|
| Rate for Payer: First Health Commercial |
$10,385.16
|
| Rate for Payer: Humana Commercial |
$9,291.99
|
| Rate for Payer: Humana KY Medicaid |
$3,759.43
|
| Rate for Payer: Kentucky WC Medicaid |
$3,797.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,964.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,067.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,279.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,834.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,619.94
|
| Rate for Payer: Ohio Health Group HMO |
$8,198.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,745.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,510.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,542.91
|
| Rate for Payer: PHCS Commercial |
$10,494.48
|
| Rate for Payer: United Healthcare All Payer |
$9,619.94
|
|
|
STENT GRAFT AAA BIF 13.5*20*12
|
Facility
|
IP
|
$32,187.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,656.25 |
| Max. Negotiated Rate |
$30,900.00 |
| Rate for Payer: Aetna Commercial |
$24,784.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,106.25
|
| Rate for Payer: Cash Price |
$16,093.75
|
| Rate for Payer: Cigna Commercial |
$26,715.62
|
| Rate for Payer: First Health Commercial |
$30,578.12
|
| Rate for Payer: Humana Commercial |
$27,359.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26,393.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,754.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,656.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$28,325.00
|
| Rate for Payer: Ohio Health Group HMO |
$24,140.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25,750.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,003.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,209.38
|
| Rate for Payer: PHCS Commercial |
$30,900.00
|
| Rate for Payer: United Healthcare All Payer |
$28,325.00
|
|
|
STENT GRAFT AAA BIF 13.5*20*12
|
Facility
|
OP
|
$32,187.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,656.25 |
| Max. Negotiated Rate |
$30,900.00 |
| Rate for Payer: Aetna Commercial |
$24,784.38
|
| Rate for Payer: Anthem Medicaid |
$11,069.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,106.25
|
| Rate for Payer: Cash Price |
$16,093.75
|
| Rate for Payer: Cigna Commercial |
$26,715.62
|
| Rate for Payer: First Health Commercial |
$30,578.12
|
| Rate for Payer: Humana Commercial |
$27,359.38
|
| Rate for Payer: Humana KY Medicaid |
$11,069.28
|
| Rate for Payer: Kentucky WC Medicaid |
$11,181.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26,393.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,754.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,656.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,291.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$28,325.00
|
| Rate for Payer: Ohio Health Group HMO |
$24,140.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25,750.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,003.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,209.38
|
| Rate for Payer: PHCS Commercial |
$30,900.00
|
| Rate for Payer: United Healthcare All Payer |
$28,325.00
|
|
|
STENT GRAFT AAA BIF 13.5*22*13
|
Facility
|
OP
|
$32,187.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,656.25 |
| Max. Negotiated Rate |
$30,900.00 |
| Rate for Payer: Aetna Commercial |
$24,784.38
|
| Rate for Payer: Anthem Medicaid |
$11,069.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,106.25
|
| Rate for Payer: Cash Price |
$16,093.75
|
| Rate for Payer: Cigna Commercial |
$26,715.62
|
| Rate for Payer: First Health Commercial |
$30,578.12
|
| Rate for Payer: Humana Commercial |
$27,359.38
|
| Rate for Payer: Humana KY Medicaid |
$11,069.28
|
| Rate for Payer: Kentucky WC Medicaid |
$11,181.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26,393.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,754.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,656.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,291.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$28,325.00
|
| Rate for Payer: Ohio Health Group HMO |
$24,140.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25,750.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,003.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,209.38
|
| Rate for Payer: PHCS Commercial |
$30,900.00
|
| Rate for Payer: United Healthcare All Payer |
$28,325.00
|
|
|
STENT GRAFT AAA BIF 13.5*22*13
|
Facility
|
IP
|
$32,187.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,656.25 |
| Max. Negotiated Rate |
$30,900.00 |
| Rate for Payer: Aetna Commercial |
$24,784.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,106.25
|
| Rate for Payer: Cash Price |
$16,093.75
|
| Rate for Payer: Cigna Commercial |
$26,715.62
|
| Rate for Payer: First Health Commercial |
$30,578.12
|
| Rate for Payer: Humana Commercial |
$27,359.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26,393.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,754.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,656.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$28,325.00
|
| Rate for Payer: Ohio Health Group HMO |
$24,140.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25,750.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,003.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,209.38
|
| Rate for Payer: PHCS Commercial |
$30,900.00
|
| Rate for Payer: United Healthcare All Payer |
$28,325.00
|
|
|
STENT GRAFT AAA BIF 13.5*26*15
|
Facility
|
IP
|
$32,187.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,656.25 |
| Max. Negotiated Rate |
$30,900.00 |
| Rate for Payer: Aetna Commercial |
$24,784.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,106.25
|
| Rate for Payer: Cash Price |
$16,093.75
|
| Rate for Payer: Cigna Commercial |
$26,715.62
|
| Rate for Payer: First Health Commercial |
$30,578.12
|
| Rate for Payer: Humana Commercial |
$27,359.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26,393.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,754.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,656.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$28,325.00
|
| Rate for Payer: Ohio Health Group HMO |
$24,140.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25,750.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,003.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,209.38
|
| Rate for Payer: PHCS Commercial |
$30,900.00
|
| Rate for Payer: United Healthcare All Payer |
$28,325.00
|
|
|
STENT GRAFT AAA BIF 13.5*26*15
|
Facility
|
OP
|
$32,187.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,656.25 |
| Max. Negotiated Rate |
$30,900.00 |
| Rate for Payer: Aetna Commercial |
$24,784.38
|
| Rate for Payer: Anthem Medicaid |
$11,069.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,106.25
|
| Rate for Payer: Cash Price |
$16,093.75
|
| Rate for Payer: Cigna Commercial |
$26,715.62
|
| Rate for Payer: First Health Commercial |
$30,578.12
|
| Rate for Payer: Humana Commercial |
$27,359.38
|
| Rate for Payer: Humana KY Medicaid |
$11,069.28
|
| Rate for Payer: Kentucky WC Medicaid |
$11,181.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$26,393.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,754.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,656.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,291.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$28,325.00
|
| Rate for Payer: Ohio Health Group HMO |
$24,140.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25,750.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,003.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,209.38
|
| Rate for Payer: PHCS Commercial |
$30,900.00
|
| Rate for Payer: United Healthcare All Payer |
$28,325.00
|
|
|
STENT GRAFT AAA BIF 16.5*20*12
|
Facility
|
OP
|
$33,312.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,993.75 |
| Max. Negotiated Rate |
$31,980.00 |
| Rate for Payer: Aetna Commercial |
$25,650.62
|
| Rate for Payer: Anthem Medicaid |
$11,456.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,983.75
|
| Rate for Payer: Cash Price |
$16,656.25
|
| Rate for Payer: Cigna Commercial |
$27,649.38
|
| Rate for Payer: First Health Commercial |
$31,646.88
|
| Rate for Payer: Humana Commercial |
$28,315.62
|
| Rate for Payer: Humana KY Medicaid |
$11,456.17
|
| Rate for Payer: Kentucky WC Medicaid |
$11,572.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,316.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,584.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,993.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,686.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,315.00
|
| Rate for Payer: Ohio Health Group HMO |
$24,984.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26,650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,981.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,985.62
|
| Rate for Payer: PHCS Commercial |
$31,980.00
|
| Rate for Payer: United Healthcare All Payer |
$29,315.00
|
|
|
STENT GRAFT AAA BIF 16.5*20*12
|
Facility
|
IP
|
$33,312.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,993.75 |
| Max. Negotiated Rate |
$31,980.00 |
| Rate for Payer: Aetna Commercial |
$25,650.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,983.75
|
| Rate for Payer: Cash Price |
$16,656.25
|
| Rate for Payer: Cigna Commercial |
$27,649.38
|
| Rate for Payer: First Health Commercial |
$31,646.88
|
| Rate for Payer: Humana Commercial |
$28,315.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,316.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,584.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,993.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,315.00
|
| Rate for Payer: Ohio Health Group HMO |
$24,984.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26,650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,981.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,985.62
|
| Rate for Payer: PHCS Commercial |
$31,980.00
|
| Rate for Payer: United Healthcare All Payer |
$29,315.00
|
|
|
STENT GRAFT AAA BIF 16.5*22*13
|
Facility
|
OP
|
$33,312.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,993.75 |
| Max. Negotiated Rate |
$31,980.00 |
| Rate for Payer: Aetna Commercial |
$25,650.62
|
| Rate for Payer: Anthem Medicaid |
$11,456.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,983.75
|
| Rate for Payer: Cash Price |
$16,656.25
|
| Rate for Payer: Cigna Commercial |
$27,649.38
|
| Rate for Payer: First Health Commercial |
$31,646.88
|
| Rate for Payer: Humana Commercial |
$28,315.62
|
| Rate for Payer: Humana KY Medicaid |
$11,456.17
|
| Rate for Payer: Kentucky WC Medicaid |
$11,572.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,316.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,584.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,993.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,686.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,315.00
|
| Rate for Payer: Ohio Health Group HMO |
$24,984.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26,650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,981.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,985.62
|
| Rate for Payer: PHCS Commercial |
$31,980.00
|
| Rate for Payer: United Healthcare All Payer |
$29,315.00
|
|
|
STENT GRAFT AAA BIF 16.5*22*13
|
Facility
|
IP
|
$33,312.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,993.75 |
| Max. Negotiated Rate |
$31,980.00 |
| Rate for Payer: Aetna Commercial |
$25,650.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,983.75
|
| Rate for Payer: Cash Price |
$16,656.25
|
| Rate for Payer: Cigna Commercial |
$27,649.38
|
| Rate for Payer: First Health Commercial |
$31,646.88
|
| Rate for Payer: Humana Commercial |
$28,315.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,316.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,584.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,993.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,315.00
|
| Rate for Payer: Ohio Health Group HMO |
$24,984.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26,650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28,981.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,985.62
|
| Rate for Payer: PHCS Commercial |
$31,980.00
|
| Rate for Payer: United Healthcare All Payer |
$29,315.00
|
|
