|
STENT GRAFT AAA BIF 16.5*24*14
|
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*24*14
|
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*26*15
|
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*26*15
|
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*28*16
|
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*28*16
|
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 ILIAC 11.5*12
|
Facility
|
OP
|
$12,399.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,719.93 |
| Max. Negotiated Rate |
$11,903.76 |
| Rate for Payer: Aetna Commercial |
$9,547.81
|
| Rate for Payer: Anthem Medicaid |
$4,264.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,671.81
|
| Rate for Payer: Cash Price |
$6,199.88
|
| Rate for Payer: Cigna Commercial |
$10,291.79
|
| Rate for Payer: First Health Commercial |
$11,779.76
|
| Rate for Payer: Humana Commercial |
$10,539.79
|
| Rate for Payer: Humana KY Medicaid |
$4,264.27
|
| Rate for Payer: Kentucky WC Medicaid |
$4,307.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,167.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,151.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,719.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,349.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,911.78
|
| Rate for Payer: Ohio Health Group HMO |
$9,299.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,919.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,787.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,555.83
|
| Rate for Payer: PHCS Commercial |
$11,903.76
|
| Rate for Payer: United Healthcare All Payer |
$10,911.78
|
|
|
STENT GRAFT AAA ILIAC 11.5*12
|
Facility
|
IP
|
$12,399.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,719.93 |
| Max. Negotiated Rate |
$11,903.76 |
| Rate for Payer: Aetna Commercial |
$9,547.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,671.81
|
| Rate for Payer: Cash Price |
$6,199.88
|
| Rate for Payer: Cigna Commercial |
$10,291.79
|
| Rate for Payer: First Health Commercial |
$11,779.76
|
| Rate for Payer: Humana Commercial |
$10,539.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,167.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,151.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,719.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,911.78
|
| Rate for Payer: Ohio Health Group HMO |
$9,299.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,919.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,787.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,555.83
|
| Rate for Payer: PHCS Commercial |
$11,903.76
|
| Rate for Payer: United Healthcare All Payer |
$10,911.78
|
|
|
STENT GRAFT AAA ILIAC 11.5*13
|
Facility
|
OP
|
$12,399.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,719.93 |
| Max. Negotiated Rate |
$11,903.76 |
| Rate for Payer: Aetna Commercial |
$9,547.81
|
| Rate for Payer: Anthem Medicaid |
$4,264.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,671.81
|
| Rate for Payer: Cash Price |
$6,199.88
|
| Rate for Payer: Cigna Commercial |
$10,291.79
|
| Rate for Payer: First Health Commercial |
$11,779.76
|
| Rate for Payer: Humana Commercial |
$10,539.79
|
| Rate for Payer: Humana KY Medicaid |
$4,264.27
|
| Rate for Payer: Kentucky WC Medicaid |
$4,307.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,167.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,151.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,719.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,349.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,911.78
|
| Rate for Payer: Ohio Health Group HMO |
$9,299.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,919.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,787.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,555.83
|
| Rate for Payer: PHCS Commercial |
$11,903.76
|
| Rate for Payer: United Healthcare All Payer |
$10,911.78
|
|
|
STENT GRAFT AAA ILIAC 11.5*13
|
Facility
|
IP
|
$12,399.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,719.93 |
| Max. Negotiated Rate |
$11,903.76 |
| Rate for Payer: Aetna Commercial |
$9,547.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,671.81
|
| Rate for Payer: Cash Price |
$6,199.88
|
| Rate for Payer: Cigna Commercial |
$10,291.79
|
| Rate for Payer: First Health Commercial |
$11,779.76
|
| Rate for Payer: Humana Commercial |
$10,539.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,167.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,151.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,719.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,911.78
|
| Rate for Payer: Ohio Health Group HMO |
$9,299.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,919.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,787.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,555.83
|
| Rate for Payer: PHCS Commercial |
$11,903.76
|
| Rate for Payer: United Healthcare All Payer |
$10,911.78
|
|
|
STENT GRAFT AAA ILIAC 11.5*15
|
Facility
|
IP
|
$12,399.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,719.93 |
| Max. Negotiated Rate |
$11,903.76 |
| Rate for Payer: Aetna Commercial |
$9,547.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,671.81
|
| Rate for Payer: Cash Price |
$6,199.88
|
| Rate for Payer: Cigna Commercial |
$10,291.79
|
| Rate for Payer: First Health Commercial |
$11,779.76
|
| Rate for Payer: Humana Commercial |
$10,539.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,167.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,151.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,719.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,911.78
|
| Rate for Payer: Ohio Health Group HMO |
$9,299.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,919.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,787.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,555.83
|
| Rate for Payer: PHCS Commercial |
$11,903.76
|
| Rate for Payer: United Healthcare All Payer |
$10,911.78
|
|
|
STENT GRAFT AAA ILIAC 11.5*15
|
Facility
|
OP
|
$12,399.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,719.93 |
| Max. Negotiated Rate |
$11,903.76 |
| Rate for Payer: Aetna Commercial |
$9,547.81
|
| Rate for Payer: Anthem Medicaid |
$4,264.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,671.81
|
| Rate for Payer: Cash Price |
$6,199.88
|
| Rate for Payer: Cigna Commercial |
$10,291.79
|
| Rate for Payer: First Health Commercial |
$11,779.76
|
| Rate for Payer: Humana Commercial |
$10,539.79
|
| Rate for Payer: Humana KY Medicaid |
$4,264.27
|
| Rate for Payer: Kentucky WC Medicaid |
$4,307.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,167.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,151.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,719.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,349.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,911.78
|
| Rate for Payer: Ohio Health Group HMO |
$9,299.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,919.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,787.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,555.83
|
| Rate for Payer: PHCS Commercial |
$11,903.76
|
| Rate for Payer: United Healthcare All Payer |
$10,911.78
|
|
|
STENT GRAFT AAA ILIAC 8.5*12
|
Facility
|
OP
|
$11,665.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.72 |
| Max. Negotiated Rate |
$11,199.12 |
| Rate for Payer: Aetna Commercial |
$8,982.63
|
| Rate for Payer: Anthem Medicaid |
$4,011.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,099.28
|
| Rate for Payer: Cash Price |
$5,832.88
|
| Rate for Payer: Cigna Commercial |
$9,682.57
|
| Rate for Payer: First Health Commercial |
$11,082.46
|
| Rate for Payer: Humana Commercial |
$9,915.89
|
| Rate for Payer: Humana KY Medicaid |
$4,011.85
|
| Rate for Payer: Kentucky WC Medicaid |
$4,052.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,565.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,609.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,499.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,092.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,265.86
|
| Rate for Payer: Ohio Health Group HMO |
$8,749.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,332.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,149.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,049.37
|
| Rate for Payer: PHCS Commercial |
$11,199.12
|
| Rate for Payer: United Healthcare All Payer |
$10,265.86
|
|
|
STENT GRAFT AAA ILIAC 8.5*12
|
Facility
|
IP
|
$11,665.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.72 |
| Max. Negotiated Rate |
$11,199.12 |
| Rate for Payer: Aetna Commercial |
$8,982.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,099.28
|
| Rate for Payer: Cash Price |
$5,832.88
|
| Rate for Payer: Cigna Commercial |
$9,682.57
|
| Rate for Payer: First Health Commercial |
$11,082.46
|
| Rate for Payer: Humana Commercial |
$9,915.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,565.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,609.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,499.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,265.86
|
| Rate for Payer: Ohio Health Group HMO |
$8,749.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,332.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,149.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,049.37
|
| Rate for Payer: PHCS Commercial |
$11,199.12
|
| Rate for Payer: United Healthcare All Payer |
$10,265.86
|
|
|
STENT GRAFT AAA ILIAC 8.5*13
|
Facility
|
IP
|
$11,665.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.72 |
| Max. Negotiated Rate |
$11,199.12 |
| Rate for Payer: Aetna Commercial |
$8,982.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,099.28
|
| Rate for Payer: Cash Price |
$5,832.88
|
| Rate for Payer: Cigna Commercial |
$9,682.57
|
| Rate for Payer: First Health Commercial |
$11,082.46
|
| Rate for Payer: Humana Commercial |
$9,915.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,565.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,609.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,499.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,265.86
|
| Rate for Payer: Ohio Health Group HMO |
$8,749.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,332.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,149.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,049.37
|
| Rate for Payer: PHCS Commercial |
$11,199.12
|
| Rate for Payer: United Healthcare All Payer |
$10,265.86
|
|
|
STENT GRAFT AAA ILIAC 8.5*13
|
Facility
|
OP
|
$11,665.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.72 |
| Max. Negotiated Rate |
$11,199.12 |
| Rate for Payer: Aetna Commercial |
$8,982.63
|
| Rate for Payer: Anthem Medicaid |
$4,011.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,099.28
|
| Rate for Payer: Cash Price |
$5,832.88
|
| Rate for Payer: Cigna Commercial |
$9,682.57
|
| Rate for Payer: First Health Commercial |
$11,082.46
|
| Rate for Payer: Humana Commercial |
$9,915.89
|
| Rate for Payer: Humana KY Medicaid |
$4,011.85
|
| Rate for Payer: Kentucky WC Medicaid |
$4,052.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,565.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,609.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,499.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,092.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,265.86
|
| Rate for Payer: Ohio Health Group HMO |
$8,749.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,332.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,149.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,049.37
|
| Rate for Payer: PHCS Commercial |
$11,199.12
|
| Rate for Payer: United Healthcare All Payer |
$10,265.86
|
|
|
STENT GRAFT AAA ILIAC 8.5*15
|
Facility
|
IP
|
$11,665.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.72 |
| Max. Negotiated Rate |
$11,199.12 |
| Rate for Payer: Aetna Commercial |
$8,982.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,099.28
|
| Rate for Payer: Cash Price |
$5,832.88
|
| Rate for Payer: Cigna Commercial |
$9,682.57
|
| Rate for Payer: First Health Commercial |
$11,082.46
|
| Rate for Payer: Humana Commercial |
$9,915.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,565.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,609.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,499.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,265.86
|
| Rate for Payer: Ohio Health Group HMO |
$8,749.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,332.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,149.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,049.37
|
| Rate for Payer: PHCS Commercial |
$11,199.12
|
| Rate for Payer: United Healthcare All Payer |
$10,265.86
|
|
|
STENT GRAFT AAA ILIAC 8.5*15
|
Facility
|
OP
|
$11,665.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.72 |
| Max. Negotiated Rate |
$11,199.12 |
| Rate for Payer: Aetna Commercial |
$8,982.63
|
| Rate for Payer: Anthem Medicaid |
$4,011.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,099.28
|
| Rate for Payer: Cash Price |
$5,832.88
|
| Rate for Payer: Cigna Commercial |
$9,682.57
|
| Rate for Payer: First Health Commercial |
$11,082.46
|
| Rate for Payer: Humana Commercial |
$9,915.89
|
| Rate for Payer: Humana KY Medicaid |
$4,011.85
|
| Rate for Payer: Kentucky WC Medicaid |
$4,052.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,565.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,609.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,499.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,092.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,265.86
|
| Rate for Payer: Ohio Health Group HMO |
$8,749.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,332.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,149.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,049.37
|
| Rate for Payer: PHCS Commercial |
$11,199.12
|
| Rate for Payer: United Healthcare All Payer |
$10,265.86
|
|
|
STENT ILIAC FLR 16*20MM 11.5CM
|
Facility
|
OP
|
$14,234.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,270.43 |
| Max. Negotiated Rate |
$13,665.36 |
| Rate for Payer: Aetna Commercial |
$10,960.76
|
| Rate for Payer: Anthem Medicaid |
$4,895.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,103.10
|
| Rate for Payer: Cash Price |
$7,117.38
|
| Rate for Payer: Cigna Commercial |
$11,814.84
|
| Rate for Payer: First Health Commercial |
$13,523.01
|
| Rate for Payer: Humana Commercial |
$12,099.54
|
| Rate for Payer: Humana KY Medicaid |
$4,895.33
|
| Rate for Payer: Kentucky WC Medicaid |
$4,945.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,672.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,505.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,270.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,993.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,526.58
|
| Rate for Payer: Ohio Health Group HMO |
$10,676.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,387.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,384.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,821.98
|
| Rate for Payer: PHCS Commercial |
$13,665.36
|
| Rate for Payer: United Healthcare All Payer |
$12,526.58
|
|
|
STENT ILIAC FLR 16*20MM 11.5CM
|
Facility
|
IP
|
$14,234.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,270.43 |
| Max. Negotiated Rate |
$13,665.36 |
| Rate for Payer: Aetna Commercial |
$10,960.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,103.10
|
| Rate for Payer: Cash Price |
$7,117.38
|
| Rate for Payer: Cigna Commercial |
$11,814.84
|
| Rate for Payer: First Health Commercial |
$13,523.01
|
| Rate for Payer: Humana Commercial |
$12,099.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,672.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,505.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,270.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,526.58
|
| Rate for Payer: Ohio Health Group HMO |
$10,676.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,387.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,384.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,821.98
|
| Rate for Payer: PHCS Commercial |
$13,665.36
|
| Rate for Payer: United Healthcare All Payer |
$12,526.58
|
|
|
STENT ILIAC FLR 16*20MM 13.5CM
|
Facility
|
OP
|
$17,165.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,149.50 |
| Max. Negotiated Rate |
$16,478.40 |
| Rate for Payer: Aetna Commercial |
$13,217.05
|
| Rate for Payer: Anthem Medicaid |
$5,903.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,388.70
|
| Rate for Payer: Cash Price |
$8,582.50
|
| Rate for Payer: Cigna Commercial |
$14,246.95
|
| Rate for Payer: First Health Commercial |
$16,306.75
|
| Rate for Payer: Humana Commercial |
$14,590.25
|
| Rate for Payer: Humana KY Medicaid |
$5,903.04
|
| Rate for Payer: Kentucky WC Medicaid |
$5,963.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,075.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,667.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,149.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,021.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,105.20
|
| Rate for Payer: Ohio Health Group HMO |
$12,873.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,732.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,933.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,843.85
|
| Rate for Payer: PHCS Commercial |
$16,478.40
|
| Rate for Payer: United Healthcare All Payer |
$15,105.20
|
|
|
STENT ILIAC FLR 16*20MM 13.5CM
|
Facility
|
IP
|
$17,165.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,149.50 |
| Max. Negotiated Rate |
$16,478.40 |
| Rate for Payer: Aetna Commercial |
$13,217.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,388.70
|
| Rate for Payer: Cash Price |
$8,582.50
|
| Rate for Payer: Cigna Commercial |
$14,246.95
|
| Rate for Payer: First Health Commercial |
$16,306.75
|
| Rate for Payer: Humana Commercial |
$14,590.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,075.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,667.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,149.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,105.20
|
| Rate for Payer: Ohio Health Group HMO |
$12,873.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,732.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,933.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,843.85
|
| Rate for Payer: PHCS Commercial |
$16,478.40
|
| Rate for Payer: United Healthcare All Payer |
$15,105.20
|
|
|
STENT ILIAC FLR 18*22MM 11.5CM
|
Facility
|
IP
|
$17,165.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,149.50 |
| Max. Negotiated Rate |
$16,478.40 |
| Rate for Payer: Aetna Commercial |
$13,217.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,388.70
|
| Rate for Payer: Cash Price |
$8,582.50
|
| Rate for Payer: Cigna Commercial |
$14,246.95
|
| Rate for Payer: First Health Commercial |
$16,306.75
|
| Rate for Payer: Humana Commercial |
$14,590.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,075.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,667.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,149.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,105.20
|
| Rate for Payer: Ohio Health Group HMO |
$12,873.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,732.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,933.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,843.85
|
| Rate for Payer: PHCS Commercial |
$16,478.40
|
| Rate for Payer: United Healthcare All Payer |
$15,105.20
|
|
|
STENT ILIAC FLR 18*22MM 11.5CM
|
Facility
|
OP
|
$17,165.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,149.50 |
| Max. Negotiated Rate |
$16,478.40 |
| Rate for Payer: Aetna Commercial |
$13,217.05
|
| Rate for Payer: Anthem Medicaid |
$5,903.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,388.70
|
| Rate for Payer: Cash Price |
$8,582.50
|
| Rate for Payer: Cigna Commercial |
$14,246.95
|
| Rate for Payer: First Health Commercial |
$16,306.75
|
| Rate for Payer: Humana Commercial |
$14,590.25
|
| Rate for Payer: Humana KY Medicaid |
$5,903.04
|
| Rate for Payer: Kentucky WC Medicaid |
$5,963.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,075.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,667.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,149.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,021.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,105.20
|
| Rate for Payer: Ohio Health Group HMO |
$12,873.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,732.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,933.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,843.85
|
| Rate for Payer: PHCS Commercial |
$16,478.40
|
| Rate for Payer: United Healthcare All Payer |
$15,105.20
|
|
|
STENT ILIAC FLR 18*22MM 13.5CM
|
Facility
|
IP
|
$17,905.00
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,371.50 |
| Max. Negotiated Rate |
$17,188.80 |
| Rate for Payer: Aetna Commercial |
$13,786.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,965.90
|
| Rate for Payer: Cash Price |
$8,952.50
|
| Rate for Payer: Cigna Commercial |
$14,861.15
|
| Rate for Payer: First Health Commercial |
$17,009.75
|
| Rate for Payer: Humana Commercial |
$15,219.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,682.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,213.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,371.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,756.40
|
| Rate for Payer: Ohio Health Group HMO |
$13,428.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,324.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,577.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,354.45
|
| Rate for Payer: PHCS Commercial |
$17,188.80
|
| Rate for Payer: United Healthcare All Payer |
$15,756.40
|
|
