|
STENT PLYFLX ESOPH 23/18MM*90M
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
STENT PLYFLX ESOPH 23/18MM*90M
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
STENT PLYFLX SELF EXP 16*70*10
|
Facility
|
OP
|
$9,387.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,816.25 |
| Max. Negotiated Rate |
$9,012.00 |
| Rate for Payer: Aetna Commercial |
$7,228.38
|
| Rate for Payer: Anthem Medicaid |
$3,228.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,322.25
|
| Rate for Payer: Cash Price |
$4,693.75
|
| Rate for Payer: Cigna Commercial |
$7,791.62
|
| Rate for Payer: First Health Commercial |
$8,918.12
|
| Rate for Payer: Humana Commercial |
$7,979.38
|
| Rate for Payer: Humana KY Medicaid |
$3,228.36
|
| Rate for Payer: Kentucky WC Medicaid |
$3,261.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,697.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,927.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,816.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,293.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,261.00
|
| Rate for Payer: Ohio Health Group HMO |
$7,040.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,510.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,167.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,477.38
|
| Rate for Payer: PHCS Commercial |
$9,012.00
|
| Rate for Payer: United Healthcare All Payer |
$8,261.00
|
|
|
STENT PLYFLX SELF EXP 16*70*10
|
Facility
|
IP
|
$9,387.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,816.25 |
| Max. Negotiated Rate |
$9,012.00 |
| Rate for Payer: Aetna Commercial |
$7,228.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,322.25
|
| Rate for Payer: Cash Price |
$4,693.75
|
| Rate for Payer: Cigna Commercial |
$7,791.62
|
| Rate for Payer: First Health Commercial |
$8,918.12
|
| Rate for Payer: Humana Commercial |
$7,979.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,697.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,927.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,816.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,261.00
|
| Rate for Payer: Ohio Health Group HMO |
$7,040.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,510.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,167.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,477.38
|
| Rate for Payer: PHCS Commercial |
$9,012.00
|
| Rate for Payer: United Healthcare All Payer |
$8,261.00
|
|
|
STENT POLARIS LOOP URETERAL 6*
|
Facility
|
IP
|
$1,898.58
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$569.57 |
| Max. Negotiated Rate |
$1,822.64 |
| Rate for Payer: Aetna Commercial |
$1,461.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,480.89
|
| Rate for Payer: Cash Price |
$949.29
|
| Rate for Payer: Cigna Commercial |
$1,575.82
|
| Rate for Payer: First Health Commercial |
$1,803.65
|
| Rate for Payer: Humana Commercial |
$1,613.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,556.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,401.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$569.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,670.75
|
| Rate for Payer: Ohio Health Group HMO |
$1,423.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,518.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,651.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,310.02
|
| Rate for Payer: PHCS Commercial |
$1,822.64
|
| Rate for Payer: United Healthcare All Payer |
$1,670.75
|
|
|
STENT POLARIS LOOP URETERAL 6*
|
Facility
|
OP
|
$1,898.58
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$569.57 |
| Max. Negotiated Rate |
$1,822.64 |
| Rate for Payer: Aetna Commercial |
$1,461.91
|
| Rate for Payer: Anthem Medicaid |
$652.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,480.89
|
| Rate for Payer: Cash Price |
$949.29
|
| Rate for Payer: Cigna Commercial |
$1,575.82
|
| Rate for Payer: First Health Commercial |
$1,803.65
|
| Rate for Payer: Humana Commercial |
$1,613.79
|
| Rate for Payer: Humana KY Medicaid |
$652.92
|
| Rate for Payer: Kentucky WC Medicaid |
$659.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,556.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,401.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$569.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$666.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,670.75
|
| Rate for Payer: Ohio Health Group HMO |
$1,423.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,518.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,651.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,310.02
|
| Rate for Payer: PHCS Commercial |
$1,822.64
|
| Rate for Payer: United Healthcare All Payer |
$1,670.75
|
|
|
STENT POLARIS ULTRA 7*26
|
Facility
|
OP
|
$1,807.98
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$542.39 |
| Max. Negotiated Rate |
$1,735.66 |
| Rate for Payer: Aetna Commercial |
$1,392.14
|
| Rate for Payer: Anthem Medicaid |
$621.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,410.22
|
| Rate for Payer: Cash Price |
$903.99
|
| Rate for Payer: Cigna Commercial |
$1,500.62
|
| Rate for Payer: First Health Commercial |
$1,717.58
|
| Rate for Payer: Humana Commercial |
$1,536.78
|
| Rate for Payer: Humana KY Medicaid |
$621.76
|
| Rate for Payer: Kentucky WC Medicaid |
$628.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,482.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,334.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$542.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$634.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,591.02
|
| Rate for Payer: Ohio Health Group HMO |
$1,355.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,446.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,572.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,247.51
|
| Rate for Payer: PHCS Commercial |
$1,735.66
|
| Rate for Payer: United Healthcare All Payer |
$1,591.02
|
|
|
STENT POLARIS ULTRA 7*26
|
Facility
|
IP
|
$1,807.98
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$542.39 |
| Max. Negotiated Rate |
$1,735.66 |
| Rate for Payer: Aetna Commercial |
$1,392.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,410.22
|
| Rate for Payer: Cash Price |
$903.99
|
| Rate for Payer: Cigna Commercial |
$1,500.62
|
| Rate for Payer: First Health Commercial |
$1,717.58
|
| Rate for Payer: Humana Commercial |
$1,536.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,482.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,334.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$542.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,591.02
|
| Rate for Payer: Ohio Health Group HMO |
$1,355.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,446.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,572.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,247.51
|
| Rate for Payer: PHCS Commercial |
$1,735.66
|
| Rate for Payer: United Healthcare All Payer |
$1,591.02
|
|
|
STENT POLARIS ULTRA 8*24
|
Facility
|
IP
|
$1,807.98
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$542.39 |
| Max. Negotiated Rate |
$1,735.66 |
| Rate for Payer: Aetna Commercial |
$1,392.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,410.22
|
| Rate for Payer: Cash Price |
$903.99
|
| Rate for Payer: Cigna Commercial |
$1,500.62
|
| Rate for Payer: First Health Commercial |
$1,717.58
|
| Rate for Payer: Humana Commercial |
$1,536.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,482.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,334.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$542.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,591.02
|
| Rate for Payer: Ohio Health Group HMO |
$1,355.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,446.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,572.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,247.51
|
| Rate for Payer: PHCS Commercial |
$1,735.66
|
| Rate for Payer: United Healthcare All Payer |
$1,591.02
|
|
|
STENT POLARIS ULTRA 8*24
|
Facility
|
OP
|
$1,807.98
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$542.39 |
| Max. Negotiated Rate |
$1,735.66 |
| Rate for Payer: Aetna Commercial |
$1,392.14
|
| Rate for Payer: Anthem Medicaid |
$621.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,410.22
|
| Rate for Payer: Cash Price |
$903.99
|
| Rate for Payer: Cigna Commercial |
$1,500.62
|
| Rate for Payer: First Health Commercial |
$1,717.58
|
| Rate for Payer: Humana Commercial |
$1,536.78
|
| Rate for Payer: Humana KY Medicaid |
$621.76
|
| Rate for Payer: Kentucky WC Medicaid |
$628.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,482.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,334.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$542.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$634.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,591.02
|
| Rate for Payer: Ohio Health Group HMO |
$1,355.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,446.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,572.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,247.51
|
| Rate for Payer: PHCS Commercial |
$1,735.66
|
| Rate for Payer: United Healthcare All Payer |
$1,591.02
|
|
|
STENT POLARIS ULTRA 8*26
|
Facility
|
IP
|
$1,807.98
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$542.39 |
| Max. Negotiated Rate |
$1,735.66 |
| Rate for Payer: Aetna Commercial |
$1,392.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,410.22
|
| Rate for Payer: Cash Price |
$903.99
|
| Rate for Payer: Cigna Commercial |
$1,500.62
|
| Rate for Payer: First Health Commercial |
$1,717.58
|
| Rate for Payer: Humana Commercial |
$1,536.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,482.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,334.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$542.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,591.02
|
| Rate for Payer: Ohio Health Group HMO |
$1,355.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,446.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,572.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,247.51
|
| Rate for Payer: PHCS Commercial |
$1,735.66
|
| Rate for Payer: United Healthcare All Payer |
$1,591.02
|
|
|
STENT POLARIS ULTRA 8*26
|
Facility
|
OP
|
$1,807.98
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$542.39 |
| Max. Negotiated Rate |
$1,735.66 |
| Rate for Payer: Aetna Commercial |
$1,392.14
|
| Rate for Payer: Anthem Medicaid |
$621.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,410.22
|
| Rate for Payer: Cash Price |
$903.99
|
| Rate for Payer: Cigna Commercial |
$1,500.62
|
| Rate for Payer: First Health Commercial |
$1,717.58
|
| Rate for Payer: Humana Commercial |
$1,536.78
|
| Rate for Payer: Humana KY Medicaid |
$621.76
|
| Rate for Payer: Kentucky WC Medicaid |
$628.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,482.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,334.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$542.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$634.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,591.02
|
| Rate for Payer: Ohio Health Group HMO |
$1,355.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,446.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,572.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,247.51
|
| Rate for Payer: PHCS Commercial |
$1,735.66
|
| Rate for Payer: United Healthcare All Payer |
$1,591.02
|
|
|
STENT POLARIS URETERAL 5.0*26
|
Facility
|
OP
|
$1,818.36
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$545.51 |
| Max. Negotiated Rate |
$1,745.63 |
| Rate for Payer: Aetna Commercial |
$1,400.14
|
| Rate for Payer: Anthem Medicaid |
$625.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,418.32
|
| Rate for Payer: Cash Price |
$909.18
|
| Rate for Payer: Cigna Commercial |
$1,509.24
|
| Rate for Payer: First Health Commercial |
$1,727.44
|
| Rate for Payer: Humana Commercial |
$1,545.61
|
| Rate for Payer: Humana KY Medicaid |
$625.33
|
| Rate for Payer: Kentucky WC Medicaid |
$631.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,491.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,341.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$545.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$637.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,600.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,363.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,454.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,581.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,254.67
|
| Rate for Payer: PHCS Commercial |
$1,745.63
|
| Rate for Payer: United Healthcare All Payer |
$1,600.16
|
|
|
STENT POLARIS URETERAL 5.0*26
|
Facility
|
IP
|
$1,818.36
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$545.51 |
| Max. Negotiated Rate |
$1,745.63 |
| Rate for Payer: Aetna Commercial |
$1,400.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,418.32
|
| Rate for Payer: Cash Price |
$909.18
|
| Rate for Payer: Cigna Commercial |
$1,509.24
|
| Rate for Payer: First Health Commercial |
$1,727.44
|
| Rate for Payer: Humana Commercial |
$1,545.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,491.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,341.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$545.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,600.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,363.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,454.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,581.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,254.67
|
| Rate for Payer: PHCS Commercial |
$1,745.63
|
| Rate for Payer: United Healthcare All Payer |
$1,600.16
|
|
|
STENT POLARIS URETERAL 5*22
|
Facility
|
IP
|
$1,818.36
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$545.51 |
| Max. Negotiated Rate |
$1,745.63 |
| Rate for Payer: Aetna Commercial |
$1,400.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,418.32
|
| Rate for Payer: Cash Price |
$909.18
|
| Rate for Payer: Cigna Commercial |
$1,509.24
|
| Rate for Payer: First Health Commercial |
$1,727.44
|
| Rate for Payer: Humana Commercial |
$1,545.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,491.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,341.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$545.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,600.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,363.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,454.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,581.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,254.67
|
| Rate for Payer: PHCS Commercial |
$1,745.63
|
| Rate for Payer: United Healthcare All Payer |
$1,600.16
|
|
|
STENT POLARIS URETERAL 5*22
|
Facility
|
OP
|
$1,818.36
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$545.51 |
| Max. Negotiated Rate |
$1,745.63 |
| Rate for Payer: Aetna Commercial |
$1,400.14
|
| Rate for Payer: Anthem Medicaid |
$625.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,418.32
|
| Rate for Payer: Cash Price |
$909.18
|
| Rate for Payer: Cigna Commercial |
$1,509.24
|
| Rate for Payer: First Health Commercial |
$1,727.44
|
| Rate for Payer: Humana Commercial |
$1,545.61
|
| Rate for Payer: Humana KY Medicaid |
$625.33
|
| Rate for Payer: Kentucky WC Medicaid |
$631.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,491.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,341.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$545.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$637.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,600.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,363.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,454.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,581.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,254.67
|
| Rate for Payer: PHCS Commercial |
$1,745.63
|
| Rate for Payer: United Healthcare All Payer |
$1,600.16
|
|
|
STENT POLARIS URETERAL 5*24
|
Facility
|
IP
|
$1,818.36
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$545.51 |
| Max. Negotiated Rate |
$1,745.63 |
| Rate for Payer: Aetna Commercial |
$1,400.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,418.32
|
| Rate for Payer: Cash Price |
$909.18
|
| Rate for Payer: Cigna Commercial |
$1,509.24
|
| Rate for Payer: First Health Commercial |
$1,727.44
|
| Rate for Payer: Humana Commercial |
$1,545.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,491.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,341.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$545.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,600.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,363.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,454.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,581.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,254.67
|
| Rate for Payer: PHCS Commercial |
$1,745.63
|
| Rate for Payer: United Healthcare All Payer |
$1,600.16
|
|
|
STENT POLARIS URETERAL 5*24
|
Facility
|
OP
|
$1,818.36
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$545.51 |
| Max. Negotiated Rate |
$1,745.63 |
| Rate for Payer: Aetna Commercial |
$1,400.14
|
| Rate for Payer: Anthem Medicaid |
$625.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,418.32
|
| Rate for Payer: Cash Price |
$909.18
|
| Rate for Payer: Cigna Commercial |
$1,509.24
|
| Rate for Payer: First Health Commercial |
$1,727.44
|
| Rate for Payer: Humana Commercial |
$1,545.61
|
| Rate for Payer: Humana KY Medicaid |
$625.33
|
| Rate for Payer: Kentucky WC Medicaid |
$631.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,491.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,341.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$545.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$637.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,600.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,363.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,454.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,581.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,254.67
|
| Rate for Payer: PHCS Commercial |
$1,745.63
|
| Rate for Payer: United Healthcare All Payer |
$1,600.16
|
|
|
STENT POLARIS URETERAL 6.0*22
|
Facility
|
OP
|
$1,834.39
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$550.32 |
| Max. Negotiated Rate |
$1,761.01 |
| Rate for Payer: Aetna Commercial |
$1,412.48
|
| Rate for Payer: Anthem Medicaid |
$630.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,430.82
|
| Rate for Payer: Cash Price |
$917.20
|
| Rate for Payer: Cigna Commercial |
$1,522.54
|
| Rate for Payer: First Health Commercial |
$1,742.67
|
| Rate for Payer: Humana Commercial |
$1,559.23
|
| Rate for Payer: Humana KY Medicaid |
$630.85
|
| Rate for Payer: Kentucky WC Medicaid |
$637.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,504.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,353.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$550.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$643.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,614.26
|
| Rate for Payer: Ohio Health Group HMO |
$1,375.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,467.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,595.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,265.73
|
| Rate for Payer: PHCS Commercial |
$1,761.01
|
| Rate for Payer: United Healthcare All Payer |
$1,614.26
|
|
|
STENT POLARIS URETERAL 6.0*22
|
Facility
|
IP
|
$1,834.39
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$550.32 |
| Max. Negotiated Rate |
$1,761.01 |
| Rate for Payer: Aetna Commercial |
$1,412.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,430.82
|
| Rate for Payer: Cash Price |
$917.20
|
| Rate for Payer: Cigna Commercial |
$1,522.54
|
| Rate for Payer: First Health Commercial |
$1,742.67
|
| Rate for Payer: Humana Commercial |
$1,559.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,504.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,353.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$550.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,614.26
|
| Rate for Payer: Ohio Health Group HMO |
$1,375.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,467.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,595.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,265.73
|
| Rate for Payer: PHCS Commercial |
$1,761.01
|
| Rate for Payer: United Healthcare All Payer |
$1,614.26
|
|
|
STENT POLARIS URETERAL 6.0*24
|
Facility
|
OP
|
$1,807.98
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$542.39 |
| Max. Negotiated Rate |
$1,735.66 |
| Rate for Payer: Aetna Commercial |
$1,392.14
|
| Rate for Payer: Anthem Medicaid |
$621.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,410.22
|
| Rate for Payer: Cash Price |
$903.99
|
| Rate for Payer: Cigna Commercial |
$1,500.62
|
| Rate for Payer: First Health Commercial |
$1,717.58
|
| Rate for Payer: Humana Commercial |
$1,536.78
|
| Rate for Payer: Humana KY Medicaid |
$621.76
|
| Rate for Payer: Kentucky WC Medicaid |
$628.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,482.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,334.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$542.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$634.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,591.02
|
| Rate for Payer: Ohio Health Group HMO |
$1,355.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,446.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,572.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,247.51
|
| Rate for Payer: PHCS Commercial |
$1,735.66
|
| Rate for Payer: United Healthcare All Payer |
$1,591.02
|
|
|
STENT POLARIS URETERAL 6.0*24
|
Facility
|
IP
|
$1,807.98
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$542.39 |
| Max. Negotiated Rate |
$1,735.66 |
| Rate for Payer: Aetna Commercial |
$1,392.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,410.22
|
| Rate for Payer: Cash Price |
$903.99
|
| Rate for Payer: Cigna Commercial |
$1,500.62
|
| Rate for Payer: First Health Commercial |
$1,717.58
|
| Rate for Payer: Humana Commercial |
$1,536.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,482.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,334.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$542.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,591.02
|
| Rate for Payer: Ohio Health Group HMO |
$1,355.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,446.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,572.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,247.51
|
| Rate for Payer: PHCS Commercial |
$1,735.66
|
| Rate for Payer: United Healthcare All Payer |
$1,591.02
|
|
|
STENT POLARIS URETERAL 6.0*26
|
Facility
|
OP
|
$1,834.39
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$550.32 |
| Max. Negotiated Rate |
$1,761.01 |
| Rate for Payer: Aetna Commercial |
$1,412.48
|
| Rate for Payer: Anthem Medicaid |
$630.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,430.82
|
| Rate for Payer: Cash Price |
$917.20
|
| Rate for Payer: Cigna Commercial |
$1,522.54
|
| Rate for Payer: First Health Commercial |
$1,742.67
|
| Rate for Payer: Humana Commercial |
$1,559.23
|
| Rate for Payer: Humana KY Medicaid |
$630.85
|
| Rate for Payer: Kentucky WC Medicaid |
$637.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,504.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,353.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$550.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$643.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,614.26
|
| Rate for Payer: Ohio Health Group HMO |
$1,375.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,467.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,595.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,265.73
|
| Rate for Payer: PHCS Commercial |
$1,761.01
|
| Rate for Payer: United Healthcare All Payer |
$1,614.26
|
|
|
STENT POLARIS URETERAL 6.0*26
|
Facility
|
IP
|
$1,834.39
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$550.32 |
| Max. Negotiated Rate |
$1,761.01 |
| Rate for Payer: Aetna Commercial |
$1,412.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,430.82
|
| Rate for Payer: Cash Price |
$917.20
|
| Rate for Payer: Cigna Commercial |
$1,522.54
|
| Rate for Payer: First Health Commercial |
$1,742.67
|
| Rate for Payer: Humana Commercial |
$1,559.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,504.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,353.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$550.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,614.26
|
| Rate for Payer: Ohio Health Group HMO |
$1,375.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,467.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,595.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,265.73
|
| Rate for Payer: PHCS Commercial |
$1,761.01
|
| Rate for Payer: United Healthcare All Payer |
$1,614.26
|
|
|
STENT POLARIS URETERAL 6*28
|
Facility
|
IP
|
$1,845.30
|
|
|
Service Code
|
HCPCS C2617
|
| Hospital Charge Code |
27000129
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$553.59 |
| Max. Negotiated Rate |
$1,771.49 |
| Rate for Payer: Aetna Commercial |
$1,420.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,439.33
|
| Rate for Payer: Cash Price |
$922.65
|
| Rate for Payer: Cigna Commercial |
$1,531.60
|
| Rate for Payer: First Health Commercial |
$1,753.04
|
| Rate for Payer: Humana Commercial |
$1,568.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,513.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,361.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$553.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,623.86
|
| Rate for Payer: Ohio Health Group HMO |
$1,383.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,476.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,605.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,273.26
|
| Rate for Payer: PHCS Commercial |
$1,771.49
|
| Rate for Payer: United Healthcare All Payer |
$1,623.86
|
|
