|
STENT POLARIS URETERAL 6*28
|
Facility
|
OP
|
$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 Medicaid |
$634.60
|
| 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: Humana KY Medicaid |
$634.60
|
| Rate for Payer: Kentucky WC Medicaid |
$641.06
|
| 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: Molina Healthcare Medicaid |
$647.33
|
| 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
|
|
|
STENT POLARIS URETERAL 7*22
|
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 7*22
|
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 7*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 7*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 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 URETERAL 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 URETERAL 7*28
|
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 7*28
|
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 POLYFLEX 18*40 SELF EXP
|
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 POLYFLEX 18*40 SELF EXP
|
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 POLYFLEX 20*4 SELF EXP
|
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 POLYFLEX 20*4 SELF EXP
|
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 POLYFLEX 20*80 SELF EXP
|
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 POLYFLEX 20*80 SELF EXP
|
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 POLYFLEX 22*80 SELF EXP
|
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 POLYFLEX 22*80 SELF EXP
|
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 POLYFLEX 8*30 SELF EXP
|
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 POLYFLEX 8*30 SELF EXP
|
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 POLYFLEX AIRWAY 16*10MM
|
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 POLYFLEX AIRWAY 16*10MM
|
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 POLYFLX SELF EXP 14*60*9
|
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 POLYFLX SELF EXP 14*60*9
|
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 QUADRA-COIL 6.0*22-28CM
|
Facility
|
IP
|
$1,881.21
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$564.36 |
| Max. Negotiated Rate |
$1,805.96 |
| Rate for Payer: Aetna Commercial |
$1,448.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,467.34
|
| Rate for Payer: Cash Price |
$940.60
|
| Rate for Payer: Cigna Commercial |
$1,561.40
|
| Rate for Payer: First Health Commercial |
$1,787.15
|
| Rate for Payer: Humana Commercial |
$1,599.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,542.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,388.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,655.46
|
| Rate for Payer: Ohio Health Group HMO |
$1,410.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,504.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,636.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,298.03
|
| Rate for Payer: PHCS Commercial |
$1,805.96
|
| Rate for Payer: United Healthcare All Payer |
$1,655.46
|
|
|
STENT QUADRA-COIL 6.0*22-28CM
|
Facility
|
OP
|
$1,881.21
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$564.36 |
| Max. Negotiated Rate |
$1,805.96 |
| Rate for Payer: Aetna Commercial |
$1,448.53
|
| Rate for Payer: Anthem Medicaid |
$646.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,467.34
|
| Rate for Payer: Cash Price |
$940.60
|
| Rate for Payer: Cigna Commercial |
$1,561.40
|
| Rate for Payer: First Health Commercial |
$1,787.15
|
| Rate for Payer: Humana Commercial |
$1,599.03
|
| Rate for Payer: Humana KY Medicaid |
$646.95
|
| Rate for Payer: Kentucky WC Medicaid |
$653.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,542.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,388.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$659.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,655.46
|
| Rate for Payer: Ohio Health Group HMO |
$1,410.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,504.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,636.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,298.03
|
| Rate for Payer: PHCS Commercial |
$1,805.96
|
| Rate for Payer: United Healthcare All Payer |
$1,655.46
|
|
