|
STENT TALENT AAA BIF 36*18*155
|
Facility
|
OP
|
$38,843.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,653.12 |
| Max. Negotiated Rate |
$37,290.00 |
| Rate for Payer: Aetna Commercial |
$29,909.69
|
| Rate for Payer: Anthem Medicaid |
$13,358.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30,298.12
|
| Rate for Payer: Cash Price |
$19,421.88
|
| Rate for Payer: Cigna Commercial |
$32,240.31
|
| Rate for Payer: First Health Commercial |
$36,901.56
|
| Rate for Payer: Humana Commercial |
$33,017.19
|
| Rate for Payer: Humana KY Medicaid |
$13,358.37
|
| Rate for Payer: Kentucky WC Medicaid |
$13,494.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31,851.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28,666.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,653.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,626.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$34,182.50
|
| Rate for Payer: Ohio Health Group HMO |
$29,132.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$31,075.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33,794.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26,802.19
|
| Rate for Payer: PHCS Commercial |
$37,290.00
|
| Rate for Payer: United Healthcare All Payer |
$34,182.50
|
|
|
STENT TALENT AAA BIF 36*18*155
|
Facility
|
IP
|
$38,843.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,653.12 |
| Max. Negotiated Rate |
$37,290.00 |
| Rate for Payer: Aetna Commercial |
$29,909.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30,298.12
|
| Rate for Payer: Cash Price |
$19,421.88
|
| Rate for Payer: Cigna Commercial |
$32,240.31
|
| Rate for Payer: First Health Commercial |
$36,901.56
|
| Rate for Payer: Humana Commercial |
$33,017.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31,851.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28,666.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,653.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$34,182.50
|
| Rate for Payer: Ohio Health Group HMO |
$29,132.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$31,075.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33,794.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26,802.19
|
| Rate for Payer: PHCS Commercial |
$37,290.00
|
| Rate for Payer: United Healthcare All Payer |
$34,182.50
|
|
|
STENT TALENT AAA LIMB 14*14*75
|
Facility
|
IP
|
$17,627.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,288.25 |
| Max. Negotiated Rate |
$16,922.40 |
| Rate for Payer: Aetna Commercial |
$13,573.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,749.45
|
| Rate for Payer: Cash Price |
$8,813.75
|
| Rate for Payer: Cigna Commercial |
$14,630.83
|
| Rate for Payer: First Health Commercial |
$16,746.12
|
| Rate for Payer: Humana Commercial |
$14,983.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,454.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,009.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,288.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,512.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,220.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,102.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,335.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,162.98
|
| Rate for Payer: PHCS Commercial |
$16,922.40
|
| Rate for Payer: United Healthcare All Payer |
$15,512.20
|
|
|
STENT TALENT AAA LIMB 14*14*75
|
Facility
|
OP
|
$17,627.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,288.25 |
| Max. Negotiated Rate |
$16,922.40 |
| Rate for Payer: Aetna Commercial |
$13,573.17
|
| Rate for Payer: Anthem Medicaid |
$6,062.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,749.45
|
| Rate for Payer: Cash Price |
$8,813.75
|
| Rate for Payer: Cigna Commercial |
$14,630.83
|
| Rate for Payer: First Health Commercial |
$16,746.12
|
| Rate for Payer: Humana Commercial |
$14,983.38
|
| Rate for Payer: Humana KY Medicaid |
$6,062.10
|
| Rate for Payer: Kentucky WC Medicaid |
$6,123.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,454.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,009.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,288.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,183.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,512.20
|
| Rate for Payer: Ohio Health Group HMO |
$13,220.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,102.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,335.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,162.98
|
| Rate for Payer: PHCS Commercial |
$16,922.40
|
| Rate for Payer: United Healthcare All Payer |
$15,512.20
|
|
|
STENT TALENT AAA LIMB 14*16*75
|
Facility
|
IP
|
$18,367.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,510.25 |
| Max. Negotiated Rate |
$17,632.80 |
| Rate for Payer: Aetna Commercial |
$14,142.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,326.65
|
| Rate for Payer: Cash Price |
$9,183.75
|
| Rate for Payer: Cigna Commercial |
$15,245.02
|
| Rate for Payer: First Health Commercial |
$17,449.12
|
| Rate for Payer: Humana Commercial |
$15,612.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,061.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,555.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,510.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,163.40
|
| Rate for Payer: Ohio Health Group HMO |
$13,775.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,694.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,979.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,673.58
|
| Rate for Payer: PHCS Commercial |
$17,632.80
|
| Rate for Payer: United Healthcare All Payer |
$16,163.40
|
|
|
STENT TALENT AAA LIMB 14*16*75
|
Facility
|
OP
|
$18,367.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,510.25 |
| Max. Negotiated Rate |
$17,632.80 |
| Rate for Payer: Aetna Commercial |
$14,142.98
|
| Rate for Payer: Anthem Medicaid |
$6,316.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,326.65
|
| Rate for Payer: Cash Price |
$9,183.75
|
| Rate for Payer: Cigna Commercial |
$15,245.02
|
| Rate for Payer: First Health Commercial |
$17,449.12
|
| Rate for Payer: Humana Commercial |
$15,612.38
|
| Rate for Payer: Humana KY Medicaid |
$6,316.58
|
| Rate for Payer: Kentucky WC Medicaid |
$6,380.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,061.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,555.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,510.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,443.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,163.40
|
| Rate for Payer: Ohio Health Group HMO |
$13,775.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,694.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,979.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,673.58
|
| Rate for Payer: PHCS Commercial |
$17,632.80
|
| Rate for Payer: United Healthcare All Payer |
$16,163.40
|
|
|
STENT TALENT AAA LIMB 14*18*75
|
Facility
|
OP
|
$18,922.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,676.75 |
| Max. Negotiated Rate |
$18,165.60 |
| Rate for Payer: Aetna Commercial |
$14,570.33
|
| Rate for Payer: Anthem Medicaid |
$6,507.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,759.55
|
| Rate for Payer: Cash Price |
$9,461.25
|
| Rate for Payer: Cigna Commercial |
$15,705.67
|
| Rate for Payer: First Health Commercial |
$17,976.38
|
| Rate for Payer: Humana Commercial |
$16,084.12
|
| Rate for Payer: Humana KY Medicaid |
$6,507.45
|
| Rate for Payer: Kentucky WC Medicaid |
$6,573.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,516.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,964.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,676.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,638.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,651.80
|
| Rate for Payer: Ohio Health Group HMO |
$14,191.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,138.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,462.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,056.52
|
| Rate for Payer: PHCS Commercial |
$18,165.60
|
| Rate for Payer: United Healthcare All Payer |
$16,651.80
|
|
|
STENT TALENT AAA LIMB 14*18*75
|
Facility
|
IP
|
$18,922.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,676.75 |
| Max. Negotiated Rate |
$18,165.60 |
| Rate for Payer: Aetna Commercial |
$14,570.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,759.55
|
| Rate for Payer: Cash Price |
$9,461.25
|
| Rate for Payer: Cigna Commercial |
$15,705.67
|
| Rate for Payer: First Health Commercial |
$17,976.38
|
| Rate for Payer: Humana Commercial |
$16,084.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,516.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,964.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,676.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,651.80
|
| Rate for Payer: Ohio Health Group HMO |
$14,191.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,138.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,462.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,056.52
|
| Rate for Payer: PHCS Commercial |
$18,165.60
|
| Rate for Payer: United Healthcare All Payer |
$16,651.80
|
|
|
STENT TALENT AAA LIMB 14*20*75
|
Facility
|
OP
|
$18,922.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,676.75 |
| Max. Negotiated Rate |
$18,165.60 |
| Rate for Payer: Aetna Commercial |
$14,570.33
|
| Rate for Payer: Anthem Medicaid |
$6,507.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,759.55
|
| Rate for Payer: Cash Price |
$9,461.25
|
| Rate for Payer: Cigna Commercial |
$15,705.67
|
| Rate for Payer: First Health Commercial |
$17,976.38
|
| Rate for Payer: Humana Commercial |
$16,084.12
|
| Rate for Payer: Humana KY Medicaid |
$6,507.45
|
| Rate for Payer: Kentucky WC Medicaid |
$6,573.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,516.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,964.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,676.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,638.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,651.80
|
| Rate for Payer: Ohio Health Group HMO |
$14,191.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,138.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,462.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,056.52
|
| Rate for Payer: PHCS Commercial |
$18,165.60
|
| Rate for Payer: United Healthcare All Payer |
$16,651.80
|
|
|
STENT TALENT AAA LIMB 14*20*75
|
Facility
|
IP
|
$18,922.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,676.75 |
| Max. Negotiated Rate |
$18,165.60 |
| Rate for Payer: Aetna Commercial |
$14,570.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,759.55
|
| Rate for Payer: Cash Price |
$9,461.25
|
| Rate for Payer: Cigna Commercial |
$15,705.67
|
| Rate for Payer: First Health Commercial |
$17,976.38
|
| Rate for Payer: Humana Commercial |
$16,084.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,516.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,964.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,676.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,651.80
|
| Rate for Payer: Ohio Health Group HMO |
$14,191.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,138.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,462.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,056.52
|
| Rate for Payer: PHCS Commercial |
$18,165.60
|
| Rate for Payer: United Healthcare All Payer |
$16,651.80
|
|
|
STENT TALENT AORTCEXT 28*28*29
|
Facility
|
OP
|
$14,051.25
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,215.38 |
| Max. Negotiated Rate |
$13,489.20 |
| Rate for Payer: Aetna Commercial |
$10,819.46
|
| Rate for Payer: Anthem Medicaid |
$4,832.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,959.98
|
| Rate for Payer: Cash Price |
$7,025.62
|
| Rate for Payer: Cigna Commercial |
$11,662.54
|
| Rate for Payer: First Health Commercial |
$13,348.69
|
| Rate for Payer: Humana Commercial |
$11,943.56
|
| Rate for Payer: Humana KY Medicaid |
$4,832.22
|
| Rate for Payer: Kentucky WC Medicaid |
$4,881.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,522.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,369.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,215.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,929.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,365.10
|
| Rate for Payer: Ohio Health Group HMO |
$10,538.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,241.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,224.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,695.36
|
| Rate for Payer: PHCS Commercial |
$13,489.20
|
| Rate for Payer: United Healthcare All Payer |
$12,365.10
|
|
|
STENT TALENT AORTCEXT 28*28*29
|
Facility
|
IP
|
$14,051.25
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,215.38 |
| Max. Negotiated Rate |
$13,489.20 |
| Rate for Payer: Aetna Commercial |
$10,819.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,959.98
|
| Rate for Payer: Cash Price |
$7,025.62
|
| Rate for Payer: Cigna Commercial |
$11,662.54
|
| Rate for Payer: First Health Commercial |
$13,348.69
|
| Rate for Payer: Humana Commercial |
$11,943.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,522.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,369.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,215.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,365.10
|
| Rate for Payer: Ohio Health Group HMO |
$10,538.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,241.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,224.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,695.36
|
| Rate for Payer: PHCS Commercial |
$13,489.20
|
| Rate for Payer: United Healthcare All Payer |
$12,365.10
|
|
|
STENT TALENT AORTCEXT 32*32*28
|
Facility
|
OP
|
$16,147.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,844.25 |
| Max. Negotiated Rate |
$15,501.60 |
| Rate for Payer: Aetna Commercial |
$12,433.58
|
| Rate for Payer: Anthem Medicaid |
$5,553.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,595.05
|
| Rate for Payer: Cash Price |
$8,073.75
|
| Rate for Payer: Cigna Commercial |
$13,402.42
|
| Rate for Payer: First Health Commercial |
$15,340.12
|
| Rate for Payer: Humana Commercial |
$13,725.38
|
| Rate for Payer: Humana KY Medicaid |
$5,553.13
|
| Rate for Payer: Kentucky WC Medicaid |
$5,609.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,240.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,916.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,844.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,664.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,209.80
|
| Rate for Payer: Ohio Health Group HMO |
$12,110.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,918.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,048.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,141.77
|
| Rate for Payer: PHCS Commercial |
$15,501.60
|
| Rate for Payer: United Healthcare All Payer |
$14,209.80
|
|
|
STENT TALENT AORTCEXT 32*32*28
|
Facility
|
IP
|
$16,147.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,844.25 |
| Max. Negotiated Rate |
$15,501.60 |
| Rate for Payer: Aetna Commercial |
$12,433.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,595.05
|
| Rate for Payer: Cash Price |
$8,073.75
|
| Rate for Payer: Cigna Commercial |
$13,402.42
|
| Rate for Payer: First Health Commercial |
$15,340.12
|
| Rate for Payer: Humana Commercial |
$13,725.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,240.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,916.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,844.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,209.80
|
| Rate for Payer: Ohio Health Group HMO |
$12,110.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,918.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,048.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,141.77
|
| Rate for Payer: PHCS Commercial |
$15,501.60
|
| Rate for Payer: United Healthcare All Payer |
$14,209.80
|
|
|
STENT TALENT AORTCEXT 36*36*26
|
Facility
|
IP
|
$17,997.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,399.25 |
| Max. Negotiated Rate |
$17,277.60 |
| Rate for Payer: Aetna Commercial |
$13,858.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,038.05
|
| Rate for Payer: Cash Price |
$8,998.75
|
| Rate for Payer: Cigna Commercial |
$14,937.92
|
| Rate for Payer: First Health Commercial |
$17,097.62
|
| Rate for Payer: Humana Commercial |
$15,297.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,757.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,282.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,399.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,837.80
|
| Rate for Payer: Ohio Health Group HMO |
$13,498.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,398.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,657.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,418.27
|
| Rate for Payer: PHCS Commercial |
$17,277.60
|
| Rate for Payer: United Healthcare All Payer |
$15,837.80
|
|
|
STENT TALENT AORTCEXT 36*36*26
|
Facility
|
OP
|
$17,997.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,399.25 |
| Max. Negotiated Rate |
$17,277.60 |
| Rate for Payer: Aetna Commercial |
$13,858.08
|
| Rate for Payer: Anthem Medicaid |
$6,189.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,038.05
|
| Rate for Payer: Cash Price |
$8,998.75
|
| Rate for Payer: Cigna Commercial |
$14,937.92
|
| Rate for Payer: First Health Commercial |
$17,097.62
|
| Rate for Payer: Humana Commercial |
$15,297.88
|
| Rate for Payer: Humana KY Medicaid |
$6,189.34
|
| Rate for Payer: Kentucky WC Medicaid |
$6,252.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,757.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,282.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,399.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,313.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,837.80
|
| Rate for Payer: Ohio Health Group HMO |
$13,498.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,398.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,657.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,418.27
|
| Rate for Payer: PHCS Commercial |
$17,277.60
|
| Rate for Payer: United Healthcare All Payer |
$15,837.80
|
|
|
STENT TALENT CON LIMB 14*16*90
|
Facility
|
IP
|
$19,107.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,732.25 |
| Max. Negotiated Rate |
$18,343.20 |
| Rate for Payer: Aetna Commercial |
$14,712.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,903.85
|
| Rate for Payer: Cash Price |
$9,553.75
|
| Rate for Payer: Cigna Commercial |
$15,859.23
|
| Rate for Payer: First Health Commercial |
$18,152.12
|
| Rate for Payer: Humana Commercial |
$16,241.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,668.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,101.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,732.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,814.60
|
| Rate for Payer: Ohio Health Group HMO |
$14,330.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,286.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,623.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,184.17
|
| Rate for Payer: PHCS Commercial |
$18,343.20
|
| Rate for Payer: United Healthcare All Payer |
$16,814.60
|
|
|
STENT TALENT CON LIMB 14*16*90
|
Facility
|
OP
|
$19,107.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,732.25 |
| Max. Negotiated Rate |
$18,343.20 |
| Rate for Payer: Aetna Commercial |
$14,712.77
|
| Rate for Payer: Anthem Medicaid |
$6,571.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,903.85
|
| Rate for Payer: Cash Price |
$9,553.75
|
| Rate for Payer: Cigna Commercial |
$15,859.23
|
| Rate for Payer: First Health Commercial |
$18,152.12
|
| Rate for Payer: Humana Commercial |
$16,241.38
|
| Rate for Payer: Humana KY Medicaid |
$6,571.07
|
| Rate for Payer: Kentucky WC Medicaid |
$6,637.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,668.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,101.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,732.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,702.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,814.60
|
| Rate for Payer: Ohio Health Group HMO |
$14,330.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,286.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,623.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,184.17
|
| Rate for Payer: PHCS Commercial |
$18,343.20
|
| Rate for Payer: United Healthcare All Payer |
$16,814.60
|
|
|
STENT TALENT ILIAC EXT 12*8*75
|
Facility
|
IP
|
$21,031.25
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,309.38 |
| Max. Negotiated Rate |
$20,190.00 |
| Rate for Payer: Aetna Commercial |
$16,194.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,404.38
|
| Rate for Payer: Cash Price |
$10,515.62
|
| Rate for Payer: Cigna Commercial |
$17,455.94
|
| Rate for Payer: First Health Commercial |
$19,979.69
|
| Rate for Payer: Humana Commercial |
$17,876.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,245.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,521.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,309.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,507.50
|
| Rate for Payer: Ohio Health Group HMO |
$15,773.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,297.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,511.56
|
| Rate for Payer: PHCS Commercial |
$20,190.00
|
| Rate for Payer: United Healthcare All Payer |
$18,507.50
|
|
|
STENT TALENT ILIAC EXT 12*8*75
|
Facility
|
OP
|
$21,031.25
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,309.38 |
| Max. Negotiated Rate |
$20,190.00 |
| Rate for Payer: Aetna Commercial |
$16,194.06
|
| Rate for Payer: Anthem Medicaid |
$7,232.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,404.38
|
| Rate for Payer: Cash Price |
$10,515.62
|
| Rate for Payer: Cigna Commercial |
$17,455.94
|
| Rate for Payer: First Health Commercial |
$19,979.69
|
| Rate for Payer: Humana Commercial |
$17,876.56
|
| Rate for Payer: Humana KY Medicaid |
$7,232.65
|
| Rate for Payer: Kentucky WC Medicaid |
$7,306.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,245.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,521.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,309.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,377.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,507.50
|
| Rate for Payer: Ohio Health Group HMO |
$15,773.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,297.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,511.56
|
| Rate for Payer: PHCS Commercial |
$20,190.00
|
| Rate for Payer: United Healthcare All Payer |
$18,507.50
|
|
|
STENT TALNT AAA LIMB 14*24*105
|
Facility
|
IP
|
$21,218.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,365.62 |
| Max. Negotiated Rate |
$20,370.00 |
| Rate for Payer: Aetna Commercial |
$16,338.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,550.62
|
| Rate for Payer: Cash Price |
$10,609.38
|
| Rate for Payer: Cigna Commercial |
$17,611.56
|
| Rate for Payer: First Health Commercial |
$20,157.81
|
| Rate for Payer: Humana Commercial |
$18,035.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,399.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,659.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,365.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,672.50
|
| Rate for Payer: Ohio Health Group HMO |
$15,914.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,460.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,640.94
|
| Rate for Payer: PHCS Commercial |
$20,370.00
|
| Rate for Payer: United Healthcare All Payer |
$18,672.50
|
|
|
STENT TALNT AAA LIMB 14*24*105
|
Facility
|
OP
|
$21,218.75
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,365.62 |
| Max. Negotiated Rate |
$20,370.00 |
| Rate for Payer: Aetna Commercial |
$16,338.44
|
| Rate for Payer: Anthem Medicaid |
$7,297.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,550.62
|
| Rate for Payer: Cash Price |
$10,609.38
|
| Rate for Payer: Cigna Commercial |
$17,611.56
|
| Rate for Payer: First Health Commercial |
$20,157.81
|
| Rate for Payer: Humana Commercial |
$18,035.94
|
| Rate for Payer: Humana KY Medicaid |
$7,297.13
|
| Rate for Payer: Kentucky WC Medicaid |
$7,371.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,399.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,659.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,365.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,443.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,672.50
|
| Rate for Payer: Ohio Health Group HMO |
$15,914.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,460.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,640.94
|
| Rate for Payer: PHCS Commercial |
$20,370.00
|
| Rate for Payer: United Healthcare All Payer |
$18,672.50
|
|
|
STENT TALNT ILIAC EXT 14*14*80
|
Facility
|
IP
|
$18,367.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,510.25 |
| Max. Negotiated Rate |
$17,632.80 |
| Rate for Payer: Aetna Commercial |
$14,142.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,326.65
|
| Rate for Payer: Cash Price |
$9,183.75
|
| Rate for Payer: Cigna Commercial |
$15,245.02
|
| Rate for Payer: First Health Commercial |
$17,449.12
|
| Rate for Payer: Humana Commercial |
$15,612.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,061.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,555.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,510.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,163.40
|
| Rate for Payer: Ohio Health Group HMO |
$13,775.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,694.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,979.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,673.58
|
| Rate for Payer: PHCS Commercial |
$17,632.80
|
| Rate for Payer: United Healthcare All Payer |
$16,163.40
|
|
|
STENT TALNT ILIAC EXT 14*14*80
|
Facility
|
OP
|
$18,367.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,510.25 |
| Max. Negotiated Rate |
$17,632.80 |
| Rate for Payer: Aetna Commercial |
$14,142.98
|
| Rate for Payer: Anthem Medicaid |
$6,316.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,326.65
|
| Rate for Payer: Cash Price |
$9,183.75
|
| Rate for Payer: Cigna Commercial |
$15,245.02
|
| Rate for Payer: First Health Commercial |
$17,449.12
|
| Rate for Payer: Humana Commercial |
$15,612.38
|
| Rate for Payer: Humana KY Medicaid |
$6,316.58
|
| Rate for Payer: Kentucky WC Medicaid |
$6,380.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,061.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,555.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,510.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,443.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,163.40
|
| Rate for Payer: Ohio Health Group HMO |
$13,775.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,694.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,979.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,673.58
|
| Rate for Payer: PHCS Commercial |
$17,632.80
|
| Rate for Payer: United Healthcare All Payer |
$16,163.40
|
|
|
STENT TALNT ILIAC EXT 16*16*80
|
Facility
|
IP
|
$19,107.50
|
|
|
Service Code
|
HCPCS C2625
|
| Hospital Charge Code |
27000130
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,732.25 |
| Max. Negotiated Rate |
$18,343.20 |
| Rate for Payer: Aetna Commercial |
$14,712.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,903.85
|
| Rate for Payer: Cash Price |
$9,553.75
|
| Rate for Payer: Cigna Commercial |
$15,859.23
|
| Rate for Payer: First Health Commercial |
$18,152.12
|
| Rate for Payer: Humana Commercial |
$16,241.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,668.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,101.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,732.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,814.60
|
| Rate for Payer: Ohio Health Group HMO |
$14,330.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,286.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,623.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,184.17
|
| Rate for Payer: PHCS Commercial |
$18,343.20
|
| Rate for Payer: United Healthcare All Payer |
$16,814.60
|
|
