|
SUPERA PERIPH. STENT 5*120*120
|
Facility
|
OP
|
$5,093.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,528.12 |
| Max. Negotiated Rate |
$4,890.00 |
| Rate for Payer: Aetna Commercial |
$3,922.19
|
| Rate for Payer: Anthem Medicaid |
$1,751.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,973.12
|
| Rate for Payer: Cash Price |
$2,546.88
|
| Rate for Payer: Cigna Commercial |
$4,227.81
|
| Rate for Payer: First Health Commercial |
$4,839.06
|
| Rate for Payer: Humana Commercial |
$4,329.69
|
| Rate for Payer: Humana KY Medicaid |
$1,751.74
|
| Rate for Payer: Kentucky WC Medicaid |
$1,769.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,176.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,759.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,528.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,786.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,482.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,820.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,075.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,431.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,514.69
|
| Rate for Payer: PHCS Commercial |
$4,890.00
|
| Rate for Payer: United Healthcare All Payer |
$4,482.50
|
|
|
SUPERA PERIPH STNT 4.5*100*120
|
Facility
|
IP
|
$7,745.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,323.50 |
| Max. Negotiated Rate |
$7,435.20 |
| Rate for Payer: Aetna Commercial |
$5,963.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,041.10
|
| Rate for Payer: Cash Price |
$3,872.50
|
| Rate for Payer: Cigna Commercial |
$6,428.35
|
| Rate for Payer: First Health Commercial |
$7,357.75
|
| Rate for Payer: Humana Commercial |
$6,583.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,350.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,715.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,323.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,815.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,808.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,196.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,738.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,344.05
|
| Rate for Payer: PHCS Commercial |
$7,435.20
|
| Rate for Payer: United Healthcare All Payer |
$6,815.60
|
|
|
SUPERA PERIPH STNT 4.5*100*120
|
Facility
|
OP
|
$7,745.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,323.50 |
| Max. Negotiated Rate |
$7,435.20 |
| Rate for Payer: Aetna Commercial |
$5,963.65
|
| Rate for Payer: Anthem Medicaid |
$2,663.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,041.10
|
| Rate for Payer: Cash Price |
$3,872.50
|
| Rate for Payer: Cigna Commercial |
$6,428.35
|
| Rate for Payer: First Health Commercial |
$7,357.75
|
| Rate for Payer: Humana Commercial |
$6,583.25
|
| Rate for Payer: Humana KY Medicaid |
$2,663.51
|
| Rate for Payer: Kentucky WC Medicaid |
$2,690.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,350.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,715.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,323.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,716.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,815.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,808.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,196.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,738.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,344.05
|
| Rate for Payer: PHCS Commercial |
$7,435.20
|
| Rate for Payer: United Healthcare All Payer |
$6,815.60
|
|
|
SUPERA PERIPH STNT 4.5*120*120
|
Facility
|
IP
|
$5,093.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,528.12 |
| Max. Negotiated Rate |
$4,890.00 |
| Rate for Payer: Aetna Commercial |
$3,922.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,973.12
|
| Rate for Payer: Cash Price |
$2,546.88
|
| Rate for Payer: Cigna Commercial |
$4,227.81
|
| Rate for Payer: First Health Commercial |
$4,839.06
|
| Rate for Payer: Humana Commercial |
$4,329.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,176.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,759.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,528.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,482.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,820.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,075.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,431.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,514.69
|
| Rate for Payer: PHCS Commercial |
$4,890.00
|
| Rate for Payer: United Healthcare All Payer |
$4,482.50
|
|
|
SUPERA PERIPH STNT 4.5*120*120
|
Facility
|
OP
|
$5,093.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,528.12 |
| Max. Negotiated Rate |
$4,890.00 |
| Rate for Payer: Aetna Commercial |
$3,922.19
|
| Rate for Payer: Anthem Medicaid |
$1,751.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,973.12
|
| Rate for Payer: Cash Price |
$2,546.88
|
| Rate for Payer: Cigna Commercial |
$4,227.81
|
| Rate for Payer: First Health Commercial |
$4,839.06
|
| Rate for Payer: Humana Commercial |
$4,329.69
|
| Rate for Payer: Humana KY Medicaid |
$1,751.74
|
| Rate for Payer: Kentucky WC Medicaid |
$1,769.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,176.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,759.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,528.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,786.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,482.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,820.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,075.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,431.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,514.69
|
| Rate for Payer: PHCS Commercial |
$4,890.00
|
| Rate for Payer: United Healthcare All Payer |
$4,482.50
|
|
|
SUPERA PERIPH STNT 5.5*100*120
|
Facility
|
OP
|
$7,745.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,323.50 |
| Max. Negotiated Rate |
$7,435.20 |
| Rate for Payer: Aetna Commercial |
$5,963.65
|
| Rate for Payer: Anthem Medicaid |
$2,663.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,041.10
|
| Rate for Payer: Cash Price |
$3,872.50
|
| Rate for Payer: Cigna Commercial |
$6,428.35
|
| Rate for Payer: First Health Commercial |
$7,357.75
|
| Rate for Payer: Humana Commercial |
$6,583.25
|
| Rate for Payer: Humana KY Medicaid |
$2,663.51
|
| Rate for Payer: Kentucky WC Medicaid |
$2,690.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,350.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,715.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,323.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,716.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,815.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,808.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,196.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,738.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,344.05
|
| Rate for Payer: PHCS Commercial |
$7,435.20
|
| Rate for Payer: United Healthcare All Payer |
$6,815.60
|
|
|
SUPERA PERIPH STNT 5.5*100*120
|
Facility
|
IP
|
$7,745.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,323.50 |
| Max. Negotiated Rate |
$7,435.20 |
| Rate for Payer: Aetna Commercial |
$5,963.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,041.10
|
| Rate for Payer: Cash Price |
$3,872.50
|
| Rate for Payer: Cigna Commercial |
$6,428.35
|
| Rate for Payer: First Health Commercial |
$7,357.75
|
| Rate for Payer: Humana Commercial |
$6,583.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,350.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,715.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,323.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,815.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,808.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,196.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,738.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,344.05
|
| Rate for Payer: PHCS Commercial |
$7,435.20
|
| Rate for Payer: United Healthcare All Payer |
$6,815.60
|
|
|
SUPERA PERIPH STNT 5.5*120*120
|
Facility
|
IP
|
$7,653.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,296.12 |
| Max. Negotiated Rate |
$7,347.60 |
| Rate for Payer: Aetna Commercial |
$5,893.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,969.93
|
| Rate for Payer: Cash Price |
$3,826.88
|
| Rate for Payer: Cigna Commercial |
$6,352.61
|
| Rate for Payer: First Health Commercial |
$7,271.06
|
| Rate for Payer: Humana Commercial |
$6,505.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,276.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,648.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,296.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,735.30
|
| Rate for Payer: Ohio Health Group HMO |
$5,740.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,123.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,658.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,281.09
|
| Rate for Payer: PHCS Commercial |
$7,347.60
|
| Rate for Payer: United Healthcare All Payer |
$6,735.30
|
|
|
SUPERA PERIPH STNT 5.5*120*120
|
Facility
|
OP
|
$7,653.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,296.12 |
| Max. Negotiated Rate |
$7,347.60 |
| Rate for Payer: Aetna Commercial |
$5,893.39
|
| Rate for Payer: Anthem Medicaid |
$2,632.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,969.93
|
| Rate for Payer: Cash Price |
$3,826.88
|
| Rate for Payer: Cigna Commercial |
$6,352.61
|
| Rate for Payer: First Health Commercial |
$7,271.06
|
| Rate for Payer: Humana Commercial |
$6,505.69
|
| Rate for Payer: Humana KY Medicaid |
$2,632.12
|
| Rate for Payer: Kentucky WC Medicaid |
$2,658.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,276.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,648.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,296.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,684.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,735.30
|
| Rate for Payer: Ohio Health Group HMO |
$5,740.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,123.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,658.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,281.09
|
| Rate for Payer: PHCS Commercial |
$7,347.60
|
| Rate for Payer: United Healthcare All Payer |
$6,735.30
|
|
|
SUPERA PERIPH STNT 5.5*150*120
|
Facility
|
IP
|
$7,745.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,323.50 |
| Max. Negotiated Rate |
$7,435.20 |
| Rate for Payer: Aetna Commercial |
$5,963.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,041.10
|
| Rate for Payer: Cash Price |
$3,872.50
|
| Rate for Payer: Cigna Commercial |
$6,428.35
|
| Rate for Payer: First Health Commercial |
$7,357.75
|
| Rate for Payer: Humana Commercial |
$6,583.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,350.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,715.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,323.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,815.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,808.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,196.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,738.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,344.05
|
| Rate for Payer: PHCS Commercial |
$7,435.20
|
| Rate for Payer: United Healthcare All Payer |
$6,815.60
|
|
|
SUPERA PERIPH STNT 5.5*150*120
|
Facility
|
OP
|
$7,745.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,323.50 |
| Max. Negotiated Rate |
$7,435.20 |
| Rate for Payer: Aetna Commercial |
$5,963.65
|
| Rate for Payer: Anthem Medicaid |
$2,663.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,041.10
|
| Rate for Payer: Cash Price |
$3,872.50
|
| Rate for Payer: Cigna Commercial |
$6,428.35
|
| Rate for Payer: First Health Commercial |
$7,357.75
|
| Rate for Payer: Humana Commercial |
$6,583.25
|
| Rate for Payer: Humana KY Medicaid |
$2,663.51
|
| Rate for Payer: Kentucky WC Medicaid |
$2,690.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,350.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,715.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,323.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,716.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,815.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,808.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,196.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,738.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,344.05
|
| Rate for Payer: PHCS Commercial |
$7,435.20
|
| Rate for Payer: United Healthcare All Payer |
$6,815.60
|
|
|
SUPERCROSS 120 DEG. 130CM
|
Facility
|
OP
|
$3,815.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,144.50 |
| Max. Negotiated Rate |
$3,662.40 |
| Rate for Payer: Aetna Commercial |
$2,937.55
|
| Rate for Payer: Anthem Medicaid |
$1,311.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,975.70
|
| Rate for Payer: Cash Price |
$1,907.50
|
| Rate for Payer: Cigna Commercial |
$3,166.45
|
| Rate for Payer: First Health Commercial |
$3,624.25
|
| Rate for Payer: Humana Commercial |
$3,242.75
|
| Rate for Payer: Humana KY Medicaid |
$1,311.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,325.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,128.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,815.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,144.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,338.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,357.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,861.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,052.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,319.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,632.35
|
| Rate for Payer: PHCS Commercial |
$3,662.40
|
| Rate for Payer: United Healthcare All Payer |
$3,357.20
|
|
|
SUPERCROSS 120 DEG. 130CM
|
Facility
|
IP
|
$3,815.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,144.50 |
| Max. Negotiated Rate |
$3,662.40 |
| Rate for Payer: Aetna Commercial |
$2,937.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,975.70
|
| Rate for Payer: Cash Price |
$1,907.50
|
| Rate for Payer: Cigna Commercial |
$3,166.45
|
| Rate for Payer: First Health Commercial |
$3,624.25
|
| Rate for Payer: Humana Commercial |
$3,242.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,128.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,815.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,144.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,357.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,861.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,052.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,319.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,632.35
|
| Rate for Payer: PHCS Commercial |
$3,662.40
|
| Rate for Payer: United Healthcare All Payer |
$3,357.20
|
|
|
SUPERCROSS 90DEG. 130CM
|
Facility
|
OP
|
$3,867.50
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,160.25 |
| Max. Negotiated Rate |
$3,712.80 |
| Rate for Payer: Aetna Commercial |
$2,977.97
|
| Rate for Payer: Anthem Medicaid |
$1,330.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,016.65
|
| Rate for Payer: Cash Price |
$1,933.75
|
| Rate for Payer: Cigna Commercial |
$3,210.03
|
| Rate for Payer: First Health Commercial |
$3,674.12
|
| Rate for Payer: Humana Commercial |
$3,287.38
|
| Rate for Payer: Humana KY Medicaid |
$1,330.03
|
| Rate for Payer: Kentucky WC Medicaid |
$1,343.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,171.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,854.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,160.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,356.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,403.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,900.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,364.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,668.57
|
| Rate for Payer: PHCS Commercial |
$3,712.80
|
| Rate for Payer: United Healthcare All Payer |
$3,403.40
|
|
|
SUPERCROSS 90DEG. 130CM
|
Facility
|
IP
|
$3,867.50
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,160.25 |
| Max. Negotiated Rate |
$3,712.80 |
| Rate for Payer: Aetna Commercial |
$2,977.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,016.65
|
| Rate for Payer: Cash Price |
$1,933.75
|
| Rate for Payer: Cigna Commercial |
$3,210.03
|
| Rate for Payer: First Health Commercial |
$3,674.12
|
| Rate for Payer: Humana Commercial |
$3,287.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,171.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,854.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,160.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,403.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,900.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,364.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,668.57
|
| Rate for Payer: PHCS Commercial |
$3,712.80
|
| Rate for Payer: United Healthcare All Payer |
$3,403.40
|
|
|
SUPERIOR VENACAVAGRAM
|
Facility
|
IP
|
$1,689.00
|
|
|
Service Code
|
HCPCS 75827
|
| Hospital Charge Code |
32000168
|
|
Hospital Revenue Code
|
321
|
| Min. Negotiated Rate |
$506.70 |
| Max. Negotiated Rate |
$1,621.44 |
| Rate for Payer: Aetna Commercial |
$1,300.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,317.42
|
| Rate for Payer: Cash Price |
$844.50
|
| Rate for Payer: Cigna Commercial |
$1,401.87
|
| Rate for Payer: First Health Commercial |
$1,604.55
|
| Rate for Payer: Humana Commercial |
$1,435.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,384.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,246.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$506.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,486.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,266.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,351.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,469.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,165.41
|
| Rate for Payer: PHCS Commercial |
$1,621.44
|
| Rate for Payer: United Healthcare All Payer |
$1,486.32
|
|
|
SUPERIOR VENACAVAGRAM
|
Professional
|
Both
|
$1,689.00
|
|
|
Service Code
|
HCPCS 75827
|
| Hospital Charge Code |
32000168
|
|
Hospital Revenue Code
|
321
|
| Min. Negotiated Rate |
$71.50 |
| Max. Negotiated Rate |
$1,013.40 |
| Rate for Payer: Aetna Commercial |
$407.84
|
| Rate for Payer: Ambetter Exchange |
$107.56
|
| Rate for Payer: Anthem Medicaid |
$389.16
|
| Rate for Payer: Buckeye Individual/Medicaid |
$107.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$107.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$129.07
|
| Rate for Payer: Cash Price |
$844.50
|
| Rate for Payer: Cash Price |
$844.50
|
| Rate for Payer: Cigna Commercial |
$675.61
|
| Rate for Payer: Healthspan PPO |
$382.15
|
| Rate for Payer: Humana Medicaid |
$389.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$71.50
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$107.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$107.56
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$396.94
|
| Rate for Payer: Molina Healthcare Passport |
$389.16
|
| Rate for Payer: Multiplan PHCS |
$1,013.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$139.83
|
| Rate for Payer: UHCCP Medicaid |
$591.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$393.05
|
| Rate for Payer: Wellcare Medicare Advantage |
$107.56
|
|
|
SUPERIOR VENACAVAGRAM
|
Facility
|
OP
|
$1,689.00
|
|
|
Service Code
|
HCPCS 75827
|
| Hospital Charge Code |
32000168
|
|
Hospital Revenue Code
|
321
|
| Min. Negotiated Rate |
$580.85 |
| Max. Negotiated Rate |
$2,009.49 |
| Rate for Payer: Aetna Commercial |
$1,300.53
|
| Rate for Payer: Anthem Medicaid |
$580.85
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,435.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,317.42
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,009.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,937.72
|
| Rate for Payer: Cash Price |
$844.50
|
| Rate for Payer: Cash Price |
$844.50
|
| Rate for Payer: Cigna Commercial |
$1,401.87
|
| Rate for Payer: First Health Commercial |
$1,604.55
|
| Rate for Payer: Humana Commercial |
$1,435.65
|
| Rate for Payer: Humana KY Medicaid |
$580.85
|
| Rate for Payer: Humana Medicare Advantage |
$1,435.35
|
| Rate for Payer: Kentucky WC Medicaid |
$586.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,384.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,246.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,722.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$592.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,486.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,266.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,351.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,469.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,165.41
|
| Rate for Payer: PHCS Commercial |
$1,621.44
|
| Rate for Payer: United Healthcare All Payer |
$1,486.32
|
|
|
SUPERIOR VENACAVAGRAM(P
|
Professional
|
Both
|
$203.00
|
|
|
Service Code
|
HCPCS 75827
|
| Hospital Charge Code |
320P0168
|
|
Hospital Revenue Code
|
321
|
| Min. Negotiated Rate |
$71.05 |
| Max. Negotiated Rate |
$675.61 |
| Rate for Payer: Aetna Commercial |
$407.84
|
| Rate for Payer: Ambetter Exchange |
$107.56
|
| Rate for Payer: Anthem Medicaid |
$389.16
|
| Rate for Payer: Buckeye Individual/Medicaid |
$107.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$107.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$129.07
|
| Rate for Payer: Cash Price |
$101.50
|
| Rate for Payer: Cash Price |
$101.50
|
| Rate for Payer: Cigna Commercial |
$675.61
|
| Rate for Payer: Healthspan PPO |
$382.15
|
| Rate for Payer: Humana Medicaid |
$389.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$71.50
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$107.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$107.56
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$396.94
|
| Rate for Payer: Molina Healthcare Passport |
$389.16
|
| Rate for Payer: Multiplan PHCS |
$121.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$139.83
|
| Rate for Payer: UHCCP Medicaid |
$71.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$393.05
|
| Rate for Payer: Wellcare Medicare Advantage |
$107.56
|
|
|
SUPERIOR VENACAVAGRAM(T
|
Facility
|
IP
|
$1,486.00
|
|
|
Service Code
|
HCPCS 75827
|
| Hospital Charge Code |
320T0168
|
|
Hospital Revenue Code
|
321
|
| Min. Negotiated Rate |
$445.80 |
| Max. Negotiated Rate |
$1,426.56 |
| Rate for Payer: Aetna Commercial |
$1,144.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,159.08
|
| Rate for Payer: Cash Price |
$743.00
|
| Rate for Payer: Cigna Commercial |
$1,233.38
|
| Rate for Payer: First Health Commercial |
$1,411.70
|
| Rate for Payer: Humana Commercial |
$1,263.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,218.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,096.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$445.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,307.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,114.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,188.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,292.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,025.34
|
| Rate for Payer: PHCS Commercial |
$1,426.56
|
| Rate for Payer: United Healthcare All Payer |
$1,307.68
|
|
|
SUPERIOR VENACAVAGRAM(T
|
Facility
|
OP
|
$1,486.00
|
|
|
Service Code
|
HCPCS 75827
|
| Hospital Charge Code |
320T0168
|
|
Hospital Revenue Code
|
321
|
| Min. Negotiated Rate |
$511.04 |
| Max. Negotiated Rate |
$2,009.49 |
| Rate for Payer: Aetna Commercial |
$1,144.22
|
| Rate for Payer: Anthem Medicaid |
$511.04
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,435.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,159.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,009.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,937.72
|
| Rate for Payer: Cash Price |
$743.00
|
| Rate for Payer: Cash Price |
$743.00
|
| Rate for Payer: Cigna Commercial |
$1,233.38
|
| Rate for Payer: First Health Commercial |
$1,411.70
|
| Rate for Payer: Humana Commercial |
$1,263.10
|
| Rate for Payer: Humana KY Medicaid |
$511.04
|
| Rate for Payer: Humana Medicare Advantage |
$1,435.35
|
| Rate for Payer: Kentucky WC Medicaid |
$516.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,218.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,096.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,722.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$521.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,307.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,114.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,188.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,292.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,025.34
|
| Rate for Payer: PHCS Commercial |
$1,426.56
|
| Rate for Payer: United Healthcare All Payer |
$1,307.68
|
|
|
SUPPORT FOR ORGAN DONOR
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS 01990
|
| Hospital Charge Code |
37000001
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$7.68 |
| Rate for Payer: Aetna Commercial |
$6.16
|
| Rate for Payer: Anthem Medicaid |
$2.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6.24
|
| Rate for Payer: Cash Price |
$4.00
|
| Rate for Payer: Cigna Commercial |
$6.64
|
| Rate for Payer: First Health Commercial |
$7.60
|
| Rate for Payer: Humana Commercial |
$6.80
|
| Rate for Payer: Humana KY Medicaid |
$2.75
|
| Rate for Payer: Kentucky WC Medicaid |
$2.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.04
|
| Rate for Payer: Ohio Health Group HMO |
$6.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5.52
|
| Rate for Payer: PHCS Commercial |
$7.68
|
| Rate for Payer: United Healthcare All Payer |
$7.04
|
|
|
SUPPORT FOR ORGAN DONOR
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS 01990
|
| Hospital Charge Code |
37000001
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$7.68 |
| Rate for Payer: Aetna Commercial |
$6.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6.24
|
| Rate for Payer: Cash Price |
$4.00
|
| Rate for Payer: Cigna Commercial |
$6.64
|
| Rate for Payer: First Health Commercial |
$7.60
|
| Rate for Payer: Humana Commercial |
$6.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.04
|
| Rate for Payer: Ohio Health Group HMO |
$6.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5.52
|
| Rate for Payer: PHCS Commercial |
$7.68
|
| Rate for Payer: United Healthcare All Payer |
$7.04
|
|
|
SUPPORT FOR ORGAN DONOR
|
Professional
|
Both
|
$8.00
|
|
|
Service Code
|
HCPCS 1990
|
| Hospital Charge Code |
37000001
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$5.60 |
| Rate for Payer: Cash Price |
$4.00
|
| Rate for Payer: Multiplan PHCS |
$4.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5.60
|
| Rate for Payer: UHCCP Medicaid |
$2.80
|
|
|
SUPRANE LIQ DESFLURANE EA1/2HR
|
Facility
|
OP
|
$330.22
|
|
|
Service Code
|
NDC 10019064134
|
| Hospital Charge Code |
25003501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.07 |
| Max. Negotiated Rate |
$317.01 |
| Rate for Payer: Aetna Commercial |
$254.27
|
| Rate for Payer: Anthem Medicaid |
$113.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$257.57
|
| Rate for Payer: Cash Price |
$165.11
|
| Rate for Payer: Cigna Commercial |
$274.08
|
| Rate for Payer: First Health Commercial |
$313.71
|
| Rate for Payer: Humana Commercial |
$280.69
|
| Rate for Payer: Humana KY Medicaid |
$113.56
|
| Rate for Payer: Kentucky WC Medicaid |
$114.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$270.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$243.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$99.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$115.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$290.59
|
| Rate for Payer: Ohio Health Group HMO |
$247.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$264.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$287.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$227.85
|
| Rate for Payer: PHCS Commercial |
$317.01
|
| Rate for Payer: United Healthcare All Payer |
$290.59
|
|
