Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

VISI-PRO STENT 5*27*80

Facility

$4,471.50

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$581.30
Max. Negotiated Rate	$4,292.64
Rate for Payer: Aetna Commercial	$3,443.06
Rate for Payer: Anthem POS/PPO/Traditional	$3,487.77
Rate for Payer: Cash Price	$2,235.75
Rate for Payer: Cigna Commercial	$3,711.34
Rate for Payer: First Health Commercial	$4,247.92
Rate for Payer: Humana Commercial	$3,800.78
Rate for Payer: Medical Mutual Of Ohio HMO	$3,666.63
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,299.97
Rate for Payer: Molina Healthcare Benefit Exchange	$1,341.45
Rate for Payer: Ohio Health Choice Commercial	$3,934.92
Rate for Payer: Ohio Health Group HMO	$3,353.62
Rate for Payer: Ohio Health Group PPO Differential	$894.30
Rate for Payer: Ohio Health Group PPO No Differential	$581.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,386.16
Rate for Payer: PHCS Commercial	$4,292.64
Rate for Payer: United Healthcare All Payer	$3,934.92

VISI-PRO STENT 5*27*80

Facility

$4,471.50

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$581.30
Max. Negotiated Rate	$4,292.64
Rate for Payer: Aetna Commercial	$3,443.06
Rate for Payer: Anthem Medicaid	$1,537.75
Rate for Payer: Anthem POS/PPO/Traditional	$3,487.77
Rate for Payer: Cash Price	$2,235.75
Rate for Payer: Cigna Commercial	$3,711.34
Rate for Payer: First Health Commercial	$4,247.92
Rate for Payer: Humana Commercial	$3,800.78
Rate for Payer: Humana KY Medicaid	$1,537.75
Rate for Payer: Kentucky WC Medicaid	$1,553.40
Rate for Payer: Medical Mutual Of Ohio HMO	$3,666.63
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,299.97
Rate for Payer: Molina Healthcare Benefit Exchange	$1,341.45
Rate for Payer: Molina Healthcare Medicaid	$1,568.60
Rate for Payer: Ohio Health Choice Commercial	$3,934.92
Rate for Payer: Ohio Health Group HMO	$3,353.62
Rate for Payer: Ohio Health Group PPO Differential	$894.30
Rate for Payer: Ohio Health Group PPO No Differential	$581.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,386.16
Rate for Payer: PHCS Commercial	$4,292.64
Rate for Payer: United Healthcare All Payer	$3,934.92

VISI-PRO STENT 5*37*80

Facility

$4,471.50

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$581.30
Max. Negotiated Rate	$4,292.64
Rate for Payer: Aetna Commercial	$3,443.06
Rate for Payer: Anthem Medicaid	$1,537.75
Rate for Payer: Anthem POS/PPO/Traditional	$3,487.77
Rate for Payer: Cash Price	$2,235.75
Rate for Payer: Cigna Commercial	$3,711.34
Rate for Payer: First Health Commercial	$4,247.92
Rate for Payer: Humana Commercial	$3,800.78
Rate for Payer: Humana KY Medicaid	$1,537.75
Rate for Payer: Kentucky WC Medicaid	$1,553.40
Rate for Payer: Medical Mutual Of Ohio HMO	$3,666.63
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,299.97
Rate for Payer: Molina Healthcare Benefit Exchange	$1,341.45
Rate for Payer: Molina Healthcare Medicaid	$1,568.60
Rate for Payer: Ohio Health Choice Commercial	$3,934.92
Rate for Payer: Ohio Health Group HMO	$3,353.62
Rate for Payer: Ohio Health Group PPO Differential	$894.30
Rate for Payer: Ohio Health Group PPO No Differential	$581.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,386.16
Rate for Payer: PHCS Commercial	$4,292.64
Rate for Payer: United Healthcare All Payer	$3,934.92

VISI-PRO STENT 5*37*80

Facility

$4,471.50

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$581.30
Max. Negotiated Rate	$4,292.64
Rate for Payer: Aetna Commercial	$3,443.06
Rate for Payer: Anthem POS/PPO/Traditional	$3,487.77
Rate for Payer: Cash Price	$2,235.75
Rate for Payer: Cigna Commercial	$3,711.34
Rate for Payer: First Health Commercial	$4,247.92
Rate for Payer: Humana Commercial	$3,800.78
Rate for Payer: Medical Mutual Of Ohio HMO	$3,666.63
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,299.97
Rate for Payer: Molina Healthcare Benefit Exchange	$1,341.45
Rate for Payer: Ohio Health Choice Commercial	$3,934.92
Rate for Payer: Ohio Health Group HMO	$3,353.62
Rate for Payer: Ohio Health Group PPO Differential	$894.30
Rate for Payer: Ohio Health Group PPO No Differential	$581.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,386.16
Rate for Payer: PHCS Commercial	$4,292.64
Rate for Payer: United Healthcare All Payer	$3,934.92

VISI-PRO STENT 6*17*80

Facility

$4,471.50

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$581.30
Max. Negotiated Rate	$4,292.64
Rate for Payer: Aetna Commercial	$3,443.06
Rate for Payer: Anthem Medicaid	$1,537.75
Rate for Payer: Anthem POS/PPO/Traditional	$3,487.77
Rate for Payer: Cash Price	$2,235.75
Rate for Payer: Cigna Commercial	$3,711.34
Rate for Payer: First Health Commercial	$4,247.92
Rate for Payer: Humana Commercial	$3,800.78
Rate for Payer: Humana KY Medicaid	$1,537.75
Rate for Payer: Kentucky WC Medicaid	$1,553.40
Rate for Payer: Medical Mutual Of Ohio HMO	$3,666.63
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,299.97
Rate for Payer: Molina Healthcare Benefit Exchange	$1,341.45
Rate for Payer: Molina Healthcare Medicaid	$1,568.60
Rate for Payer: Ohio Health Choice Commercial	$3,934.92
Rate for Payer: Ohio Health Group HMO	$3,353.62
Rate for Payer: Ohio Health Group PPO Differential	$894.30
Rate for Payer: Ohio Health Group PPO No Differential	$581.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,386.16
Rate for Payer: PHCS Commercial	$4,292.64
Rate for Payer: United Healthcare All Payer	$3,934.92

VISI-PRO STENT 6*17*80

Facility

$4,471.50

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$581.30
Max. Negotiated Rate	$4,292.64
Rate for Payer: Aetna Commercial	$3,443.06
Rate for Payer: Anthem POS/PPO/Traditional	$3,487.77
Rate for Payer: Cash Price	$2,235.75
Rate for Payer: Cigna Commercial	$3,711.34
Rate for Payer: First Health Commercial	$4,247.92
Rate for Payer: Humana Commercial	$3,800.78
Rate for Payer: Medical Mutual Of Ohio HMO	$3,666.63
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,299.97
Rate for Payer: Molina Healthcare Benefit Exchange	$1,341.45
Rate for Payer: Ohio Health Choice Commercial	$3,934.92
Rate for Payer: Ohio Health Group HMO	$3,353.62
Rate for Payer: Ohio Health Group PPO Differential	$894.30
Rate for Payer: Ohio Health Group PPO No Differential	$581.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,386.16
Rate for Payer: PHCS Commercial	$4,292.64
Rate for Payer: United Healthcare All Payer	$3,934.92

VISI-PRO STENT 6*27*135

Facility

$4,471.50

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$581.30
Max. Negotiated Rate	$4,292.64
Rate for Payer: Aetna Commercial	$3,443.06
Rate for Payer: Anthem Medicaid	$1,537.75
Rate for Payer: Anthem POS/PPO/Traditional	$3,487.77
Rate for Payer: Cash Price	$2,235.75
Rate for Payer: Cigna Commercial	$3,711.34
Rate for Payer: First Health Commercial	$4,247.92
Rate for Payer: Humana Commercial	$3,800.78
Rate for Payer: Humana KY Medicaid	$1,537.75
Rate for Payer: Kentucky WC Medicaid	$1,553.40
Rate for Payer: Medical Mutual Of Ohio HMO	$3,666.63
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,299.97
Rate for Payer: Molina Healthcare Benefit Exchange	$1,341.45
Rate for Payer: Molina Healthcare Medicaid	$1,568.60
Rate for Payer: Ohio Health Choice Commercial	$3,934.92
Rate for Payer: Ohio Health Group HMO	$3,353.62
Rate for Payer: Ohio Health Group PPO Differential	$894.30
Rate for Payer: Ohio Health Group PPO No Differential	$581.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,386.16
Rate for Payer: PHCS Commercial	$4,292.64
Rate for Payer: United Healthcare All Payer	$3,934.92

VISI-PRO STENT 6*27*135

Facility

$4,471.50

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$581.30
Max. Negotiated Rate	$4,292.64
Rate for Payer: Aetna Commercial	$3,443.06
Rate for Payer: Anthem POS/PPO/Traditional	$3,487.77
Rate for Payer: Cash Price	$2,235.75
Rate for Payer: Cigna Commercial	$3,711.34
Rate for Payer: First Health Commercial	$4,247.92
Rate for Payer: Humana Commercial	$3,800.78
Rate for Payer: Medical Mutual Of Ohio HMO	$3,666.63
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,299.97
Rate for Payer: Molina Healthcare Benefit Exchange	$1,341.45
Rate for Payer: Ohio Health Choice Commercial	$3,934.92
Rate for Payer: Ohio Health Group HMO	$3,353.62
Rate for Payer: Ohio Health Group PPO Differential	$894.30
Rate for Payer: Ohio Health Group PPO No Differential	$581.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,386.16
Rate for Payer: PHCS Commercial	$4,292.64
Rate for Payer: United Healthcare All Payer	$3,934.92

VISI-PRO STENT 6*27*80

Facility

$4,471.50

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$581.30
Max. Negotiated Rate	$4,292.64
Rate for Payer: Aetna Commercial	$3,443.06
Rate for Payer: Anthem POS/PPO/Traditional	$3,487.77
Rate for Payer: Cash Price	$2,235.75
Rate for Payer: Cigna Commercial	$3,711.34
Rate for Payer: First Health Commercial	$4,247.92
Rate for Payer: Humana Commercial	$3,800.78
Rate for Payer: Medical Mutual Of Ohio HMO	$3,666.63
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,299.97
Rate for Payer: Molina Healthcare Benefit Exchange	$1,341.45
Rate for Payer: Ohio Health Choice Commercial	$3,934.92
Rate for Payer: Ohio Health Group HMO	$3,353.62
Rate for Payer: Ohio Health Group PPO Differential	$894.30
Rate for Payer: Ohio Health Group PPO No Differential	$581.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,386.16
Rate for Payer: PHCS Commercial	$4,292.64
Rate for Payer: United Healthcare All Payer	$3,934.92

VISI-PRO STENT 6*27*80

Facility

$4,471.50

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$581.30
Max. Negotiated Rate	$4,292.64
Rate for Payer: Aetna Commercial	$3,443.06
Rate for Payer: Anthem Medicaid	$1,537.75
Rate for Payer: Anthem POS/PPO/Traditional	$3,487.77
Rate for Payer: Cash Price	$2,235.75
Rate for Payer: Cigna Commercial	$3,711.34
Rate for Payer: First Health Commercial	$4,247.92
Rate for Payer: Humana Commercial	$3,800.78
Rate for Payer: Humana KY Medicaid	$1,537.75
Rate for Payer: Kentucky WC Medicaid	$1,553.40
Rate for Payer: Medical Mutual Of Ohio HMO	$3,666.63
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,299.97
Rate for Payer: Molina Healthcare Benefit Exchange	$1,341.45
Rate for Payer: Molina Healthcare Medicaid	$1,568.60
Rate for Payer: Ohio Health Choice Commercial	$3,934.92
Rate for Payer: Ohio Health Group HMO	$3,353.62
Rate for Payer: Ohio Health Group PPO Differential	$894.30
Rate for Payer: Ohio Health Group PPO No Differential	$581.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,386.16
Rate for Payer: PHCS Commercial	$4,292.64
Rate for Payer: United Healthcare All Payer	$3,934.92

VISI-PRO STENT 6*37*135

Facility

$5,595.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$727.35
Max. Negotiated Rate	$5,371.20
Rate for Payer: Aetna Commercial	$4,308.15
Rate for Payer: Anthem Medicaid	$1,924.12
Rate for Payer: Anthem POS/PPO/Traditional	$4,364.10
Rate for Payer: Cash Price	$2,797.50
Rate for Payer: Cigna Commercial	$4,643.85
Rate for Payer: First Health Commercial	$5,315.25
Rate for Payer: Humana Commercial	$4,755.75
Rate for Payer: Humana KY Medicaid	$1,924.12
Rate for Payer: Kentucky WC Medicaid	$1,943.70
Rate for Payer: Medical Mutual Of Ohio HMO	$4,587.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,129.11
Rate for Payer: Molina Healthcare Benefit Exchange	$1,678.50
Rate for Payer: Molina Healthcare Medicaid	$1,962.73
Rate for Payer: Ohio Health Choice Commercial	$4,923.60
Rate for Payer: Ohio Health Group HMO	$4,196.25
Rate for Payer: Ohio Health Group PPO Differential	$1,119.00
Rate for Payer: Ohio Health Group PPO No Differential	$727.35
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,734.45
Rate for Payer: PHCS Commercial	$5,371.20
Rate for Payer: United Healthcare All Payer	$4,923.60

VISI-PRO STENT 6*37*135

Facility

$5,595.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$727.35
Max. Negotiated Rate	$5,371.20
Rate for Payer: Aetna Commercial	$4,308.15
Rate for Payer: Anthem POS/PPO/Traditional	$4,364.10
Rate for Payer: Cash Price	$2,797.50
Rate for Payer: Cigna Commercial	$4,643.85
Rate for Payer: First Health Commercial	$5,315.25
Rate for Payer: Humana Commercial	$4,755.75
Rate for Payer: Medical Mutual Of Ohio HMO	$4,587.90
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$4,129.11
Rate for Payer: Molina Healthcare Benefit Exchange	$1,678.50
Rate for Payer: Ohio Health Choice Commercial	$4,923.60
Rate for Payer: Ohio Health Group HMO	$4,196.25
Rate for Payer: Ohio Health Group PPO Differential	$1,119.00
Rate for Payer: Ohio Health Group PPO No Differential	$727.35
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,734.45
Rate for Payer: PHCS Commercial	$5,371.20
Rate for Payer: United Healthcare All Payer	$4,923.60

VISI-PRO STENT 6*37*80

Facility

$4,471.50

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$581.30
Max. Negotiated Rate	$4,292.64
Rate for Payer: Aetna Commercial	$3,443.06
Rate for Payer: Anthem POS/PPO/Traditional	$3,487.77
Rate for Payer: Cash Price	$2,235.75
Rate for Payer: Cigna Commercial	$3,711.34
Rate for Payer: First Health Commercial	$4,247.92
Rate for Payer: Humana Commercial	$3,800.78
Rate for Payer: Medical Mutual Of Ohio HMO	$3,666.63
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,299.97
Rate for Payer: Molina Healthcare Benefit Exchange	$1,341.45
Rate for Payer: Ohio Health Choice Commercial	$3,934.92
Rate for Payer: Ohio Health Group HMO	$3,353.62
Rate for Payer: Ohio Health Group PPO Differential	$894.30
Rate for Payer: Ohio Health Group PPO No Differential	$581.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,386.16
Rate for Payer: PHCS Commercial	$4,292.64
Rate for Payer: United Healthcare All Payer	$3,934.92

VISI-PRO STENT 6*37*80

Facility

$4,471.50

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$581.30
Max. Negotiated Rate	$4,292.64
Rate for Payer: Aetna Commercial	$3,443.06
Rate for Payer: Anthem Medicaid	$1,537.75
Rate for Payer: Anthem POS/PPO/Traditional	$3,487.77
Rate for Payer: Cash Price	$2,235.75
Rate for Payer: Cigna Commercial	$3,711.34
Rate for Payer: First Health Commercial	$4,247.92
Rate for Payer: Humana Commercial	$3,800.78
Rate for Payer: Humana KY Medicaid	$1,537.75
Rate for Payer: Kentucky WC Medicaid	$1,553.40
Rate for Payer: Medical Mutual Of Ohio HMO	$3,666.63
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,299.97
Rate for Payer: Molina Healthcare Benefit Exchange	$1,341.45
Rate for Payer: Molina Healthcare Medicaid	$1,568.60
Rate for Payer: Ohio Health Choice Commercial	$3,934.92
Rate for Payer: Ohio Health Group HMO	$3,353.62
Rate for Payer: Ohio Health Group PPO Differential	$894.30
Rate for Payer: Ohio Health Group PPO No Differential	$581.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,386.16
Rate for Payer: PHCS Commercial	$4,292.64
Rate for Payer: United Healthcare All Payer	$3,934.92

VISI-PRO STENT 6*57*80

Facility

$4,471.50

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$581.30
Max. Negotiated Rate	$4,292.64
Rate for Payer: Aetna Commercial	$3,443.06
Rate for Payer: Anthem POS/PPO/Traditional	$3,487.77
Rate for Payer: Cash Price	$2,235.75
Rate for Payer: Cigna Commercial	$3,711.34
Rate for Payer: First Health Commercial	$4,247.92
Rate for Payer: Humana Commercial	$3,800.78
Rate for Payer: Medical Mutual Of Ohio HMO	$3,666.63
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,299.97
Rate for Payer: Molina Healthcare Benefit Exchange	$1,341.45
Rate for Payer: Ohio Health Choice Commercial	$3,934.92
Rate for Payer: Ohio Health Group HMO	$3,353.62
Rate for Payer: Ohio Health Group PPO Differential	$894.30
Rate for Payer: Ohio Health Group PPO No Differential	$581.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,386.16
Rate for Payer: PHCS Commercial	$4,292.64
Rate for Payer: United Healthcare All Payer	$3,934.92

VISI-PRO STENT 6*57*80

Facility

$4,471.50

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$581.30
Max. Negotiated Rate	$4,292.64
Rate for Payer: Aetna Commercial	$3,443.06
Rate for Payer: Anthem Medicaid	$1,537.75
Rate for Payer: Anthem POS/PPO/Traditional	$3,487.77
Rate for Payer: Cash Price	$2,235.75
Rate for Payer: Cigna Commercial	$3,711.34
Rate for Payer: First Health Commercial	$4,247.92
Rate for Payer: Humana Commercial	$3,800.78
Rate for Payer: Humana KY Medicaid	$1,537.75
Rate for Payer: Kentucky WC Medicaid	$1,553.40
Rate for Payer: Medical Mutual Of Ohio HMO	$3,666.63
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,299.97
Rate for Payer: Molina Healthcare Benefit Exchange	$1,341.45
Rate for Payer: Molina Healthcare Medicaid	$1,568.60
Rate for Payer: Ohio Health Choice Commercial	$3,934.92
Rate for Payer: Ohio Health Group HMO	$3,353.62
Rate for Payer: Ohio Health Group PPO Differential	$894.30
Rate for Payer: Ohio Health Group PPO No Differential	$581.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,386.16
Rate for Payer: PHCS Commercial	$4,292.64
Rate for Payer: United Healthcare All Payer	$3,934.92

VISI-PRO STENT 7*17*135

Facility

$4,471.50

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$581.30
Max. Negotiated Rate	$4,292.64
Rate for Payer: Aetna Commercial	$3,443.06
Rate for Payer: Anthem POS/PPO/Traditional	$3,487.77
Rate for Payer: Cash Price	$2,235.75
Rate for Payer: Cigna Commercial	$3,711.34
Rate for Payer: First Health Commercial	$4,247.92
Rate for Payer: Humana Commercial	$3,800.78
Rate for Payer: Medical Mutual Of Ohio HMO	$3,666.63
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,299.97
Rate for Payer: Molina Healthcare Benefit Exchange	$1,341.45
Rate for Payer: Ohio Health Choice Commercial	$3,934.92
Rate for Payer: Ohio Health Group HMO	$3,353.62
Rate for Payer: Ohio Health Group PPO Differential	$894.30
Rate for Payer: Ohio Health Group PPO No Differential	$581.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,386.16
Rate for Payer: PHCS Commercial	$4,292.64
Rate for Payer: United Healthcare All Payer	$3,934.92

VISI-PRO STENT 7*17*135

Facility

$4,471.50

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$581.30
Max. Negotiated Rate	$4,292.64
Rate for Payer: Aetna Commercial	$3,443.06
Rate for Payer: Anthem Medicaid	$1,537.75
Rate for Payer: Anthem POS/PPO/Traditional	$3,487.77
Rate for Payer: Cash Price	$2,235.75
Rate for Payer: Cigna Commercial	$3,711.34
Rate for Payer: First Health Commercial	$4,247.92
Rate for Payer: Humana Commercial	$3,800.78
Rate for Payer: Humana KY Medicaid	$1,537.75
Rate for Payer: Kentucky WC Medicaid	$1,553.40
Rate for Payer: Medical Mutual Of Ohio HMO	$3,666.63
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,299.97
Rate for Payer: Molina Healthcare Benefit Exchange	$1,341.45
Rate for Payer: Molina Healthcare Medicaid	$1,568.60
Rate for Payer: Ohio Health Choice Commercial	$3,934.92
Rate for Payer: Ohio Health Group HMO	$3,353.62
Rate for Payer: Ohio Health Group PPO Differential	$894.30
Rate for Payer: Ohio Health Group PPO No Differential	$581.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,386.16
Rate for Payer: PHCS Commercial	$4,292.64
Rate for Payer: United Healthcare All Payer	$3,934.92

VISI-PRO STENT 7*17*80

Facility

$4,471.50

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$581.30
Max. Negotiated Rate	$4,292.64
Rate for Payer: Aetna Commercial	$3,443.06
Rate for Payer: Anthem POS/PPO/Traditional	$3,487.77
Rate for Payer: Cash Price	$2,235.75
Rate for Payer: Cigna Commercial	$3,711.34
Rate for Payer: First Health Commercial	$4,247.92
Rate for Payer: Humana Commercial	$3,800.78
Rate for Payer: Medical Mutual Of Ohio HMO	$3,666.63
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,299.97
Rate for Payer: Molina Healthcare Benefit Exchange	$1,341.45
Rate for Payer: Ohio Health Choice Commercial	$3,934.92
Rate for Payer: Ohio Health Group HMO	$3,353.62
Rate for Payer: Ohio Health Group PPO Differential	$894.30
Rate for Payer: Ohio Health Group PPO No Differential	$581.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,386.16
Rate for Payer: PHCS Commercial	$4,292.64
Rate for Payer: United Healthcare All Payer	$3,934.92

VISI-PRO STENT 7*17*80

Facility

$4,471.50

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$581.30
Max. Negotiated Rate	$4,292.64
Rate for Payer: Aetna Commercial	$3,443.06
Rate for Payer: Anthem Medicaid	$1,537.75
Rate for Payer: Anthem POS/PPO/Traditional	$3,487.77
Rate for Payer: Cash Price	$2,235.75
Rate for Payer: Cigna Commercial	$3,711.34
Rate for Payer: First Health Commercial	$4,247.92
Rate for Payer: Humana Commercial	$3,800.78
Rate for Payer: Humana KY Medicaid	$1,537.75
Rate for Payer: Kentucky WC Medicaid	$1,553.40
Rate for Payer: Medical Mutual Of Ohio HMO	$3,666.63
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,299.97
Rate for Payer: Molina Healthcare Benefit Exchange	$1,341.45
Rate for Payer: Molina Healthcare Medicaid	$1,568.60
Rate for Payer: Ohio Health Choice Commercial	$3,934.92
Rate for Payer: Ohio Health Group HMO	$3,353.62
Rate for Payer: Ohio Health Group PPO Differential	$894.30
Rate for Payer: Ohio Health Group PPO No Differential	$581.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,386.16
Rate for Payer: PHCS Commercial	$4,292.64
Rate for Payer: United Healthcare All Payer	$3,934.92

VISI-PRO STENT 7*27*135

Facility

$4,471.50

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$581.30
Max. Negotiated Rate	$4,292.64
Rate for Payer: Aetna Commercial	$3,443.06
Rate for Payer: Anthem Medicaid	$1,537.75
Rate for Payer: Anthem POS/PPO/Traditional	$3,487.77
Rate for Payer: Cash Price	$2,235.75
Rate for Payer: Cigna Commercial	$3,711.34
Rate for Payer: First Health Commercial	$4,247.92
Rate for Payer: Humana Commercial	$3,800.78
Rate for Payer: Humana KY Medicaid	$1,537.75
Rate for Payer: Kentucky WC Medicaid	$1,553.40
Rate for Payer: Medical Mutual Of Ohio HMO	$3,666.63
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,299.97
Rate for Payer: Molina Healthcare Benefit Exchange	$1,341.45
Rate for Payer: Molina Healthcare Medicaid	$1,568.60
Rate for Payer: Ohio Health Choice Commercial	$3,934.92
Rate for Payer: Ohio Health Group HMO	$3,353.62
Rate for Payer: Ohio Health Group PPO Differential	$894.30
Rate for Payer: Ohio Health Group PPO No Differential	$581.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,386.16
Rate for Payer: PHCS Commercial	$4,292.64
Rate for Payer: United Healthcare All Payer	$3,934.92

VISI-PRO STENT 7*27*135

Facility

$4,471.50

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$581.30
Max. Negotiated Rate	$4,292.64
Rate for Payer: Aetna Commercial	$3,443.06
Rate for Payer: Anthem POS/PPO/Traditional	$3,487.77
Rate for Payer: Cash Price	$2,235.75
Rate for Payer: Cigna Commercial	$3,711.34
Rate for Payer: First Health Commercial	$4,247.92
Rate for Payer: Humana Commercial	$3,800.78
Rate for Payer: Medical Mutual Of Ohio HMO	$3,666.63
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,299.97
Rate for Payer: Molina Healthcare Benefit Exchange	$1,341.45
Rate for Payer: Ohio Health Choice Commercial	$3,934.92
Rate for Payer: Ohio Health Group HMO	$3,353.62
Rate for Payer: Ohio Health Group PPO Differential	$894.30
Rate for Payer: Ohio Health Group PPO No Differential	$581.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,386.16
Rate for Payer: PHCS Commercial	$4,292.64
Rate for Payer: United Healthcare All Payer	$3,934.92

VISI-PRO STENT 7*27*80

Facility

$4,471.50

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$581.30
Max. Negotiated Rate	$4,292.64
Rate for Payer: Aetna Commercial	$3,443.06
Rate for Payer: Anthem POS/PPO/Traditional	$3,487.77
Rate for Payer: Cash Price	$2,235.75
Rate for Payer: Cigna Commercial	$3,711.34
Rate for Payer: First Health Commercial	$4,247.92
Rate for Payer: Humana Commercial	$3,800.78
Rate for Payer: Medical Mutual Of Ohio HMO	$3,666.63
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,299.97
Rate for Payer: Molina Healthcare Benefit Exchange	$1,341.45
Rate for Payer: Ohio Health Choice Commercial	$3,934.92
Rate for Payer: Ohio Health Group HMO	$3,353.62
Rate for Payer: Ohio Health Group PPO Differential	$894.30
Rate for Payer: Ohio Health Group PPO No Differential	$581.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,386.16
Rate for Payer: PHCS Commercial	$4,292.64
Rate for Payer: United Healthcare All Payer	$3,934.92

VISI-PRO STENT 7*27*80

Facility

$4,471.50

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$581.30
Max. Negotiated Rate	$4,292.64
Rate for Payer: Aetna Commercial	$3,443.06
Rate for Payer: Anthem Medicaid	$1,537.75
Rate for Payer: Anthem POS/PPO/Traditional	$3,487.77
Rate for Payer: Cash Price	$2,235.75
Rate for Payer: Cigna Commercial	$3,711.34
Rate for Payer: First Health Commercial	$4,247.92
Rate for Payer: Humana Commercial	$3,800.78
Rate for Payer: Humana KY Medicaid	$1,537.75
Rate for Payer: Kentucky WC Medicaid	$1,553.40
Rate for Payer: Medical Mutual Of Ohio HMO	$3,666.63
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$3,299.97
Rate for Payer: Molina Healthcare Benefit Exchange	$1,341.45
Rate for Payer: Molina Healthcare Medicaid	$1,568.60
Rate for Payer: Ohio Health Choice Commercial	$3,934.92
Rate for Payer: Ohio Health Group HMO	$3,353.62
Rate for Payer: Ohio Health Group PPO Differential	$894.30
Rate for Payer: Ohio Health Group PPO No Differential	$581.30
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,386.16
Rate for Payer: PHCS Commercial	$4,292.64
Rate for Payer: United Healthcare All Payer	$3,934.92

VISI-PRO STENT 7*37*135

Facility

$8,640.00

Service Code	HCPCS C1876
Hospital Charge Code	27000127
Hospital Revenue Code	278
Min. Negotiated Rate	$1,123.20
Max. Negotiated Rate	$8,294.40
Rate for Payer: Aetna Commercial	$6,652.80
Rate for Payer: Anthem POS/PPO/Traditional	$6,739.20
Rate for Payer: Cash Price	$4,320.00
Rate for Payer: Cigna Commercial	$7,171.20
Rate for Payer: First Health Commercial	$8,208.00
Rate for Payer: Humana Commercial	$7,344.00
Rate for Payer: Medical Mutual Of Ohio HMO	$7,084.80
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,376.32
Rate for Payer: Molina Healthcare Benefit Exchange	$2,592.00
Rate for Payer: Ohio Health Choice Commercial	$7,603.20
Rate for Payer: Ohio Health Group HMO	$6,480.00
Rate for Payer: Ohio Health Group PPO Differential	$1,728.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,123.20
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,678.40
Rate for Payer: PHCS Commercial	$8,294.40
Rate for Payer: United Healthcare All Payer	$7,603.20

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