|
WALL-STENT 14*40
|
Facility
|
OP
|
$5,300.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,590.00 |
| Max. Negotiated Rate |
$5,088.00 |
| Rate for Payer: Aetna Commercial |
$4,081.00
|
| Rate for Payer: Anthem Medicaid |
$1,822.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,134.00
|
| Rate for Payer: Cash Price |
$2,650.00
|
| Rate for Payer: Cigna Commercial |
$4,399.00
|
| Rate for Payer: First Health Commercial |
$5,035.00
|
| Rate for Payer: Humana Commercial |
$4,505.00
|
| Rate for Payer: Humana KY Medicaid |
$1,822.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1,841.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,346.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,911.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,590.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,859.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,664.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,975.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,611.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,657.00
|
| Rate for Payer: PHCS Commercial |
$5,088.00
|
| Rate for Payer: United Healthcare All Payer |
$4,664.00
|
|
|
WALL-STENT 14*60
|
Facility
|
OP
|
$5,300.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,590.00 |
| Max. Negotiated Rate |
$5,088.00 |
| Rate for Payer: Aetna Commercial |
$4,081.00
|
| Rate for Payer: Anthem Medicaid |
$1,822.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,134.00
|
| Rate for Payer: Cash Price |
$2,650.00
|
| Rate for Payer: Cigna Commercial |
$4,399.00
|
| Rate for Payer: First Health Commercial |
$5,035.00
|
| Rate for Payer: Humana Commercial |
$4,505.00
|
| Rate for Payer: Humana KY Medicaid |
$1,822.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1,841.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,346.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,911.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,590.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,859.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,664.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,975.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,611.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,657.00
|
| Rate for Payer: PHCS Commercial |
$5,088.00
|
| Rate for Payer: United Healthcare All Payer |
$4,664.00
|
|
|
WALL-STENT 14*60
|
Facility
|
IP
|
$5,300.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,590.00 |
| Max. Negotiated Rate |
$5,088.00 |
| Rate for Payer: Aetna Commercial |
$4,081.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,134.00
|
| Rate for Payer: Cash Price |
$2,650.00
|
| Rate for Payer: Cigna Commercial |
$4,399.00
|
| Rate for Payer: First Health Commercial |
$5,035.00
|
| Rate for Payer: Humana Commercial |
$4,505.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,346.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,911.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,590.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,664.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,975.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,611.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,657.00
|
| Rate for Payer: PHCS Commercial |
$5,088.00
|
| Rate for Payer: United Healthcare All Payer |
$4,664.00
|
|
|
WALL-STENT 16*20
|
Facility
|
IP
|
$6,795.05
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,038.52 |
| Max. Negotiated Rate |
$6,523.25 |
| Rate for Payer: Aetna Commercial |
$5,232.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,300.14
|
| Rate for Payer: Cash Price |
$3,397.53
|
| Rate for Payer: Cigna Commercial |
$5,639.89
|
| Rate for Payer: First Health Commercial |
$6,455.30
|
| Rate for Payer: Humana Commercial |
$5,775.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,571.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,014.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,038.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,979.64
|
| Rate for Payer: Ohio Health Group HMO |
$5,096.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,436.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,911.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,688.58
|
| Rate for Payer: PHCS Commercial |
$6,523.25
|
| Rate for Payer: United Healthcare All Payer |
$5,979.64
|
|
|
WALL-STENT 16*20
|
Facility
|
OP
|
$6,795.05
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,038.52 |
| Max. Negotiated Rate |
$6,523.25 |
| Rate for Payer: Aetna Commercial |
$5,232.19
|
| Rate for Payer: Anthem Medicaid |
$2,336.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,300.14
|
| Rate for Payer: Cash Price |
$3,397.53
|
| Rate for Payer: Cigna Commercial |
$5,639.89
|
| Rate for Payer: First Health Commercial |
$6,455.30
|
| Rate for Payer: Humana Commercial |
$5,775.79
|
| Rate for Payer: Humana KY Medicaid |
$2,336.82
|
| Rate for Payer: Kentucky WC Medicaid |
$2,360.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,571.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,014.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,038.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,383.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,979.64
|
| Rate for Payer: Ohio Health Group HMO |
$5,096.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,436.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,911.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,688.58
|
| Rate for Payer: PHCS Commercial |
$6,523.25
|
| Rate for Payer: United Healthcare All Payer |
$5,979.64
|
|
|
WALL-STENT 16*40
|
Facility
|
IP
|
$5,300.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,590.00 |
| Max. Negotiated Rate |
$5,088.00 |
| Rate for Payer: Aetna Commercial |
$4,081.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,134.00
|
| Rate for Payer: Cash Price |
$2,650.00
|
| Rate for Payer: Cigna Commercial |
$4,399.00
|
| Rate for Payer: First Health Commercial |
$5,035.00
|
| Rate for Payer: Humana Commercial |
$4,505.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,346.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,911.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,590.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,664.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,975.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,611.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,657.00
|
| Rate for Payer: PHCS Commercial |
$5,088.00
|
| Rate for Payer: United Healthcare All Payer |
$4,664.00
|
|
|
WALL-STENT 16*40
|
Facility
|
OP
|
$5,300.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,590.00 |
| Max. Negotiated Rate |
$5,088.00 |
| Rate for Payer: Aetna Commercial |
$4,081.00
|
| Rate for Payer: Anthem Medicaid |
$1,822.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,134.00
|
| Rate for Payer: Cash Price |
$2,650.00
|
| Rate for Payer: Cigna Commercial |
$4,399.00
|
| Rate for Payer: First Health Commercial |
$5,035.00
|
| Rate for Payer: Humana Commercial |
$4,505.00
|
| Rate for Payer: Humana KY Medicaid |
$1,822.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1,841.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,346.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,911.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,590.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,859.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,664.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,975.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,611.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,657.00
|
| Rate for Payer: PHCS Commercial |
$5,088.00
|
| Rate for Payer: United Healthcare All Payer |
$4,664.00
|
|
|
WALL-STENT 16*60
|
Facility
|
IP
|
$5,300.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,590.00 |
| Max. Negotiated Rate |
$5,088.00 |
| Rate for Payer: Aetna Commercial |
$4,081.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,134.00
|
| Rate for Payer: Cash Price |
$2,650.00
|
| Rate for Payer: Cigna Commercial |
$4,399.00
|
| Rate for Payer: First Health Commercial |
$5,035.00
|
| Rate for Payer: Humana Commercial |
$4,505.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,346.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,911.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,590.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,664.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,975.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,611.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,657.00
|
| Rate for Payer: PHCS Commercial |
$5,088.00
|
| Rate for Payer: United Healthcare All Payer |
$4,664.00
|
|
|
WALL-STENT 16*60
|
Facility
|
OP
|
$5,300.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,590.00 |
| Max. Negotiated Rate |
$5,088.00 |
| Rate for Payer: Aetna Commercial |
$4,081.00
|
| Rate for Payer: Anthem Medicaid |
$1,822.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,134.00
|
| Rate for Payer: Cash Price |
$2,650.00
|
| Rate for Payer: Cigna Commercial |
$4,399.00
|
| Rate for Payer: First Health Commercial |
$5,035.00
|
| Rate for Payer: Humana Commercial |
$4,505.00
|
| Rate for Payer: Humana KY Medicaid |
$1,822.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1,841.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,346.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,911.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,590.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,859.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,664.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,975.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,611.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,657.00
|
| Rate for Payer: PHCS Commercial |
$5,088.00
|
| Rate for Payer: United Healthcare All Payer |
$4,664.00
|
|
|
WALL-STENT 18*40
|
Facility
|
OP
|
$5,300.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,590.00 |
| Max. Negotiated Rate |
$5,088.00 |
| Rate for Payer: Aetna Commercial |
$4,081.00
|
| Rate for Payer: Anthem Medicaid |
$1,822.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,134.00
|
| Rate for Payer: Cash Price |
$2,650.00
|
| Rate for Payer: Cigna Commercial |
$4,399.00
|
| Rate for Payer: First Health Commercial |
$5,035.00
|
| Rate for Payer: Humana Commercial |
$4,505.00
|
| Rate for Payer: Humana KY Medicaid |
$1,822.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1,841.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,346.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,911.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,590.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,859.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,664.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,975.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,611.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,657.00
|
| Rate for Payer: PHCS Commercial |
$5,088.00
|
| Rate for Payer: United Healthcare All Payer |
$4,664.00
|
|
|
WALL-STENT 18*40
|
Facility
|
IP
|
$5,300.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,590.00 |
| Max. Negotiated Rate |
$5,088.00 |
| Rate for Payer: Aetna Commercial |
$4,081.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,134.00
|
| Rate for Payer: Cash Price |
$2,650.00
|
| Rate for Payer: Cigna Commercial |
$4,399.00
|
| Rate for Payer: First Health Commercial |
$5,035.00
|
| Rate for Payer: Humana Commercial |
$4,505.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,346.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,911.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,590.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,664.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,975.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,611.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,657.00
|
| Rate for Payer: PHCS Commercial |
$5,088.00
|
| Rate for Payer: United Healthcare All Payer |
$4,664.00
|
|
|
WALL-STENT 18*90*75
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
WALL-STENT 18*90*75
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
WALL-STENT 20*40
|
Facility
|
OP
|
$5,300.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,590.00 |
| Max. Negotiated Rate |
$5,088.00 |
| Rate for Payer: Aetna Commercial |
$4,081.00
|
| Rate for Payer: Anthem Medicaid |
$1,822.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,134.00
|
| Rate for Payer: Cash Price |
$2,650.00
|
| Rate for Payer: Cigna Commercial |
$4,399.00
|
| Rate for Payer: First Health Commercial |
$5,035.00
|
| Rate for Payer: Humana Commercial |
$4,505.00
|
| Rate for Payer: Humana KY Medicaid |
$1,822.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1,841.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,346.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,911.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,590.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,859.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,664.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,975.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,611.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,657.00
|
| Rate for Payer: PHCS Commercial |
$5,088.00
|
| Rate for Payer: United Healthcare All Payer |
$4,664.00
|
|
|
WALL-STENT 20*40
|
Facility
|
IP
|
$5,300.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,590.00 |
| Max. Negotiated Rate |
$5,088.00 |
| Rate for Payer: Aetna Commercial |
$4,081.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,134.00
|
| Rate for Payer: Cash Price |
$2,650.00
|
| Rate for Payer: Cigna Commercial |
$4,399.00
|
| Rate for Payer: First Health Commercial |
$5,035.00
|
| Rate for Payer: Humana Commercial |
$4,505.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,346.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,911.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,590.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,664.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,975.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,611.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,657.00
|
| Rate for Payer: PHCS Commercial |
$5,088.00
|
| Rate for Payer: United Healthcare All Payer |
$4,664.00
|
|
|
WALL-STENT 20*55
|
Facility
|
OP
|
$5,300.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,590.00 |
| Max. Negotiated Rate |
$5,088.00 |
| Rate for Payer: Aetna Commercial |
$4,081.00
|
| Rate for Payer: Anthem Medicaid |
$1,822.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,134.00
|
| Rate for Payer: Cash Price |
$2,650.00
|
| Rate for Payer: Cigna Commercial |
$4,399.00
|
| Rate for Payer: First Health Commercial |
$5,035.00
|
| Rate for Payer: Humana Commercial |
$4,505.00
|
| Rate for Payer: Humana KY Medicaid |
$1,822.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1,841.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,346.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,911.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,590.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,859.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,664.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,975.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,611.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,657.00
|
| Rate for Payer: PHCS Commercial |
$5,088.00
|
| Rate for Payer: United Healthcare All Payer |
$4,664.00
|
|
|
WALL-STENT 20*55
|
Facility
|
IP
|
$5,300.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,590.00 |
| Max. Negotiated Rate |
$5,088.00 |
| Rate for Payer: Aetna Commercial |
$4,081.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,134.00
|
| Rate for Payer: Cash Price |
$2,650.00
|
| Rate for Payer: Cigna Commercial |
$4,399.00
|
| Rate for Payer: First Health Commercial |
$5,035.00
|
| Rate for Payer: Humana Commercial |
$4,505.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,346.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,911.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,590.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,664.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,975.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,611.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,657.00
|
| Rate for Payer: PHCS Commercial |
$5,088.00
|
| Rate for Payer: United Healthcare All Payer |
$4,664.00
|
|
|
WALL-STENT 22*35
|
Facility
|
IP
|
$7,120.70
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,136.21 |
| Max. Negotiated Rate |
$6,835.87 |
| Rate for Payer: Aetna Commercial |
$5,482.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,554.15
|
| Rate for Payer: Cash Price |
$3,560.35
|
| Rate for Payer: Cigna Commercial |
$5,910.18
|
| Rate for Payer: First Health Commercial |
$6,764.66
|
| Rate for Payer: Humana Commercial |
$6,052.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,838.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,255.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,136.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,266.22
|
| Rate for Payer: Ohio Health Group HMO |
$5,340.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,696.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,195.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,913.28
|
| Rate for Payer: PHCS Commercial |
$6,835.87
|
| Rate for Payer: United Healthcare All Payer |
$6,266.22
|
|
|
WALL-STENT 22*35
|
Facility
|
OP
|
$7,120.70
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,136.21 |
| Max. Negotiated Rate |
$6,835.87 |
| Rate for Payer: Aetna Commercial |
$5,482.94
|
| Rate for Payer: Anthem Medicaid |
$2,448.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,554.15
|
| Rate for Payer: Cash Price |
$3,560.35
|
| Rate for Payer: Cigna Commercial |
$5,910.18
|
| Rate for Payer: First Health Commercial |
$6,764.66
|
| Rate for Payer: Humana Commercial |
$6,052.60
|
| Rate for Payer: Humana KY Medicaid |
$2,448.81
|
| Rate for Payer: Kentucky WC Medicaid |
$2,473.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,838.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,255.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,136.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,497.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,266.22
|
| Rate for Payer: Ohio Health Group HMO |
$5,340.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,696.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,195.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,913.28
|
| Rate for Payer: PHCS Commercial |
$6,835.87
|
| Rate for Payer: United Healthcare All Payer |
$6,266.22
|
|
|
WALL-STENT 22*45
|
Facility
|
IP
|
$5,300.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,590.00 |
| Max. Negotiated Rate |
$5,088.00 |
| Rate for Payer: Aetna Commercial |
$4,081.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,134.00
|
| Rate for Payer: Cash Price |
$2,650.00
|
| Rate for Payer: Cigna Commercial |
$4,399.00
|
| Rate for Payer: First Health Commercial |
$5,035.00
|
| Rate for Payer: Humana Commercial |
$4,505.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,346.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,911.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,590.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,664.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,975.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,611.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,657.00
|
| Rate for Payer: PHCS Commercial |
$5,088.00
|
| Rate for Payer: United Healthcare All Payer |
$4,664.00
|
|
|
WALL-STENT 22*45
|
Facility
|
OP
|
$5,300.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,590.00 |
| Max. Negotiated Rate |
$5,088.00 |
| Rate for Payer: Aetna Commercial |
$4,081.00
|
| Rate for Payer: Anthem Medicaid |
$1,822.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,134.00
|
| Rate for Payer: Cash Price |
$2,650.00
|
| Rate for Payer: Cigna Commercial |
$4,399.00
|
| Rate for Payer: First Health Commercial |
$5,035.00
|
| Rate for Payer: Humana Commercial |
$4,505.00
|
| Rate for Payer: Humana KY Medicaid |
$1,822.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1,841.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,346.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,911.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,590.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,859.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,664.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,975.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,611.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,657.00
|
| Rate for Payer: PHCS Commercial |
$5,088.00
|
| Rate for Payer: United Healthcare All Payer |
$4,664.00
|
|
|
WALL-STENT 24*45
|
Facility
|
IP
|
$7,218.82
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,165.65 |
| Max. Negotiated Rate |
$6,930.07 |
| Rate for Payer: Aetna Commercial |
$5,558.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,630.68
|
| Rate for Payer: Cash Price |
$3,609.41
|
| Rate for Payer: Cigna Commercial |
$5,991.62
|
| Rate for Payer: First Health Commercial |
$6,857.88
|
| Rate for Payer: Humana Commercial |
$6,136.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,919.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,327.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,165.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,352.56
|
| Rate for Payer: Ohio Health Group HMO |
$5,414.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,775.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,280.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,980.99
|
| Rate for Payer: PHCS Commercial |
$6,930.07
|
| Rate for Payer: United Healthcare All Payer |
$6,352.56
|
|
|
WALL-STENT 24*45
|
Facility
|
OP
|
$7,218.82
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,165.65 |
| Max. Negotiated Rate |
$6,930.07 |
| Rate for Payer: Aetna Commercial |
$5,558.49
|
| Rate for Payer: Anthem Medicaid |
$2,482.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,630.68
|
| Rate for Payer: Cash Price |
$3,609.41
|
| Rate for Payer: Cigna Commercial |
$5,991.62
|
| Rate for Payer: First Health Commercial |
$6,857.88
|
| Rate for Payer: Humana Commercial |
$6,136.00
|
| Rate for Payer: Humana KY Medicaid |
$2,482.55
|
| Rate for Payer: Kentucky WC Medicaid |
$2,507.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,919.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,327.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,165.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,532.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,352.56
|
| Rate for Payer: Ohio Health Group HMO |
$5,414.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,775.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,280.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,980.99
|
| Rate for Payer: PHCS Commercial |
$6,930.07
|
| Rate for Payer: United Healthcare All Payer |
$6,352.56
|
|
|
WALL-STENT 5*20*160
|
Facility
|
IP
|
$7,477.46
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,243.24 |
| Max. Negotiated Rate |
$7,178.36 |
| Rate for Payer: Aetna Commercial |
$5,757.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,832.42
|
| Rate for Payer: Cash Price |
$3,738.73
|
| Rate for Payer: Cigna Commercial |
$6,206.29
|
| Rate for Payer: First Health Commercial |
$7,103.59
|
| Rate for Payer: Humana Commercial |
$6,355.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,131.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,518.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,243.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,580.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,608.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,981.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,505.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,159.45
|
| Rate for Payer: PHCS Commercial |
$7,178.36
|
| Rate for Payer: United Healthcare All Payer |
$6,580.16
|
|
|
WALL-STENT 5*20*160
|
Facility
|
OP
|
$7,477.46
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,243.24 |
| Max. Negotiated Rate |
$7,178.36 |
| Rate for Payer: Aetna Commercial |
$5,757.64
|
| Rate for Payer: Anthem Medicaid |
$2,571.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,832.42
|
| Rate for Payer: Cash Price |
$3,738.73
|
| Rate for Payer: Cigna Commercial |
$6,206.29
|
| Rate for Payer: First Health Commercial |
$7,103.59
|
| Rate for Payer: Humana Commercial |
$6,355.84
|
| Rate for Payer: Humana KY Medicaid |
$2,571.50
|
| Rate for Payer: Kentucky WC Medicaid |
$2,597.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,131.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,518.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,243.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,623.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,580.16
|
| Rate for Payer: Ohio Health Group HMO |
$5,608.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,981.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,505.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,159.45
|
| Rate for Payer: PHCS Commercial |
$7,178.36
|
| Rate for Payer: United Healthcare All Payer |
$6,580.16
|
|
