|
XIENCE SIERRA 2.25*28
|
Facility
|
OP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem Medicaid |
$2,412.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Humana KY Medicaid |
$2,412.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,437.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,460.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.25*28
|
Facility
|
IP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.25*33
|
Facility
|
IP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.25*33
|
Facility
|
OP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem Medicaid |
$2,412.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Humana KY Medicaid |
$2,412.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,437.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,460.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.25*38
|
Facility
|
OP
|
$4,625.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,387.50 |
| Max. Negotiated Rate |
$4,440.00 |
| Rate for Payer: Aetna Commercial |
$3,561.25
|
| Rate for Payer: Anthem Medicaid |
$1,590.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,607.50
|
| Rate for Payer: Cash Price |
$2,312.50
|
| Rate for Payer: Cigna Commercial |
$3,838.75
|
| Rate for Payer: First Health Commercial |
$4,393.75
|
| Rate for Payer: Humana Commercial |
$3,931.25
|
| Rate for Payer: Humana KY Medicaid |
$1,590.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1,606.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,792.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,413.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,387.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,622.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,070.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,468.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,700.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,023.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,191.25
|
| Rate for Payer: PHCS Commercial |
$4,440.00
|
| Rate for Payer: United Healthcare All Payer |
$4,070.00
|
|
|
XIENCE SIERRA 2.25*38
|
Facility
|
IP
|
$4,625.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,387.50 |
| Max. Negotiated Rate |
$4,440.00 |
| Rate for Payer: Aetna Commercial |
$3,561.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,607.50
|
| Rate for Payer: Cash Price |
$2,312.50
|
| Rate for Payer: Cigna Commercial |
$3,838.75
|
| Rate for Payer: First Health Commercial |
$4,393.75
|
| Rate for Payer: Humana Commercial |
$3,931.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,792.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,413.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,387.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,070.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,468.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,700.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,023.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,191.25
|
| Rate for Payer: PHCS Commercial |
$4,440.00
|
| Rate for Payer: United Healthcare All Payer |
$4,070.00
|
|
|
XIENCE SIERRA 2.25*8
|
Facility
|
IP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.25*8
|
Facility
|
OP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem Medicaid |
$2,412.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Humana KY Medicaid |
$2,412.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,437.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,460.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.50*12
|
Facility
|
IP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.50*12
|
Facility
|
OP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem Medicaid |
$2,412.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Humana KY Medicaid |
$2,412.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,437.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,460.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.50*15
|
Facility
|
OP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem Medicaid |
$2,412.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Humana KY Medicaid |
$2,412.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,437.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,460.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.50*15
|
Facility
|
IP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.50*18
|
Facility
|
IP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.50*18
|
Facility
|
OP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem Medicaid |
$2,412.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Humana KY Medicaid |
$2,412.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,437.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,460.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.50*23
|
Facility
|
IP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.50*23
|
Facility
|
OP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem Medicaid |
$2,412.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Humana KY Medicaid |
$2,412.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,437.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,460.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.50*28
|
Facility
|
IP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.50*28
|
Facility
|
OP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem Medicaid |
$2,412.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Humana KY Medicaid |
$2,412.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,437.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,460.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.50*33
|
Facility
|
IP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.50*33
|
Facility
|
OP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem Medicaid |
$2,412.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Humana KY Medicaid |
$2,412.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,437.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,460.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.50*38
|
Facility
|
IP
|
$3,875.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,162.50 |
| Max. Negotiated Rate |
$3,720.00 |
| Rate for Payer: Aetna Commercial |
$2,983.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,022.50
|
| Rate for Payer: Cash Price |
$1,937.50
|
| Rate for Payer: Cigna Commercial |
$3,216.25
|
| Rate for Payer: First Health Commercial |
$3,681.25
|
| Rate for Payer: Humana Commercial |
$3,293.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,177.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,859.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,162.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,410.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,906.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,371.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,673.75
|
| Rate for Payer: PHCS Commercial |
$3,720.00
|
| Rate for Payer: United Healthcare All Payer |
$3,410.00
|
|
|
XIENCE SIERRA 2.50*38
|
Facility
|
OP
|
$3,875.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,162.50 |
| Max. Negotiated Rate |
$3,720.00 |
| Rate for Payer: Aetna Commercial |
$2,983.75
|
| Rate for Payer: Anthem Medicaid |
$1,332.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,022.50
|
| Rate for Payer: Cash Price |
$1,937.50
|
| Rate for Payer: Cigna Commercial |
$3,216.25
|
| Rate for Payer: First Health Commercial |
$3,681.25
|
| Rate for Payer: Humana Commercial |
$3,293.75
|
| Rate for Payer: Humana KY Medicaid |
$1,332.61
|
| Rate for Payer: Kentucky WC Medicaid |
$1,346.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,177.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,859.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,162.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,359.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,410.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,906.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,371.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,673.75
|
| Rate for Payer: PHCS Commercial |
$3,720.00
|
| Rate for Payer: United Healthcare All Payer |
$3,410.00
|
|
|
XIENCE SIERRA 2.50*8
|
Facility
|
OP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem Medicaid |
$2,412.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Humana KY Medicaid |
$2,412.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,437.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,460.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.50*8
|
Facility
|
IP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
XIENCE SIERRA 2.75*12
|
Facility
|
OP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem Medicaid |
$2,412.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Humana KY Medicaid |
$2,412.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,437.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,460.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
