|
EXPRESS STENT SD 4*19*150
|
Facility
|
IP
|
$7,382.58
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$959.74 |
| Max. Negotiated Rate |
$7,087.28 |
| Rate for Payer: Aetna Commercial |
$5,684.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,758.41
|
| Rate for Payer: Cash Price |
$3,691.29
|
| Rate for Payer: Cigna Commercial |
$6,127.54
|
| Rate for Payer: First Health Commercial |
$7,013.45
|
| Rate for Payer: Humana Commercial |
$6,275.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,053.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,448.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,214.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,496.67
|
| Rate for Payer: Ohio Health Group HMO |
$5,536.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,476.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$959.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,288.60
|
| Rate for Payer: PHCS Commercial |
$7,087.28
|
| Rate for Payer: United Healthcare All Payer |
$6,496.67
|
|
|
EXPRESS STENT SD 6*14
|
Facility
|
IP
|
$7,382.58
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$959.74 |
| Max. Negotiated Rate |
$7,087.28 |
| Rate for Payer: Aetna Commercial |
$5,684.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,758.41
|
| Rate for Payer: Cash Price |
$3,691.29
|
| Rate for Payer: Cigna Commercial |
$6,127.54
|
| Rate for Payer: First Health Commercial |
$7,013.45
|
| Rate for Payer: Humana Commercial |
$6,275.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,053.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,448.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,214.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,496.67
|
| Rate for Payer: Ohio Health Group HMO |
$5,536.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,476.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$959.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,288.60
|
| Rate for Payer: PHCS Commercial |
$7,087.28
|
| Rate for Payer: United Healthcare All Payer |
$6,496.67
|
|
|
EXPRESS STENT SD 6*14
|
Facility
|
OP
|
$7,382.58
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$959.74 |
| Max. Negotiated Rate |
$7,087.28 |
| Rate for Payer: Aetna Commercial |
$5,684.59
|
| Rate for Payer: Anthem Medicaid |
$2,538.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,758.41
|
| Rate for Payer: Cash Price |
$3,691.29
|
| Rate for Payer: Cigna Commercial |
$6,127.54
|
| Rate for Payer: First Health Commercial |
$7,013.45
|
| Rate for Payer: Humana Commercial |
$6,275.19
|
| Rate for Payer: Humana KY Medicaid |
$2,538.87
|
| Rate for Payer: Kentucky WC Medicaid |
$2,564.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,053.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,448.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,214.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,589.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,496.67
|
| Rate for Payer: Ohio Health Group HMO |
$5,536.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,476.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$959.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,288.60
|
| Rate for Payer: PHCS Commercial |
$7,087.28
|
| Rate for Payer: United Healthcare All Payer |
$6,496.67
|
|
|
EXT. CEPHALIC VERSION
|
Facility
|
OP
|
$3,731.00
|
|
|
Service Code
|
HCPCS 59412
|
| Hospital Charge Code |
72000002
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$485.03 |
| Max. Negotiated Rate |
$3,784.94 |
| Rate for Payer: Aetna Commercial |
$2,872.87
|
| Rate for Payer: Anthem Medicaid |
$1,283.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,703.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,910.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,784.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,649.77
|
| Rate for Payer: Cash Price |
$1,865.50
|
| Rate for Payer: Cash Price |
$1,865.50
|
| Rate for Payer: Cigna Commercial |
$3,096.73
|
| Rate for Payer: First Health Commercial |
$3,544.45
|
| Rate for Payer: Humana Commercial |
$3,171.35
|
| Rate for Payer: Humana KY Medicaid |
$1,283.09
|
| Rate for Payer: Humana Medicare Advantage |
$2,703.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1,296.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,059.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,753.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,244.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,308.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,283.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,798.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$746.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$485.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,156.61
|
| Rate for Payer: PHCS Commercial |
$3,581.76
|
| Rate for Payer: United Healthcare All Payer |
$3,283.28
|
|
|
EXT. CEPHALIC VERSION
|
Facility
|
IP
|
$3,731.00
|
|
|
Service Code
|
HCPCS 59412
|
| Hospital Charge Code |
72000002
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$485.03 |
| Max. Negotiated Rate |
$3,581.76 |
| Rate for Payer: Aetna Commercial |
$2,872.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,910.18
|
| Rate for Payer: Cash Price |
$1,865.50
|
| Rate for Payer: Cigna Commercial |
$3,096.73
|
| Rate for Payer: First Health Commercial |
$3,544.45
|
| Rate for Payer: Humana Commercial |
$3,171.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,059.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,753.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,119.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,283.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,798.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$746.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$485.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,156.61
|
| Rate for Payer: PHCS Commercial |
$3,581.76
|
| Rate for Payer: United Healthcare All Payer |
$3,283.28
|
|
|
EXTENDED 4H GTR W/4 CBL 23X232
|
Facility
|
OP
|
$21,911.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,848.46 |
| Max. Negotiated Rate |
$21,034.75 |
| Rate for Payer: Aetna Commercial |
$16,871.62
|
| Rate for Payer: Anthem Medicaid |
$7,535.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,090.74
|
| Rate for Payer: Cash Price |
$10,955.60
|
| Rate for Payer: Cigna Commercial |
$18,186.30
|
| Rate for Payer: First Health Commercial |
$20,815.64
|
| Rate for Payer: Humana Commercial |
$18,624.52
|
| Rate for Payer: Humana KY Medicaid |
$7,535.26
|
| Rate for Payer: Kentucky WC Medicaid |
$7,611.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,967.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,170.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,573.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,686.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,281.86
|
| Rate for Payer: Ohio Health Group HMO |
$16,433.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,382.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,848.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,792.47
|
| Rate for Payer: PHCS Commercial |
$21,034.75
|
| Rate for Payer: United Healthcare All Payer |
$19,281.86
|
|
|
EXTENDED 4H GTR W/4 CBL 23X232
|
Facility
|
IP
|
$21,911.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,848.46 |
| Max. Negotiated Rate |
$21,034.75 |
| Rate for Payer: Aetna Commercial |
$16,871.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,090.74
|
| Rate for Payer: Cash Price |
$10,955.60
|
| Rate for Payer: Cigna Commercial |
$18,186.30
|
| Rate for Payer: First Health Commercial |
$20,815.64
|
| Rate for Payer: Humana Commercial |
$18,624.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,967.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,170.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,573.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,281.86
|
| Rate for Payer: Ohio Health Group HMO |
$16,433.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,382.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,848.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,792.47
|
| Rate for Payer: PHCS Commercial |
$21,034.75
|
| Rate for Payer: United Healthcare All Payer |
$19,281.86
|
|
|
EXTENDED 5H GTR W/4 CBL 23X261
|
Facility
|
OP
|
$24,626.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,201.48 |
| Max. Negotiated Rate |
$23,641.73 |
| Rate for Payer: Aetna Commercial |
$18,962.64
|
| Rate for Payer: Anthem Medicaid |
$8,469.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,208.90
|
| Rate for Payer: Cash Price |
$12,313.40
|
| Rate for Payer: Cigna Commercial |
$20,440.24
|
| Rate for Payer: First Health Commercial |
$23,395.46
|
| Rate for Payer: Humana Commercial |
$20,932.78
|
| Rate for Payer: Humana KY Medicaid |
$8,469.16
|
| Rate for Payer: Kentucky WC Medicaid |
$8,555.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,193.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,174.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,388.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,639.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,671.58
|
| Rate for Payer: Ohio Health Group HMO |
$18,470.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,925.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,201.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,634.31
|
| Rate for Payer: PHCS Commercial |
$23,641.73
|
| Rate for Payer: United Healthcare All Payer |
$21,671.58
|
|
|
EXTENDED 5H GTR W/4 CBL 23X261
|
Facility
|
IP
|
$24,626.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,201.48 |
| Max. Negotiated Rate |
$23,641.73 |
| Rate for Payer: Aetna Commercial |
$18,962.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,208.90
|
| Rate for Payer: Cash Price |
$12,313.40
|
| Rate for Payer: Cigna Commercial |
$20,440.24
|
| Rate for Payer: First Health Commercial |
$23,395.46
|
| Rate for Payer: Humana Commercial |
$20,932.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,193.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,174.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,388.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,671.58
|
| Rate for Payer: Ohio Health Group HMO |
$18,470.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,925.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,201.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,634.31
|
| Rate for Payer: PHCS Commercial |
$23,641.73
|
| Rate for Payer: United Healthcare All Payer |
$21,671.58
|
|
|
EXTENDER CUFF AORTIC 4CM 20MM
|
Facility
|
OP
|
$11,421.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,484.76 |
| Max. Negotiated Rate |
$10,964.40 |
| Rate for Payer: Aetna Commercial |
$8,794.36
|
| Rate for Payer: Anthem Medicaid |
$3,927.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,908.58
|
| Rate for Payer: Cash Price |
$5,710.62
|
| Rate for Payer: Cigna Commercial |
$9,479.64
|
| Rate for Payer: First Health Commercial |
$10,850.19
|
| Rate for Payer: Humana Commercial |
$9,708.06
|
| Rate for Payer: Humana KY Medicaid |
$3,927.77
|
| Rate for Payer: Kentucky WC Medicaid |
$3,967.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,365.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,428.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,426.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,006.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,050.70
|
| Rate for Payer: Ohio Health Group HMO |
$8,565.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,284.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,484.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,540.59
|
| Rate for Payer: PHCS Commercial |
$10,964.40
|
| Rate for Payer: United Healthcare All Payer |
$10,050.70
|
|
|
EXTENDER CUFF AORTIC 4CM 20MM
|
Facility
|
IP
|
$11,421.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,484.76 |
| Max. Negotiated Rate |
$10,964.40 |
| Rate for Payer: Aetna Commercial |
$8,794.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,908.58
|
| Rate for Payer: Cash Price |
$5,710.62
|
| Rate for Payer: Cigna Commercial |
$9,479.64
|
| Rate for Payer: First Health Commercial |
$10,850.19
|
| Rate for Payer: Humana Commercial |
$9,708.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,365.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,428.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,426.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,050.70
|
| Rate for Payer: Ohio Health Group HMO |
$8,565.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,284.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,484.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,540.59
|
| Rate for Payer: PHCS Commercial |
$10,964.40
|
| Rate for Payer: United Healthcare All Payer |
$10,050.70
|
|
|
EXTENDER CUFF AORTIC 4CM 22MM
|
Facility
|
IP
|
$11,421.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,484.76 |
| Max. Negotiated Rate |
$10,964.40 |
| Rate for Payer: Aetna Commercial |
$8,794.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,908.58
|
| Rate for Payer: Cash Price |
$5,710.62
|
| Rate for Payer: Cigna Commercial |
$9,479.64
|
| Rate for Payer: First Health Commercial |
$10,850.19
|
| Rate for Payer: Humana Commercial |
$9,708.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,365.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,428.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,426.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,050.70
|
| Rate for Payer: Ohio Health Group HMO |
$8,565.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,284.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,484.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,540.59
|
| Rate for Payer: PHCS Commercial |
$10,964.40
|
| Rate for Payer: United Healthcare All Payer |
$10,050.70
|
|
|
EXTENDER CUFF AORTIC 4CM 22MM
|
Facility
|
OP
|
$11,421.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,484.76 |
| Max. Negotiated Rate |
$10,964.40 |
| Rate for Payer: Aetna Commercial |
$8,794.36
|
| Rate for Payer: Anthem Medicaid |
$3,927.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,908.58
|
| Rate for Payer: Cash Price |
$5,710.62
|
| Rate for Payer: Cigna Commercial |
$9,479.64
|
| Rate for Payer: First Health Commercial |
$10,850.19
|
| Rate for Payer: Humana Commercial |
$9,708.06
|
| Rate for Payer: Humana KY Medicaid |
$3,927.77
|
| Rate for Payer: Kentucky WC Medicaid |
$3,967.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,365.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,428.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,426.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,006.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,050.70
|
| Rate for Payer: Ohio Health Group HMO |
$8,565.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,284.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,484.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,540.59
|
| Rate for Payer: PHCS Commercial |
$10,964.40
|
| Rate for Payer: United Healthcare All Payer |
$10,050.70
|
|
|
EXTENDER CUFF AORTIC 4CM 26MM
|
Facility
|
IP
|
$11,421.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,484.76 |
| Max. Negotiated Rate |
$10,964.40 |
| Rate for Payer: Aetna Commercial |
$8,794.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,908.58
|
| Rate for Payer: Cash Price |
$5,710.62
|
| Rate for Payer: Cigna Commercial |
$9,479.64
|
| Rate for Payer: First Health Commercial |
$10,850.19
|
| Rate for Payer: Humana Commercial |
$9,708.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,365.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,428.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,426.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,050.70
|
| Rate for Payer: Ohio Health Group HMO |
$8,565.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,284.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,484.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,540.59
|
| Rate for Payer: PHCS Commercial |
$10,964.40
|
| Rate for Payer: United Healthcare All Payer |
$10,050.70
|
|
|
EXTENDER CUFF AORTIC 4CM 26MM
|
Facility
|
OP
|
$11,421.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,484.76 |
| Max. Negotiated Rate |
$10,964.40 |
| Rate for Payer: Aetna Commercial |
$8,794.36
|
| Rate for Payer: Anthem Medicaid |
$3,927.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,908.58
|
| Rate for Payer: Cash Price |
$5,710.62
|
| Rate for Payer: Cigna Commercial |
$9,479.64
|
| Rate for Payer: First Health Commercial |
$10,850.19
|
| Rate for Payer: Humana Commercial |
$9,708.06
|
| Rate for Payer: Humana KY Medicaid |
$3,927.77
|
| Rate for Payer: Kentucky WC Medicaid |
$3,967.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,365.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,428.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,426.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,006.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,050.70
|
| Rate for Payer: Ohio Health Group HMO |
$8,565.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,284.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,484.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,540.59
|
| Rate for Payer: PHCS Commercial |
$10,964.40
|
| Rate for Payer: United Healthcare All Payer |
$10,050.70
|
|
|
EXTENDER CUFF AORTIC 4CM 28MM
|
Facility
|
IP
|
$11,421.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,484.76 |
| Max. Negotiated Rate |
$10,964.40 |
| Rate for Payer: Aetna Commercial |
$8,794.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,908.58
|
| Rate for Payer: Cash Price |
$5,710.62
|
| Rate for Payer: Cigna Commercial |
$9,479.64
|
| Rate for Payer: First Health Commercial |
$10,850.19
|
| Rate for Payer: Humana Commercial |
$9,708.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,365.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,428.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,426.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,050.70
|
| Rate for Payer: Ohio Health Group HMO |
$8,565.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,284.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,484.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,540.59
|
| Rate for Payer: PHCS Commercial |
$10,964.40
|
| Rate for Payer: United Healthcare All Payer |
$10,050.70
|
|
|
EXTENDER CUFF AORTIC 4CM 28MM
|
Facility
|
OP
|
$11,421.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,484.76 |
| Max. Negotiated Rate |
$10,964.40 |
| Rate for Payer: Aetna Commercial |
$8,794.36
|
| Rate for Payer: Anthem Medicaid |
$3,927.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,908.58
|
| Rate for Payer: Cash Price |
$5,710.62
|
| Rate for Payer: Cigna Commercial |
$9,479.64
|
| Rate for Payer: First Health Commercial |
$10,850.19
|
| Rate for Payer: Humana Commercial |
$9,708.06
|
| Rate for Payer: Humana KY Medicaid |
$3,927.77
|
| Rate for Payer: Kentucky WC Medicaid |
$3,967.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,365.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,428.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,426.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,006.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,050.70
|
| Rate for Payer: Ohio Health Group HMO |
$8,565.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,284.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,484.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,540.59
|
| Rate for Payer: PHCS Commercial |
$10,964.40
|
| Rate for Payer: United Healthcare All Payer |
$10,050.70
|
|
|
EXTENDER CUFF ILIAC FLR 16*20
|
Facility
|
OP
|
$15,900.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,067.00 |
| Max. Negotiated Rate |
$15,264.00 |
| Rate for Payer: Aetna Commercial |
$12,243.00
|
| Rate for Payer: Anthem Medicaid |
$5,468.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,402.00
|
| Rate for Payer: Cash Price |
$7,950.00
|
| Rate for Payer: Cigna Commercial |
$13,197.00
|
| Rate for Payer: First Health Commercial |
$15,105.00
|
| Rate for Payer: Humana Commercial |
$13,515.00
|
| Rate for Payer: Humana KY Medicaid |
$5,468.01
|
| Rate for Payer: Kentucky WC Medicaid |
$5,523.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,038.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,734.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,770.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,577.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,992.00
|
| Rate for Payer: Ohio Health Group HMO |
$11,925.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,180.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,067.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,929.00
|
| Rate for Payer: PHCS Commercial |
$15,264.00
|
| Rate for Payer: United Healthcare All Payer |
$13,992.00
|
|
|
EXTENDER CUFF ILIAC FLR 16*20
|
Facility
|
IP
|
$15,900.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,067.00 |
| Max. Negotiated Rate |
$15,264.00 |
| Rate for Payer: Aetna Commercial |
$12,243.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,402.00
|
| Rate for Payer: Cash Price |
$7,950.00
|
| Rate for Payer: Cigna Commercial |
$13,197.00
|
| Rate for Payer: First Health Commercial |
$15,105.00
|
| Rate for Payer: Humana Commercial |
$13,515.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,038.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,734.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,770.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,992.00
|
| Rate for Payer: Ohio Health Group HMO |
$11,925.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,180.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,067.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,929.00
|
| Rate for Payer: PHCS Commercial |
$15,264.00
|
| Rate for Payer: United Healthcare All Payer |
$13,992.00
|
|
|
EXTENDER CUFF ILIAC FLR 18*22
|
Facility
|
OP
|
$15,900.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,067.00 |
| Max. Negotiated Rate |
$15,264.00 |
| Rate for Payer: Aetna Commercial |
$12,243.00
|
| Rate for Payer: Anthem Medicaid |
$5,468.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,402.00
|
| Rate for Payer: Cash Price |
$7,950.00
|
| Rate for Payer: Cigna Commercial |
$13,197.00
|
| Rate for Payer: First Health Commercial |
$15,105.00
|
| Rate for Payer: Humana Commercial |
$13,515.00
|
| Rate for Payer: Humana KY Medicaid |
$5,468.01
|
| Rate for Payer: Kentucky WC Medicaid |
$5,523.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,038.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,734.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,770.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,577.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,992.00
|
| Rate for Payer: Ohio Health Group HMO |
$11,925.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,180.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,067.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,929.00
|
| Rate for Payer: PHCS Commercial |
$15,264.00
|
| Rate for Payer: United Healthcare All Payer |
$13,992.00
|
|
|
EXTENDER CUFF ILIAC FLR 18*22
|
Facility
|
IP
|
$15,900.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,067.00 |
| Max. Negotiated Rate |
$15,264.00 |
| Rate for Payer: Aetna Commercial |
$12,243.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,402.00
|
| Rate for Payer: Cash Price |
$7,950.00
|
| Rate for Payer: Cigna Commercial |
$13,197.00
|
| Rate for Payer: First Health Commercial |
$15,105.00
|
| Rate for Payer: Humana Commercial |
$13,515.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,038.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,734.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,770.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,992.00
|
| Rate for Payer: Ohio Health Group HMO |
$11,925.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,180.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,067.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,929.00
|
| Rate for Payer: PHCS Commercial |
$15,264.00
|
| Rate for Payer: United Healthcare All Payer |
$13,992.00
|
|
|
EXTENDER CUFF ILIAC FLR 18*24
|
Facility
|
IP
|
$17,700.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,301.00 |
| Max. Negotiated Rate |
$16,992.00 |
| Rate for Payer: Aetna Commercial |
$13,629.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,806.00
|
| Rate for Payer: Cash Price |
$8,850.00
|
| Rate for Payer: Cigna Commercial |
$14,691.00
|
| Rate for Payer: First Health Commercial |
$16,815.00
|
| Rate for Payer: Humana Commercial |
$15,045.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,514.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,062.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,310.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,576.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,301.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,487.00
|
| Rate for Payer: PHCS Commercial |
$16,992.00
|
| Rate for Payer: United Healthcare All Payer |
$15,576.00
|
|
|
EXTENDER CUFF ILIAC FLR 18*24
|
Facility
|
OP
|
$17,700.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,301.00 |
| Max. Negotiated Rate |
$16,992.00 |
| Rate for Payer: Aetna Commercial |
$13,629.00
|
| Rate for Payer: Anthem Medicaid |
$6,087.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,806.00
|
| Rate for Payer: Cash Price |
$8,850.00
|
| Rate for Payer: Cigna Commercial |
$14,691.00
|
| Rate for Payer: First Health Commercial |
$16,815.00
|
| Rate for Payer: Humana Commercial |
$15,045.00
|
| Rate for Payer: Humana KY Medicaid |
$6,087.03
|
| Rate for Payer: Kentucky WC Medicaid |
$6,148.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,514.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,062.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,310.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,209.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,576.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,301.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,487.00
|
| Rate for Payer: PHCS Commercial |
$16,992.00
|
| Rate for Payer: United Healthcare All Payer |
$15,576.00
|
|
|
EXTENDER CUFF ILIAC STR 12*12
|
Facility
|
OP
|
$11,421.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,484.76 |
| Max. Negotiated Rate |
$10,964.40 |
| Rate for Payer: Aetna Commercial |
$8,794.36
|
| Rate for Payer: Anthem Medicaid |
$3,927.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,908.58
|
| Rate for Payer: Cash Price |
$5,710.62
|
| Rate for Payer: Cigna Commercial |
$9,479.64
|
| Rate for Payer: First Health Commercial |
$10,850.19
|
| Rate for Payer: Humana Commercial |
$9,708.06
|
| Rate for Payer: Humana KY Medicaid |
$3,927.77
|
| Rate for Payer: Kentucky WC Medicaid |
$3,967.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,365.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,428.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,426.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,006.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,050.70
|
| Rate for Payer: Ohio Health Group HMO |
$8,565.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,284.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,484.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,540.59
|
| Rate for Payer: PHCS Commercial |
$10,964.40
|
| Rate for Payer: United Healthcare All Payer |
$10,050.70
|
|
|
EXTENDER CUFF ILIAC STR 12*12
|
Facility
|
IP
|
$11,421.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,484.76 |
| Max. Negotiated Rate |
$10,964.40 |
| Rate for Payer: Aetna Commercial |
$8,794.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,908.58
|
| Rate for Payer: Cash Price |
$5,710.62
|
| Rate for Payer: Cigna Commercial |
$9,479.64
|
| Rate for Payer: First Health Commercial |
$10,850.19
|
| Rate for Payer: Humana Commercial |
$9,708.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,365.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,428.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,426.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,050.70
|
| Rate for Payer: Ohio Health Group HMO |
$8,565.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,284.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,484.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,540.59
|
| Rate for Payer: PHCS Commercial |
$10,964.40
|
| Rate for Payer: United Healthcare All Payer |
$10,050.70
|
|
