|
EXTENDER CUFF AORTIC 4CM 22MM
|
Facility
|
IP
|
$11,665.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.72 |
| Max. Negotiated Rate |
$11,199.12 |
| Rate for Payer: Aetna Commercial |
$8,982.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,099.28
|
| Rate for Payer: Cash Price |
$5,832.88
|
| Rate for Payer: Cigna Commercial |
$9,682.57
|
| Rate for Payer: First Health Commercial |
$11,082.46
|
| Rate for Payer: Humana Commercial |
$9,915.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,565.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,609.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,499.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,265.86
|
| Rate for Payer: Ohio Health Group HMO |
$8,749.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,332.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,149.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,049.37
|
| Rate for Payer: PHCS Commercial |
$11,199.12
|
| Rate for Payer: United Healthcare All Payer |
$10,265.86
|
|
|
EXTENDER CUFF AORTIC 4CM 22MM
|
Facility
|
OP
|
$11,665.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.72 |
| Max. Negotiated Rate |
$11,199.12 |
| Rate for Payer: Aetna Commercial |
$8,982.63
|
| Rate for Payer: Anthem Medicaid |
$4,011.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,099.28
|
| Rate for Payer: Cash Price |
$5,832.88
|
| Rate for Payer: Cigna Commercial |
$9,682.57
|
| Rate for Payer: First Health Commercial |
$11,082.46
|
| Rate for Payer: Humana Commercial |
$9,915.89
|
| Rate for Payer: Humana KY Medicaid |
$4,011.85
|
| Rate for Payer: Kentucky WC Medicaid |
$4,052.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,565.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,609.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,499.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,092.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,265.86
|
| Rate for Payer: Ohio Health Group HMO |
$8,749.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,332.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,149.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,049.37
|
| Rate for Payer: PHCS Commercial |
$11,199.12
|
| Rate for Payer: United Healthcare All Payer |
$10,265.86
|
|
|
EXTENDER CUFF AORTIC 4CM 26MM
|
Facility
|
OP
|
$11,665.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.72 |
| Max. Negotiated Rate |
$11,199.12 |
| Rate for Payer: Aetna Commercial |
$8,982.63
|
| Rate for Payer: Anthem Medicaid |
$4,011.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,099.28
|
| Rate for Payer: Cash Price |
$5,832.88
|
| Rate for Payer: Cigna Commercial |
$9,682.57
|
| Rate for Payer: First Health Commercial |
$11,082.46
|
| Rate for Payer: Humana Commercial |
$9,915.89
|
| Rate for Payer: Humana KY Medicaid |
$4,011.85
|
| Rate for Payer: Kentucky WC Medicaid |
$4,052.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,565.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,609.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,499.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,092.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,265.86
|
| Rate for Payer: Ohio Health Group HMO |
$8,749.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,332.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,149.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,049.37
|
| Rate for Payer: PHCS Commercial |
$11,199.12
|
| Rate for Payer: United Healthcare All Payer |
$10,265.86
|
|
|
EXTENDER CUFF AORTIC 4CM 26MM
|
Facility
|
IP
|
$11,665.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.72 |
| Max. Negotiated Rate |
$11,199.12 |
| Rate for Payer: Aetna Commercial |
$8,982.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,099.28
|
| Rate for Payer: Cash Price |
$5,832.88
|
| Rate for Payer: Cigna Commercial |
$9,682.57
|
| Rate for Payer: First Health Commercial |
$11,082.46
|
| Rate for Payer: Humana Commercial |
$9,915.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,565.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,609.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,499.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,265.86
|
| Rate for Payer: Ohio Health Group HMO |
$8,749.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,332.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,149.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,049.37
|
| Rate for Payer: PHCS Commercial |
$11,199.12
|
| Rate for Payer: United Healthcare All Payer |
$10,265.86
|
|
|
EXTENDER CUFF AORTIC 4CM 28MM
|
Facility
|
IP
|
$11,665.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.72 |
| Max. Negotiated Rate |
$11,199.12 |
| Rate for Payer: Aetna Commercial |
$8,982.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,099.28
|
| Rate for Payer: Cash Price |
$5,832.88
|
| Rate for Payer: Cigna Commercial |
$9,682.57
|
| Rate for Payer: First Health Commercial |
$11,082.46
|
| Rate for Payer: Humana Commercial |
$9,915.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,565.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,609.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,499.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,265.86
|
| Rate for Payer: Ohio Health Group HMO |
$8,749.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,332.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,149.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,049.37
|
| Rate for Payer: PHCS Commercial |
$11,199.12
|
| Rate for Payer: United Healthcare All Payer |
$10,265.86
|
|
|
EXTENDER CUFF AORTIC 4CM 28MM
|
Facility
|
OP
|
$11,665.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.72 |
| Max. Negotiated Rate |
$11,199.12 |
| Rate for Payer: Aetna Commercial |
$8,982.63
|
| Rate for Payer: Anthem Medicaid |
$4,011.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,099.28
|
| Rate for Payer: Cash Price |
$5,832.88
|
| Rate for Payer: Cigna Commercial |
$9,682.57
|
| Rate for Payer: First Health Commercial |
$11,082.46
|
| Rate for Payer: Humana Commercial |
$9,915.89
|
| Rate for Payer: Humana KY Medicaid |
$4,011.85
|
| Rate for Payer: Kentucky WC Medicaid |
$4,052.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,565.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,609.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,499.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,092.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,265.86
|
| Rate for Payer: Ohio Health Group HMO |
$8,749.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,332.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,149.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,049.37
|
| Rate for Payer: PHCS Commercial |
$11,199.12
|
| Rate for Payer: United Healthcare All Payer |
$10,265.86
|
|
|
EXTENDER CUFF ILIAC FLR 16*20
|
Facility
|
OP
|
$16,425.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,927.50 |
| Max. Negotiated Rate |
$15,768.00 |
| Rate for Payer: Aetna Commercial |
$12,647.25
|
| Rate for Payer: Anthem Medicaid |
$5,648.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,811.50
|
| Rate for Payer: Cash Price |
$8,212.50
|
| Rate for Payer: Cigna Commercial |
$13,632.75
|
| Rate for Payer: First Health Commercial |
$15,603.75
|
| Rate for Payer: Humana Commercial |
$13,961.25
|
| Rate for Payer: Humana KY Medicaid |
$5,648.56
|
| Rate for Payer: Kentucky WC Medicaid |
$5,706.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,468.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,121.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,927.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,761.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,454.00
|
| Rate for Payer: Ohio Health Group HMO |
$12,318.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,289.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,333.25
|
| Rate for Payer: PHCS Commercial |
$15,768.00
|
| Rate for Payer: United Healthcare All Payer |
$14,454.00
|
|
|
EXTENDER CUFF ILIAC FLR 16*20
|
Facility
|
IP
|
$16,425.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,927.50 |
| Max. Negotiated Rate |
$15,768.00 |
| Rate for Payer: Aetna Commercial |
$12,647.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,811.50
|
| Rate for Payer: Cash Price |
$8,212.50
|
| Rate for Payer: Cigna Commercial |
$13,632.75
|
| Rate for Payer: First Health Commercial |
$15,603.75
|
| Rate for Payer: Humana Commercial |
$13,961.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,468.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,121.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,927.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,454.00
|
| Rate for Payer: Ohio Health Group HMO |
$12,318.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,289.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,333.25
|
| Rate for Payer: PHCS Commercial |
$15,768.00
|
| Rate for Payer: United Healthcare All Payer |
$14,454.00
|
|
|
EXTENDER CUFF ILIAC FLR 18*22
|
Facility
|
IP
|
$16,425.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,927.50 |
| Max. Negotiated Rate |
$15,768.00 |
| Rate for Payer: Aetna Commercial |
$12,647.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,811.50
|
| Rate for Payer: Cash Price |
$8,212.50
|
| Rate for Payer: Cigna Commercial |
$13,632.75
|
| Rate for Payer: First Health Commercial |
$15,603.75
|
| Rate for Payer: Humana Commercial |
$13,961.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,468.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,121.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,927.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,454.00
|
| Rate for Payer: Ohio Health Group HMO |
$12,318.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,289.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,333.25
|
| Rate for Payer: PHCS Commercial |
$15,768.00
|
| Rate for Payer: United Healthcare All Payer |
$14,454.00
|
|
|
EXTENDER CUFF ILIAC FLR 18*22
|
Facility
|
OP
|
$16,425.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,927.50 |
| Max. Negotiated Rate |
$15,768.00 |
| Rate for Payer: Aetna Commercial |
$12,647.25
|
| Rate for Payer: Anthem Medicaid |
$5,648.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,811.50
|
| Rate for Payer: Cash Price |
$8,212.50
|
| Rate for Payer: Cigna Commercial |
$13,632.75
|
| Rate for Payer: First Health Commercial |
$15,603.75
|
| Rate for Payer: Humana Commercial |
$13,961.25
|
| Rate for Payer: Humana KY Medicaid |
$5,648.56
|
| Rate for Payer: Kentucky WC Medicaid |
$5,706.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,468.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,121.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,927.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,761.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,454.00
|
| Rate for Payer: Ohio Health Group HMO |
$12,318.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,289.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,333.25
|
| Rate for Payer: PHCS Commercial |
$15,768.00
|
| Rate for Payer: United Healthcare All Payer |
$14,454.00
|
|
|
EXTENDER CUFF ILIAC FLR 18*24
|
Facility
|
OP
|
$18,275.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,482.50 |
| Max. Negotiated Rate |
$17,544.00 |
| Rate for Payer: Aetna Commercial |
$14,071.75
|
| Rate for Payer: Anthem Medicaid |
$6,284.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,254.50
|
| Rate for Payer: Cash Price |
$9,137.50
|
| Rate for Payer: Cigna Commercial |
$15,168.25
|
| Rate for Payer: First Health Commercial |
$17,361.25
|
| Rate for Payer: Humana Commercial |
$15,533.75
|
| Rate for Payer: Humana KY Medicaid |
$6,284.77
|
| Rate for Payer: Kentucky WC Medicaid |
$6,348.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,985.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,486.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,482.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,410.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,082.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,706.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,620.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,899.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,609.75
|
| Rate for Payer: PHCS Commercial |
$17,544.00
|
| Rate for Payer: United Healthcare All Payer |
$16,082.00
|
|
|
EXTENDER CUFF ILIAC FLR 18*24
|
Facility
|
IP
|
$18,275.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,482.50 |
| Max. Negotiated Rate |
$17,544.00 |
| Rate for Payer: Aetna Commercial |
$14,071.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,254.50
|
| Rate for Payer: Cash Price |
$9,137.50
|
| Rate for Payer: Cigna Commercial |
$15,168.25
|
| Rate for Payer: First Health Commercial |
$17,361.25
|
| Rate for Payer: Humana Commercial |
$15,533.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,985.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,486.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,482.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,082.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,706.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,620.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,899.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,609.75
|
| Rate for Payer: PHCS Commercial |
$17,544.00
|
| Rate for Payer: United Healthcare All Payer |
$16,082.00
|
|
|
EXTENDER CUFF ILIAC STR 12*12
|
Facility
|
IP
|
$11,665.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.72 |
| Max. Negotiated Rate |
$11,199.12 |
| Rate for Payer: Aetna Commercial |
$8,982.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,099.28
|
| Rate for Payer: Cash Price |
$5,832.88
|
| Rate for Payer: Cigna Commercial |
$9,682.57
|
| Rate for Payer: First Health Commercial |
$11,082.46
|
| Rate for Payer: Humana Commercial |
$9,915.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,565.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,609.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,499.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,265.86
|
| Rate for Payer: Ohio Health Group HMO |
$8,749.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,332.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,149.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,049.37
|
| Rate for Payer: PHCS Commercial |
$11,199.12
|
| Rate for Payer: United Healthcare All Payer |
$10,265.86
|
|
|
EXTENDER CUFF ILIAC STR 12*12
|
Facility
|
OP
|
$11,665.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.72 |
| Max. Negotiated Rate |
$11,199.12 |
| Rate for Payer: Aetna Commercial |
$8,982.63
|
| Rate for Payer: Anthem Medicaid |
$4,011.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,099.28
|
| Rate for Payer: Cash Price |
$5,832.88
|
| Rate for Payer: Cigna Commercial |
$9,682.57
|
| Rate for Payer: First Health Commercial |
$11,082.46
|
| Rate for Payer: Humana Commercial |
$9,915.89
|
| Rate for Payer: Humana KY Medicaid |
$4,011.85
|
| Rate for Payer: Kentucky WC Medicaid |
$4,052.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,565.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,609.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,499.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,092.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,265.86
|
| Rate for Payer: Ohio Health Group HMO |
$8,749.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,332.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,149.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,049.37
|
| Rate for Payer: PHCS Commercial |
$11,199.12
|
| Rate for Payer: United Healthcare All Payer |
$10,265.86
|
|
|
EXTENDER CUFF ILIAC STR 13*13
|
Facility
|
OP
|
$11,665.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.72 |
| Max. Negotiated Rate |
$11,199.12 |
| Rate for Payer: Aetna Commercial |
$8,982.63
|
| Rate for Payer: Anthem Medicaid |
$4,011.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,099.28
|
| Rate for Payer: Cash Price |
$5,832.88
|
| Rate for Payer: Cigna Commercial |
$9,682.57
|
| Rate for Payer: First Health Commercial |
$11,082.46
|
| Rate for Payer: Humana Commercial |
$9,915.89
|
| Rate for Payer: Humana KY Medicaid |
$4,011.85
|
| Rate for Payer: Kentucky WC Medicaid |
$4,052.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,565.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,609.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,499.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,092.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,265.86
|
| Rate for Payer: Ohio Health Group HMO |
$8,749.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,332.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,149.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,049.37
|
| Rate for Payer: PHCS Commercial |
$11,199.12
|
| Rate for Payer: United Healthcare All Payer |
$10,265.86
|
|
|
EXTENDER CUFF ILIAC STR 13*13
|
Facility
|
IP
|
$11,665.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.72 |
| Max. Negotiated Rate |
$11,199.12 |
| Rate for Payer: Aetna Commercial |
$8,982.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,099.28
|
| Rate for Payer: Cash Price |
$5,832.88
|
| Rate for Payer: Cigna Commercial |
$9,682.57
|
| Rate for Payer: First Health Commercial |
$11,082.46
|
| Rate for Payer: Humana Commercial |
$9,915.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,565.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,609.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,499.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,265.86
|
| Rate for Payer: Ohio Health Group HMO |
$8,749.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,332.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,149.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,049.37
|
| Rate for Payer: PHCS Commercial |
$11,199.12
|
| Rate for Payer: United Healthcare All Payer |
$10,265.86
|
|
|
EXTENDER CUFF ILIAC STR 14*14
|
Facility
|
OP
|
$11,665.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.72 |
| Max. Negotiated Rate |
$11,199.12 |
| Rate for Payer: Aetna Commercial |
$8,982.63
|
| Rate for Payer: Anthem Medicaid |
$4,011.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,099.28
|
| Rate for Payer: Cash Price |
$5,832.88
|
| Rate for Payer: Cigna Commercial |
$9,682.57
|
| Rate for Payer: First Health Commercial |
$11,082.46
|
| Rate for Payer: Humana Commercial |
$9,915.89
|
| Rate for Payer: Humana KY Medicaid |
$4,011.85
|
| Rate for Payer: Kentucky WC Medicaid |
$4,052.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,565.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,609.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,499.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,092.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,265.86
|
| Rate for Payer: Ohio Health Group HMO |
$8,749.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,332.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,149.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,049.37
|
| Rate for Payer: PHCS Commercial |
$11,199.12
|
| Rate for Payer: United Healthcare All Payer |
$10,265.86
|
|
|
EXTENDER CUFF ILIAC STR 14*14
|
Facility
|
IP
|
$11,665.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.72 |
| Max. Negotiated Rate |
$11,199.12 |
| Rate for Payer: Aetna Commercial |
$8,982.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,099.28
|
| Rate for Payer: Cash Price |
$5,832.88
|
| Rate for Payer: Cigna Commercial |
$9,682.57
|
| Rate for Payer: First Health Commercial |
$11,082.46
|
| Rate for Payer: Humana Commercial |
$9,915.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,565.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,609.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,499.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,265.86
|
| Rate for Payer: Ohio Health Group HMO |
$8,749.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,332.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,149.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,049.37
|
| Rate for Payer: PHCS Commercial |
$11,199.12
|
| Rate for Payer: United Healthcare All Payer |
$10,265.86
|
|
|
EXTENDER CUFF ILIAC STR 15*15
|
Facility
|
OP
|
$11,665.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.72 |
| Max. Negotiated Rate |
$11,199.12 |
| Rate for Payer: Aetna Commercial |
$8,982.63
|
| Rate for Payer: Anthem Medicaid |
$4,011.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,099.28
|
| Rate for Payer: Cash Price |
$5,832.88
|
| Rate for Payer: Cigna Commercial |
$9,682.57
|
| Rate for Payer: First Health Commercial |
$11,082.46
|
| Rate for Payer: Humana Commercial |
$9,915.89
|
| Rate for Payer: Humana KY Medicaid |
$4,011.85
|
| Rate for Payer: Kentucky WC Medicaid |
$4,052.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,565.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,609.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,499.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,092.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,265.86
|
| Rate for Payer: Ohio Health Group HMO |
$8,749.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,332.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,149.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,049.37
|
| Rate for Payer: PHCS Commercial |
$11,199.12
|
| Rate for Payer: United Healthcare All Payer |
$10,265.86
|
|
|
EXTENDER CUFF ILIAC STR 15*15
|
Facility
|
IP
|
$11,665.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,499.72 |
| Max. Negotiated Rate |
$11,199.12 |
| Rate for Payer: Aetna Commercial |
$8,982.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,099.28
|
| Rate for Payer: Cash Price |
$5,832.88
|
| Rate for Payer: Cigna Commercial |
$9,682.57
|
| Rate for Payer: First Health Commercial |
$11,082.46
|
| Rate for Payer: Humana Commercial |
$9,915.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,565.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,609.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,499.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,265.86
|
| Rate for Payer: Ohio Health Group HMO |
$8,749.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,332.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,149.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,049.37
|
| Rate for Payer: PHCS Commercial |
$11,199.12
|
| Rate for Payer: United Healthcare All Payer |
$10,265.86
|
|
|
EXTENDER CUFF ILIAC STR 16*16
|
Facility
|
OP
|
$12,308.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,692.40 |
| Max. Negotiated Rate |
$11,815.68 |
| Rate for Payer: Aetna Commercial |
$9,477.16
|
| Rate for Payer: Anthem Medicaid |
$4,232.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,600.24
|
| Rate for Payer: Cash Price |
$6,154.00
|
| Rate for Payer: Cigna Commercial |
$10,215.64
|
| Rate for Payer: First Health Commercial |
$11,692.60
|
| Rate for Payer: Humana Commercial |
$10,461.80
|
| Rate for Payer: Humana KY Medicaid |
$4,232.72
|
| Rate for Payer: Kentucky WC Medicaid |
$4,275.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,092.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,083.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,692.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,317.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,831.04
|
| Rate for Payer: Ohio Health Group HMO |
$9,231.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,846.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,707.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,492.52
|
| Rate for Payer: PHCS Commercial |
$11,815.68
|
| Rate for Payer: United Healthcare All Payer |
$10,831.04
|
|
|
EXTENDER CUFF ILIAC STR 16*16
|
Facility
|
IP
|
$12,308.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,692.40 |
| Max. Negotiated Rate |
$11,815.68 |
| Rate for Payer: Aetna Commercial |
$9,477.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,600.24
|
| Rate for Payer: Cash Price |
$6,154.00
|
| Rate for Payer: Cigna Commercial |
$10,215.64
|
| Rate for Payer: First Health Commercial |
$11,692.60
|
| Rate for Payer: Humana Commercial |
$10,461.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,092.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,083.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,692.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,831.04
|
| Rate for Payer: Ohio Health Group HMO |
$9,231.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,846.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,707.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,492.52
|
| Rate for Payer: PHCS Commercial |
$11,815.68
|
| Rate for Payer: United Healthcare All Payer |
$10,831.04
|
|
|
EXTENDER CUFF ILIAC STR 18*18
|
Facility
|
IP
|
$13,592.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,077.75 |
| Max. Negotiated Rate |
$13,048.80 |
| Rate for Payer: Aetna Commercial |
$10,466.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,602.15
|
| Rate for Payer: Cash Price |
$6,796.25
|
| Rate for Payer: Cigna Commercial |
$11,281.77
|
| Rate for Payer: First Health Commercial |
$12,912.88
|
| Rate for Payer: Humana Commercial |
$11,553.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,145.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,031.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,077.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,961.40
|
| Rate for Payer: Ohio Health Group HMO |
$10,194.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,874.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,825.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,378.83
|
| Rate for Payer: PHCS Commercial |
$13,048.80
|
| Rate for Payer: United Healthcare All Payer |
$11,961.40
|
|
|
EXTENDER CUFF ILIAC STR 18*18
|
Facility
|
OP
|
$13,592.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,077.75 |
| Max. Negotiated Rate |
$13,048.80 |
| Rate for Payer: Aetna Commercial |
$10,466.23
|
| Rate for Payer: Anthem Medicaid |
$4,674.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,602.15
|
| Rate for Payer: Cash Price |
$6,796.25
|
| Rate for Payer: Cigna Commercial |
$11,281.77
|
| Rate for Payer: First Health Commercial |
$12,912.88
|
| Rate for Payer: Humana Commercial |
$11,553.62
|
| Rate for Payer: Humana KY Medicaid |
$4,674.46
|
| Rate for Payer: Kentucky WC Medicaid |
$4,722.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,145.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,031.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,077.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,768.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,961.40
|
| Rate for Payer: Ohio Health Group HMO |
$10,194.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,874.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,825.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,378.83
|
| Rate for Payer: PHCS Commercial |
$13,048.80
|
| Rate for Payer: United Healthcare All Payer |
$11,961.40
|
|
|
EXTENDER CUFF ILIAC STR 20*20
|
Facility
|
IP
|
$12,032.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,609.82 |
| Max. Negotiated Rate |
$11,551.44 |
| Rate for Payer: Aetna Commercial |
$9,265.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,385.55
|
| Rate for Payer: Cash Price |
$6,016.38
|
| Rate for Payer: Cigna Commercial |
$9,987.18
|
| Rate for Payer: First Health Commercial |
$11,431.11
|
| Rate for Payer: Humana Commercial |
$10,227.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,866.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,880.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,609.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,588.82
|
| Rate for Payer: Ohio Health Group HMO |
$9,024.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,626.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,468.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,302.60
|
| Rate for Payer: PHCS Commercial |
$11,551.44
|
| Rate for Payer: United Healthcare All Payer |
$10,588.82
|
|
