|
SCAN PROC CRANIAL EXTRA
|
Professional
|
Both
|
$3,394.74
|
|
|
Service Code
|
HCPCS 61782
|
| Hospital Charge Code |
76102288
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$163.44 |
| Max. Negotiated Rate |
$2,036.84 |
| Rate for Payer: Aetna Commercial |
$351.31
|
| Rate for Payer: Ambetter Exchange |
$163.44
|
| Rate for Payer: Anthem Medicaid |
$173.57
|
| Rate for Payer: Buckeye Individual/Medicaid |
$163.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$163.44
|
| Rate for Payer: CareSource Just4Me Medicare |
$196.13
|
| Rate for Payer: Cash Price |
$1,697.37
|
| Rate for Payer: Cash Price |
$1,697.37
|
| Rate for Payer: Cigna Commercial |
$350.94
|
| Rate for Payer: Healthspan PPO |
$205.93
|
| Rate for Payer: Humana Medicaid |
$173.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$259.31
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$163.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$177.04
|
| Rate for Payer: Molina Healthcare Passport |
$173.57
|
| Rate for Payer: Multiplan PHCS |
$2,036.84
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$212.47
|
| Rate for Payer: UHCCP Medicaid |
$1,188.16
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$175.31
|
| Rate for Payer: Wellcare Medicare Advantage |
$163.44
|
|
|
SCAN PROC CRANIAL EXTRA(P
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 61782
|
| Hospital Charge Code |
761P2288
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$163.44 |
| Max. Negotiated Rate |
$351.31 |
| Rate for Payer: Aetna Commercial |
$351.31
|
| Rate for Payer: Ambetter Exchange |
$163.44
|
| Rate for Payer: Anthem Medicaid |
$173.57
|
| Rate for Payer: Buckeye Individual/Medicaid |
$163.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$163.44
|
| Rate for Payer: CareSource Just4Me Medicare |
$196.13
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$350.94
|
| Rate for Payer: Healthspan PPO |
$205.93
|
| Rate for Payer: Humana Medicaid |
$173.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$259.31
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$163.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$177.04
|
| Rate for Payer: Molina Healthcare Passport |
$173.57
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$212.47
|
| Rate for Payer: UHCCP Medicaid |
$175.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$175.31
|
| Rate for Payer: Wellcare Medicare Advantage |
$163.44
|
|
|
SCAN PROC CRANIAL EXTRA(T
|
Facility
|
OP
|
$2,894.74
|
|
|
Service Code
|
HCPCS 61782
|
| Hospital Charge Code |
761T2288
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$868.42 |
| Max. Negotiated Rate |
$2,778.95 |
| Rate for Payer: Aetna Commercial |
$2,228.95
|
| Rate for Payer: Anthem Medicaid |
$995.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,257.90
|
| Rate for Payer: Cash Price |
$1,447.37
|
| Rate for Payer: Cigna Commercial |
$2,402.63
|
| Rate for Payer: First Health Commercial |
$2,750.00
|
| Rate for Payer: Humana Commercial |
$2,460.53
|
| Rate for Payer: Humana KY Medicaid |
$995.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,005.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,373.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,136.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$868.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,015.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,547.37
|
| Rate for Payer: Ohio Health Group HMO |
$2,171.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,315.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,518.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,997.37
|
| Rate for Payer: PHCS Commercial |
$2,778.95
|
| Rate for Payer: United Healthcare All Payer |
$2,547.37
|
|
|
SCAN PROC CRANIAL EXTRA(T
|
Facility
|
IP
|
$2,894.74
|
|
|
Service Code
|
HCPCS 61782
|
| Hospital Charge Code |
761T2288
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$868.42 |
| Max. Negotiated Rate |
$2,778.95 |
| Rate for Payer: Aetna Commercial |
$2,228.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,257.90
|
| Rate for Payer: Cash Price |
$1,447.37
|
| Rate for Payer: Cigna Commercial |
$2,402.63
|
| Rate for Payer: First Health Commercial |
$2,750.00
|
| Rate for Payer: Humana Commercial |
$2,460.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,373.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,136.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$868.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,547.37
|
| Rate for Payer: Ohio Health Group HMO |
$2,171.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,315.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,518.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,997.37
|
| Rate for Payer: PHCS Commercial |
$2,778.95
|
| Rate for Payer: United Healthcare All Payer |
$2,547.37
|
|
|
SCARGUARD
|
Facility
|
IP
|
$50.00
|
|
| Hospital Charge Code |
22200020
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna Commercial |
$38.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$41.50
|
| Rate for Payer: First Health Commercial |
$47.50
|
| Rate for Payer: Humana Commercial |
$42.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$41.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$36.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.00
|
| Rate for Payer: Ohio Health Group HMO |
$37.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$43.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.50
|
| Rate for Payer: PHCS Commercial |
$48.00
|
| Rate for Payer: United Healthcare All Payer |
$44.00
|
|
|
SCARGUARD
|
Professional
|
Both
|
$50.00
|
|
| Hospital Charge Code |
22200020
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Multiplan PHCS |
$30.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$35.00
|
| Rate for Payer: UHCCP Medicaid |
$17.50
|
|
|
SCARGUARD
|
Facility
|
OP
|
$50.00
|
|
| Hospital Charge Code |
22200020
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna Commercial |
$38.50
|
| Rate for Payer: Anthem Medicaid |
$17.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$41.50
|
| Rate for Payer: First Health Commercial |
$47.50
|
| Rate for Payer: Humana Commercial |
$42.50
|
| Rate for Payer: Humana KY Medicaid |
$17.20
|
| Rate for Payer: Kentucky WC Medicaid |
$17.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$41.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$36.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$17.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.00
|
| Rate for Payer: Ohio Health Group HMO |
$37.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$43.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.50
|
| Rate for Payer: PHCS Commercial |
$48.00
|
| Rate for Payer: United Healthcare All Payer |
$44.00
|
|
|
SC EUPHORA RX BALLOON 1.50*10
|
Facility
|
OP
|
$1,523.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$456.90 |
| Max. Negotiated Rate |
$1,462.08 |
| Rate for Payer: Aetna Commercial |
$1,172.71
|
| Rate for Payer: Anthem Medicaid |
$523.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,187.94
|
| Rate for Payer: Cash Price |
$761.50
|
| Rate for Payer: Cigna Commercial |
$1,264.09
|
| Rate for Payer: First Health Commercial |
$1,446.85
|
| Rate for Payer: Humana Commercial |
$1,294.55
|
| Rate for Payer: Humana KY Medicaid |
$523.76
|
| Rate for Payer: Kentucky WC Medicaid |
$529.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,248.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,123.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$456.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$534.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,340.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,142.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,218.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,325.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,050.87
|
| Rate for Payer: PHCS Commercial |
$1,462.08
|
| Rate for Payer: United Healthcare All Payer |
$1,340.24
|
|
|
SC EUPHORA RX BALLOON 1.50*10
|
Facility
|
IP
|
$1,523.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$456.90 |
| Max. Negotiated Rate |
$1,462.08 |
| Rate for Payer: Aetna Commercial |
$1,172.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,187.94
|
| Rate for Payer: Cash Price |
$761.50
|
| Rate for Payer: Cigna Commercial |
$1,264.09
|
| Rate for Payer: First Health Commercial |
$1,446.85
|
| Rate for Payer: Humana Commercial |
$1,294.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,248.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,123.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$456.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,340.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,142.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,218.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,325.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,050.87
|
| Rate for Payer: PHCS Commercial |
$1,462.08
|
| Rate for Payer: United Healthcare All Payer |
$1,340.24
|
|
|
SC EUPHORA RX BALLOON 2.00*10
|
Facility
|
OP
|
$1,175.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$352.50 |
| Max. Negotiated Rate |
$1,128.00 |
| Rate for Payer: Aetna Commercial |
$904.75
|
| Rate for Payer: Anthem Medicaid |
$404.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$916.50
|
| Rate for Payer: Cash Price |
$587.50
|
| Rate for Payer: Cigna Commercial |
$975.25
|
| Rate for Payer: First Health Commercial |
$1,116.25
|
| Rate for Payer: Humana Commercial |
$998.75
|
| Rate for Payer: Humana KY Medicaid |
$404.08
|
| Rate for Payer: Kentucky WC Medicaid |
$408.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$963.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$867.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$352.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$412.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,034.00
|
| Rate for Payer: Ohio Health Group HMO |
$881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$940.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,022.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$810.75
|
| Rate for Payer: PHCS Commercial |
$1,128.00
|
| Rate for Payer: United Healthcare All Payer |
$1,034.00
|
|
|
SC EUPHORA RX BALLOON 2.00*10
|
Facility
|
IP
|
$1,175.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$352.50 |
| Max. Negotiated Rate |
$1,128.00 |
| Rate for Payer: Aetna Commercial |
$904.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$916.50
|
| Rate for Payer: Cash Price |
$587.50
|
| Rate for Payer: Cigna Commercial |
$975.25
|
| Rate for Payer: First Health Commercial |
$1,116.25
|
| Rate for Payer: Humana Commercial |
$998.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$963.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$867.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$352.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,034.00
|
| Rate for Payer: Ohio Health Group HMO |
$881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$940.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,022.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$810.75
|
| Rate for Payer: PHCS Commercial |
$1,128.00
|
| Rate for Payer: United Healthcare All Payer |
$1,034.00
|
|
|
SC EUPHORA RX BALLOON 2.00*12
|
Facility
|
OP
|
$1,175.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$352.50 |
| Max. Negotiated Rate |
$1,128.00 |
| Rate for Payer: Aetna Commercial |
$904.75
|
| Rate for Payer: Anthem Medicaid |
$404.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$916.50
|
| Rate for Payer: Cash Price |
$587.50
|
| Rate for Payer: Cigna Commercial |
$975.25
|
| Rate for Payer: First Health Commercial |
$1,116.25
|
| Rate for Payer: Humana Commercial |
$998.75
|
| Rate for Payer: Humana KY Medicaid |
$404.08
|
| Rate for Payer: Kentucky WC Medicaid |
$408.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$963.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$867.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$352.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$412.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,034.00
|
| Rate for Payer: Ohio Health Group HMO |
$881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$940.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,022.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$810.75
|
| Rate for Payer: PHCS Commercial |
$1,128.00
|
| Rate for Payer: United Healthcare All Payer |
$1,034.00
|
|
|
SC EUPHORA RX BALLOON 2.00*12
|
Facility
|
IP
|
$1,175.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$352.50 |
| Max. Negotiated Rate |
$1,128.00 |
| Rate for Payer: Aetna Commercial |
$904.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$916.50
|
| Rate for Payer: Cash Price |
$587.50
|
| Rate for Payer: Cigna Commercial |
$975.25
|
| Rate for Payer: First Health Commercial |
$1,116.25
|
| Rate for Payer: Humana Commercial |
$998.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$963.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$867.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$352.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,034.00
|
| Rate for Payer: Ohio Health Group HMO |
$881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$940.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,022.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$810.75
|
| Rate for Payer: PHCS Commercial |
$1,128.00
|
| Rate for Payer: United Healthcare All Payer |
$1,034.00
|
|
|
SC EUPHORA RX BALLOON 2.00*15
|
Facility
|
OP
|
$1,523.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$456.90 |
| Max. Negotiated Rate |
$1,462.08 |
| Rate for Payer: Aetna Commercial |
$1,172.71
|
| Rate for Payer: Anthem Medicaid |
$523.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,187.94
|
| Rate for Payer: Cash Price |
$761.50
|
| Rate for Payer: Cigna Commercial |
$1,264.09
|
| Rate for Payer: First Health Commercial |
$1,446.85
|
| Rate for Payer: Humana Commercial |
$1,294.55
|
| Rate for Payer: Humana KY Medicaid |
$523.76
|
| Rate for Payer: Kentucky WC Medicaid |
$529.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,248.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,123.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$456.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$534.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,340.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,142.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,218.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,325.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,050.87
|
| Rate for Payer: PHCS Commercial |
$1,462.08
|
| Rate for Payer: United Healthcare All Payer |
$1,340.24
|
|
|
SC EUPHORA RX BALLOON 2.00*15
|
Facility
|
IP
|
$1,523.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$456.90 |
| Max. Negotiated Rate |
$1,462.08 |
| Rate for Payer: Aetna Commercial |
$1,172.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,187.94
|
| Rate for Payer: Cash Price |
$761.50
|
| Rate for Payer: Cigna Commercial |
$1,264.09
|
| Rate for Payer: First Health Commercial |
$1,446.85
|
| Rate for Payer: Humana Commercial |
$1,294.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,248.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,123.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$456.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,340.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,142.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,218.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,325.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,050.87
|
| Rate for Payer: PHCS Commercial |
$1,462.08
|
| Rate for Payer: United Healthcare All Payer |
$1,340.24
|
|
|
SC EUPHORA RX BALLOON 2.00*20
|
Facility
|
IP
|
$1,523.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$456.90 |
| Max. Negotiated Rate |
$1,462.08 |
| Rate for Payer: Aetna Commercial |
$1,172.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,187.94
|
| Rate for Payer: Cash Price |
$761.50
|
| Rate for Payer: Cigna Commercial |
$1,264.09
|
| Rate for Payer: First Health Commercial |
$1,446.85
|
| Rate for Payer: Humana Commercial |
$1,294.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,248.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,123.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$456.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,340.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,142.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,218.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,325.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,050.87
|
| Rate for Payer: PHCS Commercial |
$1,462.08
|
| Rate for Payer: United Healthcare All Payer |
$1,340.24
|
|
|
SC EUPHORA RX BALLOON 2.00*20
|
Facility
|
OP
|
$1,523.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$456.90 |
| Max. Negotiated Rate |
$1,462.08 |
| Rate for Payer: Aetna Commercial |
$1,172.71
|
| Rate for Payer: Anthem Medicaid |
$523.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,187.94
|
| Rate for Payer: Cash Price |
$761.50
|
| Rate for Payer: Cigna Commercial |
$1,264.09
|
| Rate for Payer: First Health Commercial |
$1,446.85
|
| Rate for Payer: Humana Commercial |
$1,294.55
|
| Rate for Payer: Humana KY Medicaid |
$523.76
|
| Rate for Payer: Kentucky WC Medicaid |
$529.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,248.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,123.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$456.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$534.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,340.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,142.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,218.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,325.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,050.87
|
| Rate for Payer: PHCS Commercial |
$1,462.08
|
| Rate for Payer: United Healthcare All Payer |
$1,340.24
|
|
|
SC EUPHORA RX BALLOON 2.00*30
|
Facility
|
OP
|
$1,175.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$352.50 |
| Max. Negotiated Rate |
$1,128.00 |
| Rate for Payer: Aetna Commercial |
$904.75
|
| Rate for Payer: Anthem Medicaid |
$404.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$916.50
|
| Rate for Payer: Cash Price |
$587.50
|
| Rate for Payer: Cigna Commercial |
$975.25
|
| Rate for Payer: First Health Commercial |
$1,116.25
|
| Rate for Payer: Humana Commercial |
$998.75
|
| Rate for Payer: Humana KY Medicaid |
$404.08
|
| Rate for Payer: Kentucky WC Medicaid |
$408.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$963.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$867.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$352.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$412.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,034.00
|
| Rate for Payer: Ohio Health Group HMO |
$881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$940.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,022.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$810.75
|
| Rate for Payer: PHCS Commercial |
$1,128.00
|
| Rate for Payer: United Healthcare All Payer |
$1,034.00
|
|
|
SC EUPHORA RX BALLOON 2.00*30
|
Facility
|
IP
|
$1,175.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$352.50 |
| Max. Negotiated Rate |
$1,128.00 |
| Rate for Payer: Aetna Commercial |
$904.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$916.50
|
| Rate for Payer: Cash Price |
$587.50
|
| Rate for Payer: Cigna Commercial |
$975.25
|
| Rate for Payer: First Health Commercial |
$1,116.25
|
| Rate for Payer: Humana Commercial |
$998.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$963.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$867.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$352.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,034.00
|
| Rate for Payer: Ohio Health Group HMO |
$881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$940.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,022.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$810.75
|
| Rate for Payer: PHCS Commercial |
$1,128.00
|
| Rate for Payer: United Healthcare All Payer |
$1,034.00
|
|
|
SC EUPHORA RX BALLOON 2.25*12
|
Facility
|
OP
|
$1,523.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$456.90 |
| Max. Negotiated Rate |
$1,462.08 |
| Rate for Payer: Aetna Commercial |
$1,172.71
|
| Rate for Payer: Anthem Medicaid |
$523.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,187.94
|
| Rate for Payer: Cash Price |
$761.50
|
| Rate for Payer: Cigna Commercial |
$1,264.09
|
| Rate for Payer: First Health Commercial |
$1,446.85
|
| Rate for Payer: Humana Commercial |
$1,294.55
|
| Rate for Payer: Humana KY Medicaid |
$523.76
|
| Rate for Payer: Kentucky WC Medicaid |
$529.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,248.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,123.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$456.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$534.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,340.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,142.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,218.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,325.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,050.87
|
| Rate for Payer: PHCS Commercial |
$1,462.08
|
| Rate for Payer: United Healthcare All Payer |
$1,340.24
|
|
|
SC EUPHORA RX BALLOON 2.25*12
|
Facility
|
IP
|
$1,523.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$456.90 |
| Max. Negotiated Rate |
$1,462.08 |
| Rate for Payer: Aetna Commercial |
$1,172.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,187.94
|
| Rate for Payer: Cash Price |
$761.50
|
| Rate for Payer: Cigna Commercial |
$1,264.09
|
| Rate for Payer: First Health Commercial |
$1,446.85
|
| Rate for Payer: Humana Commercial |
$1,294.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,248.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,123.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$456.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,340.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,142.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,218.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,325.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,050.87
|
| Rate for Payer: PHCS Commercial |
$1,462.08
|
| Rate for Payer: United Healthcare All Payer |
$1,340.24
|
|
|
SC EUPHORA RX BALLOON 2.50*12
|
Facility
|
OP
|
$1,523.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$456.90 |
| Max. Negotiated Rate |
$1,462.08 |
| Rate for Payer: Aetna Commercial |
$1,172.71
|
| Rate for Payer: Anthem Medicaid |
$523.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,187.94
|
| Rate for Payer: Cash Price |
$761.50
|
| Rate for Payer: Cigna Commercial |
$1,264.09
|
| Rate for Payer: First Health Commercial |
$1,446.85
|
| Rate for Payer: Humana Commercial |
$1,294.55
|
| Rate for Payer: Humana KY Medicaid |
$523.76
|
| Rate for Payer: Kentucky WC Medicaid |
$529.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,248.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,123.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$456.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$534.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,340.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,142.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,218.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,325.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,050.87
|
| Rate for Payer: PHCS Commercial |
$1,462.08
|
| Rate for Payer: United Healthcare All Payer |
$1,340.24
|
|
|
SC EUPHORA RX BALLOON 2.50*12
|
Facility
|
IP
|
$1,523.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$456.90 |
| Max. Negotiated Rate |
$1,462.08 |
| Rate for Payer: Aetna Commercial |
$1,172.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,187.94
|
| Rate for Payer: Cash Price |
$761.50
|
| Rate for Payer: Cigna Commercial |
$1,264.09
|
| Rate for Payer: First Health Commercial |
$1,446.85
|
| Rate for Payer: Humana Commercial |
$1,294.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,248.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,123.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$456.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,340.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,142.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,218.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,325.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,050.87
|
| Rate for Payer: PHCS Commercial |
$1,462.08
|
| Rate for Payer: United Healthcare All Payer |
$1,340.24
|
|
|
SC EUPHORA RX BALLOON 2.50*15
|
Facility
|
IP
|
$1,523.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$456.90 |
| Max. Negotiated Rate |
$1,462.08 |
| Rate for Payer: Aetna Commercial |
$1,172.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,187.94
|
| Rate for Payer: Cash Price |
$761.50
|
| Rate for Payer: Cigna Commercial |
$1,264.09
|
| Rate for Payer: First Health Commercial |
$1,446.85
|
| Rate for Payer: Humana Commercial |
$1,294.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,248.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,123.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$456.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,340.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,142.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,218.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,325.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,050.87
|
| Rate for Payer: PHCS Commercial |
$1,462.08
|
| Rate for Payer: United Healthcare All Payer |
$1,340.24
|
|
|
SC EUPHORA RX BALLOON 2.50*15
|
Facility
|
OP
|
$1,523.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$456.90 |
| Max. Negotiated Rate |
$1,462.08 |
| Rate for Payer: Aetna Commercial |
$1,172.71
|
| Rate for Payer: Anthem Medicaid |
$523.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,187.94
|
| Rate for Payer: Cash Price |
$761.50
|
| Rate for Payer: Cigna Commercial |
$1,264.09
|
| Rate for Payer: First Health Commercial |
$1,446.85
|
| Rate for Payer: Humana Commercial |
$1,294.55
|
| Rate for Payer: Humana KY Medicaid |
$523.76
|
| Rate for Payer: Kentucky WC Medicaid |
$529.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,248.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,123.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$456.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$534.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,340.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,142.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,218.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,325.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,050.87
|
| Rate for Payer: PHCS Commercial |
$1,462.08
|
| Rate for Payer: United Healthcare All Payer |
$1,340.24
|
|
