|
SC EUPHORA RX BALLOON 2.50*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 2.50*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 3.00*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 3.00*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 3.00*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 3.00*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 3.00*20
|
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 3.00*20
|
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 3.00*30
|
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 3.00*30
|
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 3.50*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 3.50*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
|
|
|
SC EUPHORA RX BALLOON 3.50*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 3.50*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 4.00*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 4.00*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 4.00*30
|
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 4.00*30
|
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
|
|
|
SCHOOL PHYSICIAL
|
Facility
|
OP
|
$91.00
|
|
|
Service Code
|
HCPCS 99429
|
| Hospital Charge Code |
51000112
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$27.30 |
| Max. Negotiated Rate |
$87.36 |
| Rate for Payer: Aetna Commercial |
$70.07
|
| Rate for Payer: Anthem Medicaid |
$31.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$70.98
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cigna Commercial |
$75.53
|
| Rate for Payer: First Health Commercial |
$86.45
|
| Rate for Payer: Humana Commercial |
$77.35
|
| Rate for Payer: Humana KY Medicaid |
$31.29
|
| Rate for Payer: Kentucky WC Medicaid |
$31.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$31.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.08
|
| Rate for Payer: Ohio Health Group HMO |
$68.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.79
|
| Rate for Payer: PHCS Commercial |
$87.36
|
| Rate for Payer: United Healthcare All Payer |
$80.08
|
|
|
SCHOOL PHYSICIAL
|
Professional
|
Both
|
$91.00
|
|
|
Service Code
|
HCPCS 99429
|
| Hospital Charge Code |
51000112
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$63.70 |
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$54.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$63.70
|
| Rate for Payer: UHCCP Medicaid |
$31.85
|
|
|
SCHOOL PHYSICIAL
|
Facility
|
IP
|
$91.00
|
|
|
Service Code
|
HCPCS 99429
|
| Hospital Charge Code |
51000112
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$27.30 |
| Max. Negotiated Rate |
$87.36 |
| Rate for Payer: Aetna Commercial |
$70.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$70.98
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cigna Commercial |
$75.53
|
| Rate for Payer: First Health Commercial |
$86.45
|
| Rate for Payer: Humana Commercial |
$77.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.08
|
| Rate for Payer: Ohio Health Group HMO |
$68.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.79
|
| Rate for Payer: PHCS Commercial |
$87.36
|
| Rate for Payer: United Healthcare All Payer |
$80.08
|
|
|
SCHOOL PHYSICIAL(P
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 99429
|
| Hospital Charge Code |
510P0112
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$28.00
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
|
|
SCHOOL PHYSICIAL(T
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
HCPCS 99429
|
| Hospital Charge Code |
510T0112
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$48.96 |
| Rate for Payer: Aetna Commercial |
$39.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.78
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$42.33
|
| Rate for Payer: First Health Commercial |
$48.45
|
| Rate for Payer: Humana Commercial |
$43.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$41.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$37.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.88
|
| Rate for Payer: Ohio Health Group HMO |
$38.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$44.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.19
|
| Rate for Payer: PHCS Commercial |
$48.96
|
| Rate for Payer: United Healthcare All Payer |
$44.88
|
|
|
SCHOOL PHYSICIAL(T
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
HCPCS 99429
|
| Hospital Charge Code |
510T0112
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$48.96 |
| Rate for Payer: Aetna Commercial |
$39.27
|
| Rate for Payer: Anthem Medicaid |
$17.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.78
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$42.33
|
| Rate for Payer: First Health Commercial |
$48.45
|
| Rate for Payer: Humana Commercial |
$43.35
|
| Rate for Payer: Humana KY Medicaid |
$17.54
|
| Rate for Payer: Kentucky WC Medicaid |
$17.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$41.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$37.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$17.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.88
|
| Rate for Payer: Ohio Health Group HMO |
$38.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$44.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.19
|
| Rate for Payer: PHCS Commercial |
$48.96
|
| Rate for Payer: United Healthcare All Payer |
$44.88
|
|
|
SCLEROTHERAPY SPIDER VEINS
|
Facility
|
OP
|
$785.00
|
|
|
Service Code
|
HCPCS 36468
|
| Hospital Charge Code |
76101460
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$269.96 |
| Max. Negotiated Rate |
$753.60 |
| Rate for Payer: Aetna Commercial |
$604.45
|
| Rate for Payer: Anthem Medicaid |
$269.96
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$612.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$392.50
|
| Rate for Payer: Cash Price |
$392.50
|
| Rate for Payer: Cigna Commercial |
$651.55
|
| Rate for Payer: First Health Commercial |
$745.75
|
| Rate for Payer: Humana Commercial |
$667.25
|
| Rate for Payer: Humana KY Medicaid |
$269.96
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$272.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$643.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$579.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$275.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$690.80
|
| Rate for Payer: Ohio Health Group HMO |
$588.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$628.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$682.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$541.65
|
| Rate for Payer: PHCS Commercial |
$753.60
|
| Rate for Payer: United Healthcare All Payer |
$690.80
|
|
