|
BALLOON RETRIEVAL 15MM RAP EX
|
Facility
|
OP
|
$1,866.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$559.86 |
| Max. Negotiated Rate |
$1,791.55 |
| Rate for Payer: Aetna Commercial |
$1,436.97
|
| Rate for Payer: Anthem Medicaid |
$641.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,455.64
|
| Rate for Payer: Cash Price |
$933.10
|
| Rate for Payer: Cigna Commercial |
$1,548.95
|
| Rate for Payer: First Health Commercial |
$1,772.89
|
| Rate for Payer: Humana Commercial |
$1,586.27
|
| Rate for Payer: Humana KY Medicaid |
$641.79
|
| Rate for Payer: Kentucky WC Medicaid |
$648.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,530.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,377.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$559.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$654.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,642.26
|
| Rate for Payer: Ohio Health Group HMO |
$1,399.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,492.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,623.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,287.68
|
| Rate for Payer: PHCS Commercial |
$1,791.55
|
| Rate for Payer: United Healthcare All Payer |
$1,642.26
|
|
|
BALLOON RETRIEVAL 15MM RAP EX
|
Facility
|
IP
|
$1,866.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$559.86 |
| Max. Negotiated Rate |
$1,791.55 |
| Rate for Payer: Aetna Commercial |
$1,436.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,455.64
|
| Rate for Payer: Cash Price |
$933.10
|
| Rate for Payer: Cigna Commercial |
$1,548.95
|
| Rate for Payer: First Health Commercial |
$1,772.89
|
| Rate for Payer: Humana Commercial |
$1,586.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,530.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,377.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$559.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,642.26
|
| Rate for Payer: Ohio Health Group HMO |
$1,399.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,492.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,623.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,287.68
|
| Rate for Payer: PHCS Commercial |
$1,791.55
|
| Rate for Payer: United Healthcare All Payer |
$1,642.26
|
|
|
BALLOON SPACEMAKER PLUS OVAL
|
Facility
|
IP
|
$5,460.24
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,638.07 |
| Max. Negotiated Rate |
$5,241.83 |
| Rate for Payer: Aetna Commercial |
$4,204.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,258.99
|
| Rate for Payer: Cash Price |
$2,730.12
|
| Rate for Payer: Cigna Commercial |
$4,532.00
|
| Rate for Payer: First Health Commercial |
$5,187.23
|
| Rate for Payer: Humana Commercial |
$4,641.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,477.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,029.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,638.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,805.01
|
| Rate for Payer: Ohio Health Group HMO |
$4,095.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,368.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,750.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,767.57
|
| Rate for Payer: PHCS Commercial |
$5,241.83
|
| Rate for Payer: United Healthcare All Payer |
$4,805.01
|
|
|
BALLOON SPACEMAKER PLUS OVAL
|
Facility
|
OP
|
$5,460.24
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,638.07 |
| Max. Negotiated Rate |
$5,241.83 |
| Rate for Payer: Aetna Commercial |
$4,204.38
|
| Rate for Payer: Anthem Medicaid |
$1,877.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,258.99
|
| Rate for Payer: Cash Price |
$2,730.12
|
| Rate for Payer: Cigna Commercial |
$4,532.00
|
| Rate for Payer: First Health Commercial |
$5,187.23
|
| Rate for Payer: Humana Commercial |
$4,641.20
|
| Rate for Payer: Humana KY Medicaid |
$1,877.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1,896.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,477.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,029.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,638.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,915.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,805.01
|
| Rate for Payer: Ohio Health Group HMO |
$4,095.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,368.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,750.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,767.57
|
| Rate for Payer: PHCS Commercial |
$5,241.83
|
| Rate for Payer: United Healthcare All Payer |
$4,805.01
|
|
|
BALLOON SURG DISSECT OMS-PDBS2
|
Facility
|
IP
|
$2,142.69
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$642.81 |
| Max. Negotiated Rate |
$2,056.98 |
| Rate for Payer: Aetna Commercial |
$1,649.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,671.30
|
| Rate for Payer: Cash Price |
$1,071.34
|
| Rate for Payer: Cigna Commercial |
$1,778.43
|
| Rate for Payer: First Health Commercial |
$2,035.56
|
| Rate for Payer: Humana Commercial |
$1,821.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,757.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,581.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$642.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,885.57
|
| Rate for Payer: Ohio Health Group HMO |
$1,607.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,714.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,864.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,478.46
|
| Rate for Payer: PHCS Commercial |
$2,056.98
|
| Rate for Payer: United Healthcare All Payer |
$1,885.57
|
|
|
BALLOON SURG DISSECT OMS-PDBS2
|
Facility
|
OP
|
$2,142.69
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$642.81 |
| Max. Negotiated Rate |
$2,056.98 |
| Rate for Payer: Aetna Commercial |
$1,649.87
|
| Rate for Payer: Anthem Medicaid |
$736.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,671.30
|
| Rate for Payer: Cash Price |
$1,071.34
|
| Rate for Payer: Cigna Commercial |
$1,778.43
|
| Rate for Payer: First Health Commercial |
$2,035.56
|
| Rate for Payer: Humana Commercial |
$1,821.29
|
| Rate for Payer: Humana KY Medicaid |
$736.87
|
| Rate for Payer: Kentucky WC Medicaid |
$744.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,757.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,581.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$642.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$751.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,885.57
|
| Rate for Payer: Ohio Health Group HMO |
$1,607.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,714.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,864.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,478.46
|
| Rate for Payer: PHCS Commercial |
$2,056.98
|
| Rate for Payer: United Healthcare All Payer |
$1,885.57
|
|
|
BALLOON WEDGE CATH 5F 110C
|
Facility
|
IP
|
$1,930.80
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$579.24 |
| Max. Negotiated Rate |
$1,853.57 |
| Rate for Payer: Aetna Commercial |
$1,486.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,506.02
|
| Rate for Payer: Cash Price |
$965.40
|
| Rate for Payer: Cigna Commercial |
$1,602.56
|
| Rate for Payer: First Health Commercial |
$1,834.26
|
| Rate for Payer: Humana Commercial |
$1,641.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,583.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,424.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$579.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,699.10
|
| Rate for Payer: Ohio Health Group HMO |
$1,448.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,544.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,679.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,332.25
|
| Rate for Payer: PHCS Commercial |
$1,853.57
|
| Rate for Payer: United Healthcare All Payer |
$1,699.10
|
|
|
BALLOON WEDGE CATH 5F 110C
|
Facility
|
OP
|
$1,930.80
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$579.24 |
| Max. Negotiated Rate |
$1,853.57 |
| Rate for Payer: Aetna Commercial |
$1,486.72
|
| Rate for Payer: Anthem Medicaid |
$664.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,506.02
|
| Rate for Payer: Cash Price |
$965.40
|
| Rate for Payer: Cigna Commercial |
$1,602.56
|
| Rate for Payer: First Health Commercial |
$1,834.26
|
| Rate for Payer: Humana Commercial |
$1,641.18
|
| Rate for Payer: Humana KY Medicaid |
$664.00
|
| Rate for Payer: Kentucky WC Medicaid |
$670.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,583.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,424.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$579.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$677.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,699.10
|
| Rate for Payer: Ohio Health Group HMO |
$1,448.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,544.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,679.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,332.25
|
| Rate for Payer: PHCS Commercial |
$1,853.57
|
| Rate for Payer: United Healthcare All Payer |
$1,699.10
|
|
|
BALO ANGIOP CTR DIALYSIS SEG
|
Professional
|
Both
|
$425.00
|
|
|
Service Code
|
HCPCS 36907
|
| Hospital Charge Code |
76101520
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$107.04 |
| Max. Negotiated Rate |
$554.31 |
| Rate for Payer: Ambetter Exchange |
$137.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$107.04
|
| Rate for Payer: Anthem Medicaid |
$543.44
|
| Rate for Payer: Buckeye Individual/Medicaid |
$137.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$137.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$164.69
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cigna Commercial |
$208.79
|
| Rate for Payer: Humana Medicaid |
$543.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$162.03
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$137.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$554.31
|
| Rate for Payer: Molina Healthcare Passport |
$543.44
|
| Rate for Payer: Multiplan PHCS |
$255.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$178.41
|
| Rate for Payer: UHCCP Medicaid |
$112.39
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$548.87
|
| Rate for Payer: Wellcare Medicare Advantage |
$137.24
|
|
|
BALO ANGIOP CTR DIALYSIS SEG
|
Facility
|
IP
|
$7,367.00
|
|
|
Service Code
|
HCPCS 36907
|
| Hospital Charge Code |
48100034
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,210.10 |
| Max. Negotiated Rate |
$7,072.32 |
| Rate for Payer: Aetna Commercial |
$5,672.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,746.26
|
| Rate for Payer: Cash Price |
$3,683.50
|
| Rate for Payer: Cigna Commercial |
$6,114.61
|
| Rate for Payer: First Health Commercial |
$6,998.65
|
| Rate for Payer: Humana Commercial |
$6,261.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,040.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,436.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,210.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,482.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,525.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,893.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,409.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,083.23
|
| Rate for Payer: PHCS Commercial |
$7,072.32
|
| Rate for Payer: United Healthcare All Payer |
$6,482.96
|
|
|
BALO ANGIOP CTR DIALYSIS SEG
|
Facility
|
IP
|
$425.00
|
|
|
Service Code
|
HCPCS 36907
|
| Hospital Charge Code |
76101520
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$127.50 |
| Max. Negotiated Rate |
$408.00 |
| Rate for Payer: Aetna Commercial |
$327.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$331.50
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cigna Commercial |
$352.75
|
| Rate for Payer: First Health Commercial |
$403.75
|
| Rate for Payer: Humana Commercial |
$361.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$348.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$313.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$127.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$374.00
|
| Rate for Payer: Ohio Health Group HMO |
$318.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$369.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.25
|
| Rate for Payer: PHCS Commercial |
$408.00
|
| Rate for Payer: United Healthcare All Payer |
$374.00
|
|
|
BALO ANGIOP CTR DIALYSIS SEG
|
Facility
|
OP
|
$7,367.00
|
|
|
Service Code
|
HCPCS 36907
|
| Hospital Charge Code |
48100034
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,210.10 |
| Max. Negotiated Rate |
$7,072.32 |
| Rate for Payer: Aetna Commercial |
$5,672.59
|
| Rate for Payer: Anthem Medicaid |
$2,533.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,746.26
|
| Rate for Payer: Cash Price |
$3,683.50
|
| Rate for Payer: Cigna Commercial |
$6,114.61
|
| Rate for Payer: First Health Commercial |
$6,998.65
|
| Rate for Payer: Humana Commercial |
$6,261.95
|
| Rate for Payer: Humana KY Medicaid |
$2,533.51
|
| Rate for Payer: Kentucky WC Medicaid |
$2,559.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,040.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,436.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,210.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,584.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,482.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,525.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,893.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,409.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,083.23
|
| Rate for Payer: PHCS Commercial |
$7,072.32
|
| Rate for Payer: United Healthcare All Payer |
$6,482.96
|
|
|
BALO ANGIOP CTR DIALYSIS SEG
|
Facility
|
OP
|
$425.00
|
|
|
Service Code
|
HCPCS 36907
|
| Hospital Charge Code |
76101520
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$127.50 |
| Max. Negotiated Rate |
$408.00 |
| Rate for Payer: Aetna Commercial |
$327.25
|
| Rate for Payer: Anthem Medicaid |
$146.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$331.50
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cigna Commercial |
$352.75
|
| Rate for Payer: First Health Commercial |
$403.75
|
| Rate for Payer: Humana Commercial |
$361.25
|
| Rate for Payer: Humana KY Medicaid |
$146.16
|
| Rate for Payer: Kentucky WC Medicaid |
$147.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$348.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$313.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$127.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$149.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$374.00
|
| Rate for Payer: Ohio Health Group HMO |
$318.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$369.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.25
|
| Rate for Payer: PHCS Commercial |
$408.00
|
| Rate for Payer: United Healthcare All Payer |
$374.00
|
|
|
BALO ANGIOP CTR DIALYSIS SE(P
|
Professional
|
Both
|
$425.00
|
|
|
Service Code
|
HCPCS 36907
|
| Hospital Charge Code |
761P1520
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$107.04 |
| Max. Negotiated Rate |
$554.31 |
| Rate for Payer: Ambetter Exchange |
$137.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$107.04
|
| Rate for Payer: Anthem Medicaid |
$543.44
|
| Rate for Payer: Buckeye Individual/Medicaid |
$137.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$137.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$164.69
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cigna Commercial |
$208.79
|
| Rate for Payer: Humana Medicaid |
$543.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$162.03
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$137.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$554.31
|
| Rate for Payer: Molina Healthcare Passport |
$543.44
|
| Rate for Payer: Multiplan PHCS |
$255.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$178.41
|
| Rate for Payer: UHCCP Medicaid |
$112.39
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$548.87
|
| Rate for Payer: Wellcare Medicare Advantage |
$137.24
|
|
|
BALOON ATTAIN VENOGRMCATH 6215
|
Facility
|
IP
|
$1,549.60
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$464.88 |
| Max. Negotiated Rate |
$1,487.62 |
| Rate for Payer: Aetna Commercial |
$1,193.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,208.69
|
| Rate for Payer: Cash Price |
$774.80
|
| Rate for Payer: Cigna Commercial |
$1,286.17
|
| Rate for Payer: First Health Commercial |
$1,472.12
|
| Rate for Payer: Humana Commercial |
$1,317.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,270.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,143.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$464.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,363.65
|
| Rate for Payer: Ohio Health Group HMO |
$1,162.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,239.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,348.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,069.22
|
| Rate for Payer: PHCS Commercial |
$1,487.62
|
| Rate for Payer: United Healthcare All Payer |
$1,363.65
|
|
|
BALOON ATTAIN VENOGRMCATH 6215
|
Facility
|
OP
|
$1,549.60
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$464.88 |
| Max. Negotiated Rate |
$1,487.62 |
| Rate for Payer: Aetna Commercial |
$1,193.19
|
| Rate for Payer: Anthem Medicaid |
$532.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,208.69
|
| Rate for Payer: Cash Price |
$774.80
|
| Rate for Payer: Cigna Commercial |
$1,286.17
|
| Rate for Payer: First Health Commercial |
$1,472.12
|
| Rate for Payer: Humana Commercial |
$1,317.16
|
| Rate for Payer: Humana KY Medicaid |
$532.91
|
| Rate for Payer: Kentucky WC Medicaid |
$538.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,270.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,143.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$464.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$543.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,363.65
|
| Rate for Payer: Ohio Health Group HMO |
$1,162.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,239.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,348.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,069.22
|
| Rate for Payer: PHCS Commercial |
$1,487.62
|
| Rate for Payer: United Healthcare All Payer |
$1,363.65
|
|
|
BALOON CREPUL 12-13.5-15MM*5.5
|
Facility
|
IP
|
$3,275.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$982.50 |
| Max. Negotiated Rate |
$3,144.00 |
| Rate for Payer: Aetna Commercial |
$2,521.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,554.50
|
| Rate for Payer: Cash Price |
$1,637.50
|
| Rate for Payer: Cigna Commercial |
$2,718.25
|
| Rate for Payer: First Health Commercial |
$3,111.25
|
| Rate for Payer: Humana Commercial |
$2,783.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,685.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,416.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$982.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,882.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,456.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,620.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,849.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,259.75
|
| Rate for Payer: PHCS Commercial |
$3,144.00
|
| Rate for Payer: United Healthcare All Payer |
$2,882.00
|
|
|
BALOON CREPUL 12-13.5-15MM*5.5
|
Facility
|
OP
|
$3,275.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$982.50 |
| Max. Negotiated Rate |
$3,144.00 |
| Rate for Payer: Aetna Commercial |
$2,521.75
|
| Rate for Payer: Anthem Medicaid |
$1,126.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,554.50
|
| Rate for Payer: Cash Price |
$1,637.50
|
| Rate for Payer: Cigna Commercial |
$2,718.25
|
| Rate for Payer: First Health Commercial |
$3,111.25
|
| Rate for Payer: Humana Commercial |
$2,783.75
|
| Rate for Payer: Humana KY Medicaid |
$1,126.27
|
| Rate for Payer: Kentucky WC Medicaid |
$1,137.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,685.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,416.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$982.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,148.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,882.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,456.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,620.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,849.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,259.75
|
| Rate for Payer: PHCS Commercial |
$3,144.00
|
| Rate for Payer: United Healthcare All Payer |
$2,882.00
|
|
|
BALOON CREPUL 15-16.5-18MM*5.5
|
Facility
|
OP
|
$3,275.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$982.50 |
| Max. Negotiated Rate |
$3,144.00 |
| Rate for Payer: Aetna Commercial |
$2,521.75
|
| Rate for Payer: Anthem Medicaid |
$1,126.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,554.50
|
| Rate for Payer: Cash Price |
$1,637.50
|
| Rate for Payer: Cigna Commercial |
$2,718.25
|
| Rate for Payer: First Health Commercial |
$3,111.25
|
| Rate for Payer: Humana Commercial |
$2,783.75
|
| Rate for Payer: Humana KY Medicaid |
$1,126.27
|
| Rate for Payer: Kentucky WC Medicaid |
$1,137.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,685.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,416.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$982.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,148.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,882.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,456.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,620.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,849.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,259.75
|
| Rate for Payer: PHCS Commercial |
$3,144.00
|
| Rate for Payer: United Healthcare All Payer |
$2,882.00
|
|
|
BALOON CREPUL 15-16.5-18MM*5.5
|
Facility
|
IP
|
$3,275.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$982.50 |
| Max. Negotiated Rate |
$3,144.00 |
| Rate for Payer: Aetna Commercial |
$2,521.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,554.50
|
| Rate for Payer: Cash Price |
$1,637.50
|
| Rate for Payer: Cigna Commercial |
$2,718.25
|
| Rate for Payer: First Health Commercial |
$3,111.25
|
| Rate for Payer: Humana Commercial |
$2,783.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,685.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,416.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$982.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,882.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,456.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,620.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,849.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,259.75
|
| Rate for Payer: PHCS Commercial |
$3,144.00
|
| Rate for Payer: United Healthcare All Payer |
$2,882.00
|
|
|
BALOON EXTRACTION 4.5FR*1900MM
|
Facility
|
OP
|
$1,714.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$514.26 |
| Max. Negotiated Rate |
$1,645.63 |
| Rate for Payer: Aetna Commercial |
$1,319.93
|
| Rate for Payer: Anthem Medicaid |
$589.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,337.08
|
| Rate for Payer: Cash Price |
$857.10
|
| Rate for Payer: Cigna Commercial |
$1,422.79
|
| Rate for Payer: First Health Commercial |
$1,628.49
|
| Rate for Payer: Humana Commercial |
$1,457.07
|
| Rate for Payer: Humana KY Medicaid |
$589.51
|
| Rate for Payer: Kentucky WC Medicaid |
$595.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,405.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,265.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$514.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$601.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,508.50
|
| Rate for Payer: Ohio Health Group HMO |
$1,285.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,371.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,491.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,182.80
|
| Rate for Payer: PHCS Commercial |
$1,645.63
|
| Rate for Payer: United Healthcare All Payer |
$1,508.50
|
|
|
BALOON EXTRACTION 4.5FR*1900MM
|
Facility
|
IP
|
$1,714.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$514.26 |
| Max. Negotiated Rate |
$1,645.63 |
| Rate for Payer: Aetna Commercial |
$1,319.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,337.08
|
| Rate for Payer: Cash Price |
$857.10
|
| Rate for Payer: Cigna Commercial |
$1,422.79
|
| Rate for Payer: First Health Commercial |
$1,628.49
|
| Rate for Payer: Humana Commercial |
$1,457.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,405.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,265.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$514.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,508.50
|
| Rate for Payer: Ohio Health Group HMO |
$1,285.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,371.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,491.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,182.80
|
| Rate for Payer: PHCS Commercial |
$1,645.63
|
| Rate for Payer: United Healthcare All Payer |
$1,508.50
|
|
|
BALOON PERIPHL CUTTNG 5*2*90
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
BALOON PERIPHL CUTTNG 5*2*90
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
BALOON PERIPHL CUTTNG 7*2*50
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
