|
ULTRASOUND PYLORIS LTD(T
|
Facility
|
IP
|
$979.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
402T0023
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$127.27 |
| Max. Negotiated Rate |
$939.84 |
| Rate for Payer: Aetna Commercial |
$753.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$763.62
|
| Rate for Payer: Cash Price |
$489.50
|
| Rate for Payer: Cigna Commercial |
$812.57
|
| Rate for Payer: First Health Commercial |
$930.05
|
| Rate for Payer: Humana Commercial |
$832.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$802.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$722.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$293.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$861.52
|
| Rate for Payer: Ohio Health Group HMO |
$734.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$195.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$303.49
|
| Rate for Payer: PHCS Commercial |
$939.84
|
| Rate for Payer: United Healthcare All Payer |
$861.52
|
|
|
ULTRASOUND THERAPY 15 MIN
|
Facility
|
OP
|
$133.00
|
|
|
Service Code
|
HCPCS 97035
|
| Hospital Charge Code |
43000011
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$17.29 |
| Max. Negotiated Rate |
$127.68 |
| Rate for Payer: Aetna Commercial |
$102.41
|
| Rate for Payer: Anthem Medicaid |
$45.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$103.74
|
| Rate for Payer: Cash Price |
$66.50
|
| Rate for Payer: Cigna Commercial |
$110.39
|
| Rate for Payer: First Health Commercial |
$126.35
|
| Rate for Payer: Humana Commercial |
$113.05
|
| Rate for Payer: Humana KY Medicaid |
$45.74
|
| Rate for Payer: Kentucky WC Medicaid |
$46.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$109.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$98.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$46.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$117.04
|
| Rate for Payer: Ohio Health Group HMO |
$99.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.23
|
| Rate for Payer: PHCS Commercial |
$127.68
|
| Rate for Payer: United Healthcare All Payer |
$117.04
|
|
|
ULTRASOUND THERAPY 15 MIN
|
Facility
|
IP
|
$133.00
|
|
|
Service Code
|
HCPCS 97035
|
| Hospital Charge Code |
43000011
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$17.29 |
| Max. Negotiated Rate |
$127.68 |
| Rate for Payer: Aetna Commercial |
$102.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$103.74
|
| Rate for Payer: Cash Price |
$66.50
|
| Rate for Payer: Cigna Commercial |
$110.39
|
| Rate for Payer: First Health Commercial |
$126.35
|
| Rate for Payer: Humana Commercial |
$113.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$109.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$98.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$117.04
|
| Rate for Payer: Ohio Health Group HMO |
$99.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.23
|
| Rate for Payer: PHCS Commercial |
$127.68
|
| Rate for Payer: United Healthcare All Payer |
$117.04
|
|
|
ULTRASOUND TRANSRECTAL
|
Facility
|
OP
|
$1,130.00
|
|
|
Service Code
|
HCPCS 76873
|
| Hospital Charge Code |
40200054
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$1,084.80 |
| Rate for Payer: Aetna Commercial |
$870.10
|
| Rate for Payer: Anthem Medicaid |
$388.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$881.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$565.00
|
| Rate for Payer: Cash Price |
$565.00
|
| Rate for Payer: Cigna Commercial |
$937.90
|
| Rate for Payer: First Health Commercial |
$1,073.50
|
| Rate for Payer: Humana Commercial |
$960.50
|
| Rate for Payer: Humana KY Medicaid |
$388.61
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$392.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$926.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$833.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$396.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$994.40
|
| Rate for Payer: Ohio Health Group HMO |
$847.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$226.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$350.30
|
| Rate for Payer: PHCS Commercial |
$1,084.80
|
| Rate for Payer: United Healthcare All Payer |
$994.40
|
|
|
ULTRASOUND TRANSRECTAL
|
Professional
|
Both
|
$1,130.00
|
|
|
Service Code
|
HCPCS 76873
|
| Hospital Charge Code |
40200054
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$99.39 |
| Max. Negotiated Rate |
$1,130.00 |
| Rate for Payer: Aetna Commercial |
$273.72
|
| Rate for Payer: Anthem Medicaid |
$110.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,130.00
|
| Rate for Payer: Cash Price |
$565.00
|
| Rate for Payer: Cash Price |
$565.00
|
| Rate for Payer: Cigna Commercial |
$251.18
|
| Rate for Payer: Healthspan PPO |
$256.48
|
| Rate for Payer: Humana Medicaid |
$110.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$99.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$112.58
|
| Rate for Payer: Molina Healthcare Passport |
$110.37
|
| Rate for Payer: Multiplan PHCS |
$678.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$791.00
|
| Rate for Payer: UHCCP Medicaid |
$395.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$111.47
|
|
|
ULTRASOUND TRANSRECTAL
|
Facility
|
IP
|
$1,130.00
|
|
|
Service Code
|
HCPCS 76873
|
| Hospital Charge Code |
40200054
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$146.90 |
| Max. Negotiated Rate |
$1,084.80 |
| Rate for Payer: Aetna Commercial |
$870.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$881.40
|
| Rate for Payer: Cash Price |
$565.00
|
| Rate for Payer: Cigna Commercial |
$937.90
|
| Rate for Payer: First Health Commercial |
$1,073.50
|
| Rate for Payer: Humana Commercial |
$960.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$926.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$833.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$339.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$994.40
|
| Rate for Payer: Ohio Health Group HMO |
$847.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$226.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$350.30
|
| Rate for Payer: PHCS Commercial |
$1,084.80
|
| Rate for Payer: United Healthcare All Payer |
$994.40
|
|
|
ULTRASOUND TRANSRECTAL(P
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 76873
|
| Hospital Charge Code |
402P0054
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$273.72 |
| Rate for Payer: Aetna Commercial |
$273.72
|
| Rate for Payer: Anthem Medicaid |
$110.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$200.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$251.18
|
| Rate for Payer: Healthspan PPO |
$256.48
|
| Rate for Payer: Humana Medicaid |
$110.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$99.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$112.58
|
| Rate for Payer: Molina Healthcare Passport |
$110.37
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.00
|
| Rate for Payer: UHCCP Medicaid |
$70.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$111.47
|
|
|
ULTRASOUND TRANSRECTAL(T
|
Facility
|
IP
|
$930.00
|
|
|
Service Code
|
HCPCS 76873
|
| Hospital Charge Code |
402T0054
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$120.90 |
| Max. Negotiated Rate |
$892.80 |
| Rate for Payer: Aetna Commercial |
$716.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$725.40
|
| Rate for Payer: Cash Price |
$465.00
|
| Rate for Payer: Cigna Commercial |
$771.90
|
| Rate for Payer: First Health Commercial |
$883.50
|
| Rate for Payer: Humana Commercial |
$790.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$762.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$686.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$279.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$818.40
|
| Rate for Payer: Ohio Health Group HMO |
$697.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$186.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$120.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$288.30
|
| Rate for Payer: PHCS Commercial |
$892.80
|
| Rate for Payer: United Healthcare All Payer |
$818.40
|
|
|
ULTRASOUND TRANSRECTAL(T
|
Facility
|
OP
|
$930.00
|
|
|
Service Code
|
HCPCS 76873
|
| Hospital Charge Code |
402T0054
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$892.80 |
| Rate for Payer: Aetna Commercial |
$716.10
|
| Rate for Payer: Anthem Medicaid |
$319.83
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$725.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$465.00
|
| Rate for Payer: Cash Price |
$465.00
|
| Rate for Payer: Cigna Commercial |
$771.90
|
| Rate for Payer: First Health Commercial |
$883.50
|
| Rate for Payer: Humana Commercial |
$790.50
|
| Rate for Payer: Humana KY Medicaid |
$319.83
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$323.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$762.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$686.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$326.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$818.40
|
| Rate for Payer: Ohio Health Group HMO |
$697.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$186.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$120.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$288.30
|
| Rate for Payer: PHCS Commercial |
$892.80
|
| Rate for Payer: United Healthcare All Payer |
$818.40
|
|
|
ULTRASOUNDVASCULAR ACCESS
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
HCPCS 76937
|
| Hospital Charge Code |
32000218
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$140.16 |
| Rate for Payer: Aetna Commercial |
$112.42
|
| Rate for Payer: Anthem Medicaid |
$50.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$113.88
|
| Rate for Payer: Cash Price |
$73.00
|
| Rate for Payer: Cigna Commercial |
$121.18
|
| Rate for Payer: First Health Commercial |
$138.70
|
| Rate for Payer: Humana Commercial |
$124.10
|
| Rate for Payer: Humana KY Medicaid |
$50.21
|
| Rate for Payer: Kentucky WC Medicaid |
$50.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$119.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$107.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$51.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$128.48
|
| Rate for Payer: Ohio Health Group HMO |
$109.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.26
|
| Rate for Payer: PHCS Commercial |
$140.16
|
| Rate for Payer: United Healthcare All Payer |
$128.48
|
|
|
ULTRASOUNDVASCULAR ACCESS
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
HCPCS 76937
|
| Hospital Charge Code |
32000218
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$140.16 |
| Rate for Payer: Aetna Commercial |
$112.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$113.88
|
| Rate for Payer: Cash Price |
$73.00
|
| Rate for Payer: Cigna Commercial |
$121.18
|
| Rate for Payer: First Health Commercial |
$138.70
|
| Rate for Payer: Humana Commercial |
$124.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$119.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$107.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$128.48
|
| Rate for Payer: Ohio Health Group HMO |
$109.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.26
|
| Rate for Payer: PHCS Commercial |
$140.16
|
| Rate for Payer: United Healthcare All Payer |
$128.48
|
|
|
ULTRA THIN BALLOON 5*4*135
|
Facility
|
OP
|
$2,134.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$277.42 |
| Max. Negotiated Rate |
$2,048.64 |
| Rate for Payer: Aetna Commercial |
$1,643.18
|
| Rate for Payer: Anthem Medicaid |
$733.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,664.52
|
| Rate for Payer: Cash Price |
$1,067.00
|
| Rate for Payer: Cigna Commercial |
$1,771.22
|
| Rate for Payer: First Health Commercial |
$2,027.30
|
| Rate for Payer: Humana Commercial |
$1,813.90
|
| Rate for Payer: Humana KY Medicaid |
$733.88
|
| Rate for Payer: Kentucky WC Medicaid |
$741.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,749.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,574.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$640.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$748.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,877.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,600.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$426.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$277.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$661.54
|
| Rate for Payer: PHCS Commercial |
$2,048.64
|
| Rate for Payer: United Healthcare All Payer |
$1,877.92
|
|
|
ULTRA THIN BALLOON 5*4*135
|
Facility
|
IP
|
$2,134.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$277.42 |
| Max. Negotiated Rate |
$2,048.64 |
| Rate for Payer: Aetna Commercial |
$1,643.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,664.52
|
| Rate for Payer: Cash Price |
$1,067.00
|
| Rate for Payer: Cigna Commercial |
$1,771.22
|
| Rate for Payer: First Health Commercial |
$2,027.30
|
| Rate for Payer: Humana Commercial |
$1,813.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,749.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,574.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$640.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,877.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,600.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$426.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$277.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$661.54
|
| Rate for Payer: PHCS Commercial |
$2,048.64
|
| Rate for Payer: United Healthcare All Payer |
$1,877.92
|
|
|
ULTRA THIN BALLOON 5*6*136
|
Facility
|
OP
|
$2,134.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$277.42 |
| Max. Negotiated Rate |
$2,048.64 |
| Rate for Payer: Aetna Commercial |
$1,643.18
|
| Rate for Payer: Anthem Medicaid |
$733.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,664.52
|
| Rate for Payer: Cash Price |
$1,067.00
|
| Rate for Payer: Cigna Commercial |
$1,771.22
|
| Rate for Payer: First Health Commercial |
$2,027.30
|
| Rate for Payer: Humana Commercial |
$1,813.90
|
| Rate for Payer: Humana KY Medicaid |
$733.88
|
| Rate for Payer: Kentucky WC Medicaid |
$741.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,749.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,574.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$640.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$748.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,877.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,600.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$426.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$277.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$661.54
|
| Rate for Payer: PHCS Commercial |
$2,048.64
|
| Rate for Payer: United Healthcare All Payer |
$1,877.92
|
|
|
ULTRA THIN BALLOON 5*6*136
|
Facility
|
IP
|
$2,134.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$277.42 |
| Max. Negotiated Rate |
$2,048.64 |
| Rate for Payer: Aetna Commercial |
$1,643.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,664.52
|
| Rate for Payer: Cash Price |
$1,067.00
|
| Rate for Payer: Cigna Commercial |
$1,771.22
|
| Rate for Payer: First Health Commercial |
$2,027.30
|
| Rate for Payer: Humana Commercial |
$1,813.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,749.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,574.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$640.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,877.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,600.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$426.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$277.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$661.54
|
| Rate for Payer: PHCS Commercial |
$2,048.64
|
| Rate for Payer: United Healthcare All Payer |
$1,877.92
|
|
|
ULTRAVERSE BALLOON 150*1.5*120
|
Facility
|
OP
|
$3,075.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$399.75 |
| Max. Negotiated Rate |
$2,952.00 |
| Rate for Payer: Aetna Commercial |
$2,367.75
|
| Rate for Payer: Anthem Medicaid |
$1,057.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,398.50
|
| Rate for Payer: Cash Price |
$1,537.50
|
| Rate for Payer: Cigna Commercial |
$2,552.25
|
| Rate for Payer: First Health Commercial |
$2,921.25
|
| Rate for Payer: Humana Commercial |
$2,613.75
|
| Rate for Payer: Humana KY Medicaid |
$1,057.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1,068.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,521.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,269.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$922.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,078.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,706.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,306.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$615.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$399.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$953.25
|
| Rate for Payer: PHCS Commercial |
$2,952.00
|
| Rate for Payer: United Healthcare All Payer |
$2,706.00
|
|
|
ULTRAVERSE BALLOON 150*1.5*120
|
Facility
|
IP
|
$3,075.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$399.75 |
| Max. Negotiated Rate |
$2,952.00 |
| Rate for Payer: Aetna Commercial |
$2,367.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,398.50
|
| Rate for Payer: Cash Price |
$1,537.50
|
| Rate for Payer: Cigna Commercial |
$2,552.25
|
| Rate for Payer: First Health Commercial |
$2,921.25
|
| Rate for Payer: Humana Commercial |
$2,613.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,521.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,269.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$922.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,706.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,306.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$615.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$399.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$953.25
|
| Rate for Payer: PHCS Commercial |
$2,952.00
|
| Rate for Payer: United Healthcare All Payer |
$2,706.00
|
|
|
ULTRAVERSE BALLOON 150*1.5*20
|
Facility
|
IP
|
$3,075.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$399.75 |
| Max. Negotiated Rate |
$2,952.00 |
| Rate for Payer: Aetna Commercial |
$2,367.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,398.50
|
| Rate for Payer: Cash Price |
$1,537.50
|
| Rate for Payer: Cigna Commercial |
$2,552.25
|
| Rate for Payer: First Health Commercial |
$2,921.25
|
| Rate for Payer: Humana Commercial |
$2,613.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,521.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,269.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$922.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,706.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,306.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$615.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$399.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$953.25
|
| Rate for Payer: PHCS Commercial |
$2,952.00
|
| Rate for Payer: United Healthcare All Payer |
$2,706.00
|
|
|
ULTRAVERSE BALLOON 150*1.5*20
|
Facility
|
OP
|
$3,075.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$399.75 |
| Max. Negotiated Rate |
$2,952.00 |
| Rate for Payer: Aetna Commercial |
$2,367.75
|
| Rate for Payer: Anthem Medicaid |
$1,057.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,398.50
|
| Rate for Payer: Cash Price |
$1,537.50
|
| Rate for Payer: Cigna Commercial |
$2,552.25
|
| Rate for Payer: First Health Commercial |
$2,921.25
|
| Rate for Payer: Humana Commercial |
$2,613.75
|
| Rate for Payer: Humana KY Medicaid |
$1,057.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1,068.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,521.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,269.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$922.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,078.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,706.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,306.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$615.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$399.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$953.25
|
| Rate for Payer: PHCS Commercial |
$2,952.00
|
| Rate for Payer: United Healthcare All Payer |
$2,706.00
|
|
|
ULTRAVERSE BALLOON 150*1.5*40
|
Facility
|
OP
|
$3,075.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$399.75 |
| Max. Negotiated Rate |
$2,952.00 |
| Rate for Payer: Aetna Commercial |
$2,367.75
|
| Rate for Payer: Anthem Medicaid |
$1,057.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,398.50
|
| Rate for Payer: Cash Price |
$1,537.50
|
| Rate for Payer: Cigna Commercial |
$2,552.25
|
| Rate for Payer: First Health Commercial |
$2,921.25
|
| Rate for Payer: Humana Commercial |
$2,613.75
|
| Rate for Payer: Humana KY Medicaid |
$1,057.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1,068.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,521.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,269.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$922.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,078.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,706.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,306.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$615.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$399.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$953.25
|
| Rate for Payer: PHCS Commercial |
$2,952.00
|
| Rate for Payer: United Healthcare All Payer |
$2,706.00
|
|
|
ULTRAVERSE BALLOON 150*1.5*40
|
Facility
|
IP
|
$3,075.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$399.75 |
| Max. Negotiated Rate |
$2,952.00 |
| Rate for Payer: Aetna Commercial |
$2,367.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,398.50
|
| Rate for Payer: Cash Price |
$1,537.50
|
| Rate for Payer: Cigna Commercial |
$2,552.25
|
| Rate for Payer: First Health Commercial |
$2,921.25
|
| Rate for Payer: Humana Commercial |
$2,613.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,521.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,269.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$922.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,706.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,306.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$615.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$399.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$953.25
|
| Rate for Payer: PHCS Commercial |
$2,952.00
|
| Rate for Payer: United Healthcare All Payer |
$2,706.00
|
|
|
ULTRAVERSE BALLOON 150*2*100
|
Facility
|
OP
|
$3,075.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$399.75 |
| Max. Negotiated Rate |
$2,952.00 |
| Rate for Payer: Aetna Commercial |
$2,367.75
|
| Rate for Payer: Anthem Medicaid |
$1,057.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,398.50
|
| Rate for Payer: Cash Price |
$1,537.50
|
| Rate for Payer: Cigna Commercial |
$2,552.25
|
| Rate for Payer: First Health Commercial |
$2,921.25
|
| Rate for Payer: Humana Commercial |
$2,613.75
|
| Rate for Payer: Humana KY Medicaid |
$1,057.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1,068.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,521.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,269.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$922.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,078.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,706.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,306.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$615.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$399.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$953.25
|
| Rate for Payer: PHCS Commercial |
$2,952.00
|
| Rate for Payer: United Healthcare All Payer |
$2,706.00
|
|
|
ULTRAVERSE BALLOON 150*2*100
|
Facility
|
IP
|
$3,075.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$399.75 |
| Max. Negotiated Rate |
$2,952.00 |
| Rate for Payer: Aetna Commercial |
$2,367.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,398.50
|
| Rate for Payer: Cash Price |
$1,537.50
|
| Rate for Payer: Cigna Commercial |
$2,552.25
|
| Rate for Payer: First Health Commercial |
$2,921.25
|
| Rate for Payer: Humana Commercial |
$2,613.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,521.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,269.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$922.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,706.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,306.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$615.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$399.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$953.25
|
| Rate for Payer: PHCS Commercial |
$2,952.00
|
| Rate for Payer: United Healthcare All Payer |
$2,706.00
|
|
|
ULTRAVERSE BALLOON 150*2*120
|
Facility
|
OP
|
$3,075.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$399.75 |
| Max. Negotiated Rate |
$2,952.00 |
| Rate for Payer: Aetna Commercial |
$2,367.75
|
| Rate for Payer: Anthem Medicaid |
$1,057.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,398.50
|
| Rate for Payer: Cash Price |
$1,537.50
|
| Rate for Payer: Cigna Commercial |
$2,552.25
|
| Rate for Payer: First Health Commercial |
$2,921.25
|
| Rate for Payer: Humana Commercial |
$2,613.75
|
| Rate for Payer: Humana KY Medicaid |
$1,057.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1,068.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,521.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,269.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$922.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,078.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,706.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,306.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$615.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$399.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$953.25
|
| Rate for Payer: PHCS Commercial |
$2,952.00
|
| Rate for Payer: United Healthcare All Payer |
$2,706.00
|
|
|
ULTRAVERSE BALLOON 150*2*120
|
Facility
|
IP
|
$3,075.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$399.75 |
| Max. Negotiated Rate |
$2,952.00 |
| Rate for Payer: Aetna Commercial |
$2,367.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,398.50
|
| Rate for Payer: Cash Price |
$1,537.50
|
| Rate for Payer: Cigna Commercial |
$2,552.25
|
| Rate for Payer: First Health Commercial |
$2,921.25
|
| Rate for Payer: Humana Commercial |
$2,613.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,521.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,269.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$922.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,706.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,306.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$615.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$399.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$953.25
|
| Rate for Payer: PHCS Commercial |
$2,952.00
|
| Rate for Payer: United Healthcare All Payer |
$2,706.00
|
|
