|
ULTRAVERSE BALLOON 150*4*150
|
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*4*150
|
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*4*220
|
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*4*220
|
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*4*300
|
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*4*300
|
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*4*40
|
Facility
|
OP
|
$3,110.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$404.30 |
| Max. Negotiated Rate |
$2,985.60 |
| Rate for Payer: Aetna Commercial |
$2,394.70
|
| Rate for Payer: Anthem Medicaid |
$1,069.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,425.80
|
| Rate for Payer: Cash Price |
$1,555.00
|
| Rate for Payer: Cigna Commercial |
$2,581.30
|
| Rate for Payer: First Health Commercial |
$2,954.50
|
| Rate for Payer: Humana Commercial |
$2,643.50
|
| Rate for Payer: Humana KY Medicaid |
$1,069.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1,080.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,550.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,295.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$933.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,090.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,736.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,332.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$622.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$404.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$964.10
|
| Rate for Payer: PHCS Commercial |
$2,985.60
|
| Rate for Payer: United Healthcare All Payer |
$2,736.80
|
|
|
ULTRAVERSE BALLOON 150*4*40
|
Facility
|
IP
|
$3,110.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$404.30 |
| Max. Negotiated Rate |
$2,985.60 |
| Rate for Payer: Aetna Commercial |
$2,394.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,425.80
|
| Rate for Payer: Cash Price |
$1,555.00
|
| Rate for Payer: Cigna Commercial |
$2,581.30
|
| Rate for Payer: First Health Commercial |
$2,954.50
|
| Rate for Payer: Humana Commercial |
$2,643.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,550.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,295.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$933.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,736.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,332.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$622.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$404.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$964.10
|
| Rate for Payer: PHCS Commercial |
$2,985.60
|
| Rate for Payer: United Healthcare All Payer |
$2,736.80
|
|
|
ULTRAVERSE BALLOON 150*4*80
|
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*4*80
|
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*5*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*5*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*5*120
|
Facility
|
IP
|
$3,110.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$404.30 |
| Max. Negotiated Rate |
$2,985.60 |
| Rate for Payer: Aetna Commercial |
$2,394.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,425.80
|
| Rate for Payer: Cash Price |
$1,555.00
|
| Rate for Payer: Cigna Commercial |
$2,581.30
|
| Rate for Payer: First Health Commercial |
$2,954.50
|
| Rate for Payer: Humana Commercial |
$2,643.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,550.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,295.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$933.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,736.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,332.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$622.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$404.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$964.10
|
| Rate for Payer: PHCS Commercial |
$2,985.60
|
| Rate for Payer: United Healthcare All Payer |
$2,736.80
|
|
|
ULTRAVERSE BALLOON 150*5*120
|
Facility
|
OP
|
$3,110.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$404.30 |
| Max. Negotiated Rate |
$2,985.60 |
| Rate for Payer: Aetna Commercial |
$2,394.70
|
| Rate for Payer: Anthem Medicaid |
$1,069.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,425.80
|
| Rate for Payer: Cash Price |
$1,555.00
|
| Rate for Payer: Cigna Commercial |
$2,581.30
|
| Rate for Payer: First Health Commercial |
$2,954.50
|
| Rate for Payer: Humana Commercial |
$2,643.50
|
| Rate for Payer: Humana KY Medicaid |
$1,069.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1,080.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,550.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,295.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$933.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,090.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,736.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,332.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$622.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$404.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$964.10
|
| Rate for Payer: PHCS Commercial |
$2,985.60
|
| Rate for Payer: United Healthcare All Payer |
$2,736.80
|
|
|
ULTRAVERSE BALLOON 150*5*40
|
Facility
|
OP
|
$3,110.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$404.30 |
| Max. Negotiated Rate |
$2,985.60 |
| Rate for Payer: Aetna Commercial |
$2,394.70
|
| Rate for Payer: Anthem Medicaid |
$1,069.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,425.80
|
| Rate for Payer: Cash Price |
$1,555.00
|
| Rate for Payer: Cigna Commercial |
$2,581.30
|
| Rate for Payer: First Health Commercial |
$2,954.50
|
| Rate for Payer: Humana Commercial |
$2,643.50
|
| Rate for Payer: Humana KY Medicaid |
$1,069.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1,080.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,550.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,295.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$933.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,090.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,736.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,332.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$622.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$404.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$964.10
|
| Rate for Payer: PHCS Commercial |
$2,985.60
|
| Rate for Payer: United Healthcare All Payer |
$2,736.80
|
|
|
ULTRAVERSE BALLOON 150*5*40
|
Facility
|
IP
|
$3,110.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$404.30 |
| Max. Negotiated Rate |
$2,985.60 |
| Rate for Payer: Aetna Commercial |
$2,394.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,425.80
|
| Rate for Payer: Cash Price |
$1,555.00
|
| Rate for Payer: Cigna Commercial |
$2,581.30
|
| Rate for Payer: First Health Commercial |
$2,954.50
|
| Rate for Payer: Humana Commercial |
$2,643.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,550.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,295.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$933.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,736.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,332.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$622.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$404.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$964.10
|
| Rate for Payer: PHCS Commercial |
$2,985.60
|
| Rate for Payer: United Healthcare All Payer |
$2,736.80
|
|
|
ULTRAVERSE BALLOON 150*5*80
|
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*5*80
|
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
|
|
|
ULTRAVIOLET LIGHT THERAPY
|
Professional
|
Both
|
$88.00
|
|
|
Service Code
|
HCPCS 96900
|
| Hospital Charge Code |
76102703
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$10.92 |
| Max. Negotiated Rate |
$88.00 |
| Rate for Payer: Aetna Commercial |
$29.25
|
| Rate for Payer: Anthem Medicaid |
$10.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$88.00
|
| Rate for Payer: Cash Price |
$44.00
|
| Rate for Payer: Cash Price |
$44.00
|
| Rate for Payer: Cigna Commercial |
$27.06
|
| Rate for Payer: Humana Medicaid |
$10.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$24.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$11.14
|
| Rate for Payer: Molina Healthcare Passport |
$10.92
|
| Rate for Payer: Multiplan PHCS |
$52.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$61.60
|
| Rate for Payer: UHCCP Medicaid |
$30.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$11.03
|
|
|
UMBILECTOMY, OMPHALECTOMY, EXCISION OF UMBILICUS (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$4,188.46
|
|
|
Service Code
|
CPT 49250
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,991.76 |
| Max. Negotiated Rate |
$4,188.46 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,991.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,188.46
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,038.88
|
| Rate for Payer: Humana Medicare Advantage |
$2,991.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,590.11
|
|
|
UMBILICAL ARTERY ECHO
|
Facility
|
IP
|
$736.00
|
|
|
Service Code
|
HCPCS 76820
|
| Hospital Charge Code |
40200043
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.68 |
| Max. Negotiated Rate |
$706.56 |
| Rate for Payer: Aetna Commercial |
$566.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$574.08
|
| Rate for Payer: Cash Price |
$368.00
|
| Rate for Payer: Cigna Commercial |
$610.88
|
| Rate for Payer: First Health Commercial |
$699.20
|
| Rate for Payer: Humana Commercial |
$625.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$603.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$543.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$647.68
|
| Rate for Payer: Ohio Health Group HMO |
$552.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$95.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$228.16
|
| Rate for Payer: PHCS Commercial |
$706.56
|
| Rate for Payer: United Healthcare All Payer |
$647.68
|
|
|
UMBILICAL ARTERY ECHO
|
Facility
|
OP
|
$736.00
|
|
|
Service Code
|
HCPCS 76820
|
| Hospital Charge Code |
40200043
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$706.56 |
| Rate for Payer: Aetna Commercial |
$566.72
|
| Rate for Payer: Anthem Medicaid |
$253.11
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$574.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$368.00
|
| Rate for Payer: Cash Price |
$368.00
|
| Rate for Payer: Cigna Commercial |
$610.88
|
| Rate for Payer: First Health Commercial |
$699.20
|
| Rate for Payer: Humana Commercial |
$625.60
|
| Rate for Payer: Humana KY Medicaid |
$253.11
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$255.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$603.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$543.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$258.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$647.68
|
| Rate for Payer: Ohio Health Group HMO |
$552.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$95.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$228.16
|
| Rate for Payer: PHCS Commercial |
$706.56
|
| Rate for Payer: United Healthcare All Payer |
$647.68
|
|
|
UMBILICAL ARTERY ECHO
|
Professional
|
Both
|
$736.00
|
|
|
Service Code
|
HCPCS 76820
|
| Hospital Charge Code |
40200043
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$30.96 |
| Max. Negotiated Rate |
$736.00 |
| Rate for Payer: Aetna Commercial |
$86.11
|
| Rate for Payer: Anthem Medicaid |
$64.65
|
| Rate for Payer: Buckeye Medicare Advantage |
$736.00
|
| Rate for Payer: Cash Price |
$368.00
|
| Rate for Payer: Cash Price |
$368.00
|
| Rate for Payer: Cigna Commercial |
$117.24
|
| Rate for Payer: Healthspan PPO |
$80.68
|
| Rate for Payer: Humana Medicaid |
$64.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$30.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.94
|
| Rate for Payer: Molina Healthcare Passport |
$64.65
|
| Rate for Payer: Multiplan PHCS |
$441.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$515.20
|
| Rate for Payer: UHCCP Medicaid |
$257.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$65.30
|
|
|
UMBILICAL ARTERY ECHO(P
|
Professional
|
Both
|
$245.00
|
|
|
Service Code
|
HCPCS 76820
|
| Hospital Charge Code |
402P0043
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$30.96 |
| Max. Negotiated Rate |
$245.00 |
| Rate for Payer: Aetna Commercial |
$86.11
|
| Rate for Payer: Anthem Medicaid |
$64.65
|
| Rate for Payer: Buckeye Medicare Advantage |
$245.00
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cigna Commercial |
$117.24
|
| Rate for Payer: Healthspan PPO |
$80.68
|
| Rate for Payer: Humana Medicaid |
$64.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$30.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.94
|
| Rate for Payer: Molina Healthcare Passport |
$64.65
|
| Rate for Payer: Multiplan PHCS |
$147.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$171.50
|
| Rate for Payer: UHCCP Medicaid |
$85.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$65.30
|
|
|
UMBILICAL ARTERY ECHO(T
|
Facility
|
OP
|
$491.00
|
|
|
Service Code
|
HCPCS 76820
|
| Hospital Charge Code |
402T0043
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$63.83 |
| Max. Negotiated Rate |
$471.36 |
| Rate for Payer: Aetna Commercial |
$378.07
|
| Rate for Payer: Anthem Medicaid |
$168.85
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$382.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$245.50
|
| Rate for Payer: Cash Price |
$245.50
|
| Rate for Payer: Cigna Commercial |
$407.53
|
| Rate for Payer: First Health Commercial |
$466.45
|
| Rate for Payer: Humana Commercial |
$417.35
|
| Rate for Payer: Humana KY Medicaid |
$168.85
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$170.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$402.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$362.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$172.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$432.08
|
| Rate for Payer: Ohio Health Group HMO |
$368.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$152.21
|
| Rate for Payer: PHCS Commercial |
$471.36
|
| Rate for Payer: United Healthcare All Payer |
$432.08
|
|
