|
ULTRASOUNDVASCULAR ACCESS
|
Facility
|
OP
|
$155.00
|
|
|
Service Code
|
HCPCS 76937
|
| Hospital Charge Code |
32000218
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$46.50 |
| Max. Negotiated Rate |
$148.80 |
| Rate for Payer: Aetna Commercial |
$119.35
|
| Rate for Payer: Anthem Medicaid |
$53.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$120.90
|
| Rate for Payer: Cash Price |
$77.50
|
| Rate for Payer: Cigna Commercial |
$128.65
|
| Rate for Payer: First Health Commercial |
$147.25
|
| Rate for Payer: Humana Commercial |
$131.75
|
| Rate for Payer: Humana KY Medicaid |
$53.30
|
| Rate for Payer: Kentucky WC Medicaid |
$53.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$127.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$114.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$54.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$136.40
|
| Rate for Payer: Ohio Health Group HMO |
$116.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$134.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$106.95
|
| Rate for Payer: PHCS Commercial |
$148.80
|
| Rate for Payer: United Healthcare All Payer |
$136.40
|
|
|
ULTRA THIN BALLOON 5*4*135
|
Facility
|
IP
|
$2,151.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$645.36 |
| Max. Negotiated Rate |
$2,065.15 |
| Rate for Payer: Aetna Commercial |
$1,656.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,677.94
|
| Rate for Payer: Cash Price |
$1,075.60
|
| Rate for Payer: Cigna Commercial |
$1,785.50
|
| Rate for Payer: First Health Commercial |
$2,043.64
|
| Rate for Payer: Humana Commercial |
$1,828.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,763.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,587.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$645.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,893.06
|
| Rate for Payer: Ohio Health Group HMO |
$1,613.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,720.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,871.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,484.33
|
| Rate for Payer: PHCS Commercial |
$2,065.15
|
| Rate for Payer: United Healthcare All Payer |
$1,893.06
|
|
|
ULTRA THIN BALLOON 5*4*135
|
Facility
|
OP
|
$2,151.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$645.36 |
| Max. Negotiated Rate |
$2,065.15 |
| Rate for Payer: Aetna Commercial |
$1,656.42
|
| Rate for Payer: Anthem Medicaid |
$739.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,677.94
|
| Rate for Payer: Cash Price |
$1,075.60
|
| Rate for Payer: Cigna Commercial |
$1,785.50
|
| Rate for Payer: First Health Commercial |
$2,043.64
|
| Rate for Payer: Humana Commercial |
$1,828.52
|
| Rate for Payer: Humana KY Medicaid |
$739.80
|
| Rate for Payer: Kentucky WC Medicaid |
$747.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,763.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,587.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$645.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$754.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,893.06
|
| Rate for Payer: Ohio Health Group HMO |
$1,613.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,720.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,871.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,484.33
|
| Rate for Payer: PHCS Commercial |
$2,065.15
|
| Rate for Payer: United Healthcare All Payer |
$1,893.06
|
|
|
ULTRA THIN BALLOON 5*6*136
|
Facility
|
IP
|
$2,151.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$645.36 |
| Max. Negotiated Rate |
$2,065.15 |
| Rate for Payer: Aetna Commercial |
$1,656.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,677.94
|
| Rate for Payer: Cash Price |
$1,075.60
|
| Rate for Payer: Cigna Commercial |
$1,785.50
|
| Rate for Payer: First Health Commercial |
$2,043.64
|
| Rate for Payer: Humana Commercial |
$1,828.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,763.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,587.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$645.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,893.06
|
| Rate for Payer: Ohio Health Group HMO |
$1,613.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,720.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,871.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,484.33
|
| Rate for Payer: PHCS Commercial |
$2,065.15
|
| Rate for Payer: United Healthcare All Payer |
$1,893.06
|
|
|
ULTRA THIN BALLOON 5*6*136
|
Facility
|
OP
|
$2,151.20
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$645.36 |
| Max. Negotiated Rate |
$2,065.15 |
| Rate for Payer: Aetna Commercial |
$1,656.42
|
| Rate for Payer: Anthem Medicaid |
$739.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,677.94
|
| Rate for Payer: Cash Price |
$1,075.60
|
| Rate for Payer: Cigna Commercial |
$1,785.50
|
| Rate for Payer: First Health Commercial |
$2,043.64
|
| Rate for Payer: Humana Commercial |
$1,828.52
|
| Rate for Payer: Humana KY Medicaid |
$739.80
|
| Rate for Payer: Kentucky WC Medicaid |
$747.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,763.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,587.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$645.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$754.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,893.06
|
| Rate for Payer: Ohio Health Group HMO |
$1,613.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,720.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,871.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,484.33
|
| Rate for Payer: PHCS Commercial |
$2,065.15
|
| Rate for Payer: United Healthcare All Payer |
$1,893.06
|
|
|
ULTRAVERSE BALLOON 150*1.5*120
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
ULTRAVERSE BALLOON 150*1.5*120
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
ULTRAVERSE BALLOON 150*1.5*20
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
ULTRAVERSE BALLOON 150*1.5*20
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
ULTRAVERSE BALLOON 150*1.5*40
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
ULTRAVERSE BALLOON 150*1.5*40
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
ULTRAVERSE BALLOON 150*2*100
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
ULTRAVERSE BALLOON 150*2*100
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
ULTRAVERSE BALLOON 150*2*120
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
ULTRAVERSE BALLOON 150*2*120
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
ULTRAVERSE BALLOON 150*2*150
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
ULTRAVERSE BALLOON 150*2*150
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
ULTRAVERSE BALLOON 150*2*220
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
ULTRAVERSE BALLOON 150*2*220
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
ULTRAVERSE BALLOON 150*2*300
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
ULTRAVERSE BALLOON 150*2*300
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
ULTRAVERSE BALLOON 150*2*40
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
ULTRAVERSE BALLOON 150*2*40
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
ULTRAVERSE BALLOON 150*2.5*120
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
ULTRAVERSE BALLOON 150*2.5*120
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
