Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

ULTRAVERSE BALLOON 150*2.5*150

Facility

$2,975.00

Service Code	HCPCS C1725
Hospital Charge Code	27000009
Hospital Revenue Code	272
Min. Negotiated Rate	$892.50
Max. Negotiated Rate	$2,856.00
Rate for Payer: Aetna Commercial	$2,290.75
Rate for Payer: Anthem POS/PPO/Traditional	$2,320.50
Rate for Payer: Cash Price	$1,487.50
Rate for Payer: Cigna Commercial	$2,469.25
Rate for Payer: First Health Commercial	$2,826.25
Rate for Payer: Humana Commercial	$2,528.75
Rate for Payer: Medical Mutual Of Ohio HMO	$2,439.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,195.55
Rate for Payer: Molina Healthcare Benefit Exchange	$892.50
Rate for Payer: Ohio Health Choice Commercial	$2,618.00
Rate for Payer: Ohio Health Group HMO	$2,231.25
Rate for Payer: Ohio Health Group PPO Differential	$2,380.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,588.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,052.75
Rate for Payer: PHCS Commercial	$2,856.00
Rate for Payer: United Healthcare All Payer	$2,618.00

ULTRAVERSE BALLOON 150*2.5*150

Facility

$2,975.00

Service Code	HCPCS C1725
Hospital Charge Code	27000009
Hospital Revenue Code	272
Min. Negotiated Rate	$892.50
Max. Negotiated Rate	$2,856.00
Rate for Payer: Aetna Commercial	$2,290.75
Rate for Payer: Anthem Medicaid	$1,023.10
Rate for Payer: Anthem POS/PPO/Traditional	$2,320.50
Rate for Payer: Cash Price	$1,487.50
Rate for Payer: Cigna Commercial	$2,469.25
Rate for Payer: First Health Commercial	$2,826.25
Rate for Payer: Humana Commercial	$2,528.75
Rate for Payer: Humana KY Medicaid	$1,023.10
Rate for Payer: Kentucky WC Medicaid	$1,033.52
Rate for Payer: Medical Mutual Of Ohio HMO	$2,439.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,195.55
Rate for Payer: Molina Healthcare Benefit Exchange	$892.50
Rate for Payer: Molina Healthcare Medicaid	$1,043.63
Rate for Payer: Ohio Health Choice Commercial	$2,618.00
Rate for Payer: Ohio Health Group HMO	$2,231.25
Rate for Payer: Ohio Health Group PPO Differential	$2,380.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,588.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,052.75
Rate for Payer: PHCS Commercial	$2,856.00
Rate for Payer: United Healthcare All Payer	$2,618.00

ULTRAVERSE BALLOON 150*2.5*220

Facility

$2,975.00

Service Code	HCPCS C1725
Hospital Charge Code	27000009
Hospital Revenue Code	272
Min. Negotiated Rate	$892.50
Max. Negotiated Rate	$2,856.00
Rate for Payer: Aetna Commercial	$2,290.75
Rate for Payer: Anthem Medicaid	$1,023.10
Rate for Payer: Anthem POS/PPO/Traditional	$2,320.50
Rate for Payer: Cash Price	$1,487.50
Rate for Payer: Cigna Commercial	$2,469.25
Rate for Payer: First Health Commercial	$2,826.25
Rate for Payer: Humana Commercial	$2,528.75
Rate for Payer: Humana KY Medicaid	$1,023.10
Rate for Payer: Kentucky WC Medicaid	$1,033.52
Rate for Payer: Medical Mutual Of Ohio HMO	$2,439.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,195.55
Rate for Payer: Molina Healthcare Benefit Exchange	$892.50
Rate for Payer: Molina Healthcare Medicaid	$1,043.63
Rate for Payer: Ohio Health Choice Commercial	$2,618.00
Rate for Payer: Ohio Health Group HMO	$2,231.25
Rate for Payer: Ohio Health Group PPO Differential	$2,380.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,588.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,052.75
Rate for Payer: PHCS Commercial	$2,856.00
Rate for Payer: United Healthcare All Payer	$2,618.00

ULTRAVERSE BALLOON 150*2.5*220

Facility

$2,975.00

Service Code	HCPCS C1725
Hospital Charge Code	27000009
Hospital Revenue Code	272
Min. Negotiated Rate	$892.50
Max. Negotiated Rate	$2,856.00
Rate for Payer: Aetna Commercial	$2,290.75
Rate for Payer: Anthem POS/PPO/Traditional	$2,320.50
Rate for Payer: Cash Price	$1,487.50
Rate for Payer: Cigna Commercial	$2,469.25
Rate for Payer: First Health Commercial	$2,826.25
Rate for Payer: Humana Commercial	$2,528.75
Rate for Payer: Medical Mutual Of Ohio HMO	$2,439.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,195.55
Rate for Payer: Molina Healthcare Benefit Exchange	$892.50
Rate for Payer: Ohio Health Choice Commercial	$2,618.00
Rate for Payer: Ohio Health Group HMO	$2,231.25
Rate for Payer: Ohio Health Group PPO Differential	$2,380.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,588.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,052.75
Rate for Payer: PHCS Commercial	$2,856.00
Rate for Payer: United Healthcare All Payer	$2,618.00

ULTRAVERSE BALLOON 150*2.5*300

Facility

$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*300

Facility

$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*40

Facility

$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*40

Facility

$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*80

Facility

$2,975.00

Service Code	HCPCS C1725
Hospital Charge Code	27000009
Hospital Revenue Code	272
Min. Negotiated Rate	$892.50
Max. Negotiated Rate	$2,856.00
Rate for Payer: Aetna Commercial	$2,290.75
Rate for Payer: Anthem POS/PPO/Traditional	$2,320.50
Rate for Payer: Cash Price	$1,487.50
Rate for Payer: Cigna Commercial	$2,469.25
Rate for Payer: First Health Commercial	$2,826.25
Rate for Payer: Humana Commercial	$2,528.75
Rate for Payer: Medical Mutual Of Ohio HMO	$2,439.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,195.55
Rate for Payer: Molina Healthcare Benefit Exchange	$892.50
Rate for Payer: Ohio Health Choice Commercial	$2,618.00
Rate for Payer: Ohio Health Group HMO	$2,231.25
Rate for Payer: Ohio Health Group PPO Differential	$2,380.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,588.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,052.75
Rate for Payer: PHCS Commercial	$2,856.00
Rate for Payer: United Healthcare All Payer	$2,618.00

ULTRAVERSE BALLOON 150*2.5*80

Facility

$2,975.00

Service Code	HCPCS C1725
Hospital Charge Code	27000009
Hospital Revenue Code	272
Min. Negotiated Rate	$892.50
Max. Negotiated Rate	$2,856.00
Rate for Payer: Aetna Commercial	$2,290.75
Rate for Payer: Anthem Medicaid	$1,023.10
Rate for Payer: Anthem POS/PPO/Traditional	$2,320.50
Rate for Payer: Cash Price	$1,487.50
Rate for Payer: Cigna Commercial	$2,469.25
Rate for Payer: First Health Commercial	$2,826.25
Rate for Payer: Humana Commercial	$2,528.75
Rate for Payer: Humana KY Medicaid	$1,023.10
Rate for Payer: Kentucky WC Medicaid	$1,033.52
Rate for Payer: Medical Mutual Of Ohio HMO	$2,439.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,195.55
Rate for Payer: Molina Healthcare Benefit Exchange	$892.50
Rate for Payer: Molina Healthcare Medicaid	$1,043.63
Rate for Payer: Ohio Health Choice Commercial	$2,618.00
Rate for Payer: Ohio Health Group HMO	$2,231.25
Rate for Payer: Ohio Health Group PPO Differential	$2,380.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,588.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,052.75
Rate for Payer: PHCS Commercial	$2,856.00
Rate for Payer: United Healthcare All Payer	$2,618.00

ULTRAVERSE BALLOON 150*2*80

Facility

$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*80

Facility

$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*3*120

Facility

$2,975.00

Service Code	HCPCS C1725
Hospital Charge Code	27000009
Hospital Revenue Code	272
Min. Negotiated Rate	$892.50
Max. Negotiated Rate	$2,856.00
Rate for Payer: Aetna Commercial	$2,290.75
Rate for Payer: Anthem POS/PPO/Traditional	$2,320.50
Rate for Payer: Cash Price	$1,487.50
Rate for Payer: Cigna Commercial	$2,469.25
Rate for Payer: First Health Commercial	$2,826.25
Rate for Payer: Humana Commercial	$2,528.75
Rate for Payer: Medical Mutual Of Ohio HMO	$2,439.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,195.55
Rate for Payer: Molina Healthcare Benefit Exchange	$892.50
Rate for Payer: Ohio Health Choice Commercial	$2,618.00
Rate for Payer: Ohio Health Group HMO	$2,231.25
Rate for Payer: Ohio Health Group PPO Differential	$2,380.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,588.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,052.75
Rate for Payer: PHCS Commercial	$2,856.00
Rate for Payer: United Healthcare All Payer	$2,618.00

ULTRAVERSE BALLOON 150*3*120

Facility

$2,975.00

Service Code	HCPCS C1725
Hospital Charge Code	27000009
Hospital Revenue Code	272
Min. Negotiated Rate	$892.50
Max. Negotiated Rate	$2,856.00
Rate for Payer: Aetna Commercial	$2,290.75
Rate for Payer: Anthem Medicaid	$1,023.10
Rate for Payer: Anthem POS/PPO/Traditional	$2,320.50
Rate for Payer: Cash Price	$1,487.50
Rate for Payer: Cigna Commercial	$2,469.25
Rate for Payer: First Health Commercial	$2,826.25
Rate for Payer: Humana Commercial	$2,528.75
Rate for Payer: Humana KY Medicaid	$1,023.10
Rate for Payer: Kentucky WC Medicaid	$1,033.52
Rate for Payer: Medical Mutual Of Ohio HMO	$2,439.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,195.55
Rate for Payer: Molina Healthcare Benefit Exchange	$892.50
Rate for Payer: Molina Healthcare Medicaid	$1,043.63
Rate for Payer: Ohio Health Choice Commercial	$2,618.00
Rate for Payer: Ohio Health Group HMO	$2,231.25
Rate for Payer: Ohio Health Group PPO Differential	$2,380.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,588.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,052.75
Rate for Payer: PHCS Commercial	$2,856.00
Rate for Payer: United Healthcare All Payer	$2,618.00

ULTRAVERSE BALLOON 150*3*150

Facility

$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*3*150

Facility

$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*3*220

Facility

$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*3*220

Facility

$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*3*300

Facility

$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*3*300

Facility

$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*3*40

Facility

$2,975.00

Service Code	HCPCS C1725
Hospital Charge Code	27000009
Hospital Revenue Code	272
Min. Negotiated Rate	$892.50
Max. Negotiated Rate	$2,856.00
Rate for Payer: Aetna Commercial	$2,290.75
Rate for Payer: Anthem POS/PPO/Traditional	$2,320.50
Rate for Payer: Cash Price	$1,487.50
Rate for Payer: Cigna Commercial	$2,469.25
Rate for Payer: First Health Commercial	$2,826.25
Rate for Payer: Humana Commercial	$2,528.75
Rate for Payer: Medical Mutual Of Ohio HMO	$2,439.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,195.55
Rate for Payer: Molina Healthcare Benefit Exchange	$892.50
Rate for Payer: Ohio Health Choice Commercial	$2,618.00
Rate for Payer: Ohio Health Group HMO	$2,231.25
Rate for Payer: Ohio Health Group PPO Differential	$2,380.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,588.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,052.75
Rate for Payer: PHCS Commercial	$2,856.00
Rate for Payer: United Healthcare All Payer	$2,618.00

ULTRAVERSE BALLOON 150*3*40

Facility

$2,975.00

Service Code	HCPCS C1725
Hospital Charge Code	27000009
Hospital Revenue Code	272
Min. Negotiated Rate	$892.50
Max. Negotiated Rate	$2,856.00
Rate for Payer: Aetna Commercial	$2,290.75
Rate for Payer: Anthem Medicaid	$1,023.10
Rate for Payer: Anthem POS/PPO/Traditional	$2,320.50
Rate for Payer: Cash Price	$1,487.50
Rate for Payer: Cigna Commercial	$2,469.25
Rate for Payer: First Health Commercial	$2,826.25
Rate for Payer: Humana Commercial	$2,528.75
Rate for Payer: Humana KY Medicaid	$1,023.10
Rate for Payer: Kentucky WC Medicaid	$1,033.52
Rate for Payer: Medical Mutual Of Ohio HMO	$2,439.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,195.55
Rate for Payer: Molina Healthcare Benefit Exchange	$892.50
Rate for Payer: Molina Healthcare Medicaid	$1,043.63
Rate for Payer: Ohio Health Choice Commercial	$2,618.00
Rate for Payer: Ohio Health Group HMO	$2,231.25
Rate for Payer: Ohio Health Group PPO Differential	$2,380.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,588.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,052.75
Rate for Payer: PHCS Commercial	$2,856.00
Rate for Payer: United Healthcare All Payer	$2,618.00

ULTRAVERSE BALLOON 150*3.5*120

Facility

$2,975.00

Service Code	HCPCS C1725
Hospital Charge Code	27000009
Hospital Revenue Code	272
Min. Negotiated Rate	$892.50
Max. Negotiated Rate	$2,856.00
Rate for Payer: Aetna Commercial	$2,290.75
Rate for Payer: Anthem Medicaid	$1,023.10
Rate for Payer: Anthem POS/PPO/Traditional	$2,320.50
Rate for Payer: Cash Price	$1,487.50
Rate for Payer: Cigna Commercial	$2,469.25
Rate for Payer: First Health Commercial	$2,826.25
Rate for Payer: Humana Commercial	$2,528.75
Rate for Payer: Humana KY Medicaid	$1,023.10
Rate for Payer: Kentucky WC Medicaid	$1,033.52
Rate for Payer: Medical Mutual Of Ohio HMO	$2,439.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,195.55
Rate for Payer: Molina Healthcare Benefit Exchange	$892.50
Rate for Payer: Molina Healthcare Medicaid	$1,043.63
Rate for Payer: Ohio Health Choice Commercial	$2,618.00
Rate for Payer: Ohio Health Group HMO	$2,231.25
Rate for Payer: Ohio Health Group PPO Differential	$2,380.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,588.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,052.75
Rate for Payer: PHCS Commercial	$2,856.00
Rate for Payer: United Healthcare All Payer	$2,618.00

ULTRAVERSE BALLOON 150*3.5*120

Facility

$2,975.00

Service Code	HCPCS C1725
Hospital Charge Code	27000009
Hospital Revenue Code	272
Min. Negotiated Rate	$892.50
Max. Negotiated Rate	$2,856.00
Rate for Payer: Aetna Commercial	$2,290.75
Rate for Payer: Anthem POS/PPO/Traditional	$2,320.50
Rate for Payer: Cash Price	$1,487.50
Rate for Payer: Cigna Commercial	$2,469.25
Rate for Payer: First Health Commercial	$2,826.25
Rate for Payer: Humana Commercial	$2,528.75
Rate for Payer: Medical Mutual Of Ohio HMO	$2,439.50
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,195.55
Rate for Payer: Molina Healthcare Benefit Exchange	$892.50
Rate for Payer: Ohio Health Choice Commercial	$2,618.00
Rate for Payer: Ohio Health Group HMO	$2,231.25
Rate for Payer: Ohio Health Group PPO Differential	$2,380.00
Rate for Payer: Ohio Health Group PPO No Differential	$2,588.25
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,052.75
Rate for Payer: PHCS Commercial	$2,856.00
Rate for Payer: United Healthcare All Payer	$2,618.00

ULTRAVERSE BALLOON 150*3.5*150

Facility

$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

Know your out-of-pocket cost for care.

All Charges