|
WOLVERINE CUT. BALLOON 2*10
|
Facility
|
OP
|
$4,418.15
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,325.44 |
| Max. Negotiated Rate |
$4,241.42 |
| Rate for Payer: Aetna Commercial |
$3,401.98
|
| Rate for Payer: Anthem Medicaid |
$1,519.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,446.16
|
| Rate for Payer: Cash Price |
$2,209.07
|
| Rate for Payer: Cigna Commercial |
$3,667.06
|
| Rate for Payer: First Health Commercial |
$4,197.24
|
| Rate for Payer: Humana Commercial |
$3,755.43
|
| Rate for Payer: Humana KY Medicaid |
$1,519.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,534.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,622.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,260.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,325.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,549.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,887.97
|
| Rate for Payer: Ohio Health Group HMO |
$3,313.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,534.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,843.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,048.52
|
| Rate for Payer: PHCS Commercial |
$4,241.42
|
| Rate for Payer: United Healthcare All Payer |
$3,887.97
|
|
|
WOLVERINE CUT. BALLOON 2*15
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
WOLVERINE CUT. BALLOON 2*15
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
WOLVERINE CUT. BALLOON 2.50*6
|
Facility
|
IP
|
$4,572.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,371.75 |
| Max. Negotiated Rate |
$4,389.60 |
| Rate for Payer: Aetna Commercial |
$3,520.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,566.55
|
| Rate for Payer: Cash Price |
$2,286.25
|
| Rate for Payer: Cigna Commercial |
$3,795.18
|
| Rate for Payer: First Health Commercial |
$4,343.88
|
| Rate for Payer: Humana Commercial |
$3,886.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,749.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,374.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,371.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,023.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,429.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,658.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,978.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,155.03
|
| Rate for Payer: PHCS Commercial |
$4,389.60
|
| Rate for Payer: United Healthcare All Payer |
$4,023.80
|
|
|
WOLVERINE CUT. BALLOON 2.50*6
|
Facility
|
OP
|
$4,572.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,371.75 |
| Max. Negotiated Rate |
$4,389.60 |
| Rate for Payer: Aetna Commercial |
$3,520.82
|
| Rate for Payer: Anthem Medicaid |
$1,572.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,566.55
|
| Rate for Payer: Cash Price |
$2,286.25
|
| Rate for Payer: Cigna Commercial |
$3,795.18
|
| Rate for Payer: First Health Commercial |
$4,343.88
|
| Rate for Payer: Humana Commercial |
$3,886.62
|
| Rate for Payer: Humana KY Medicaid |
$1,572.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1,588.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,749.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,374.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,371.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,604.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,023.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,429.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,658.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,978.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,155.03
|
| Rate for Payer: PHCS Commercial |
$4,389.60
|
| Rate for Payer: United Healthcare All Payer |
$4,023.80
|
|
|
WOLVERINE CUT. BALLOON 2.5*10
|
Facility
|
IP
|
$4,418.15
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,325.44 |
| Max. Negotiated Rate |
$4,241.42 |
| Rate for Payer: Aetna Commercial |
$3,401.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,446.16
|
| Rate for Payer: Cash Price |
$2,209.07
|
| Rate for Payer: Cigna Commercial |
$3,667.06
|
| Rate for Payer: First Health Commercial |
$4,197.24
|
| Rate for Payer: Humana Commercial |
$3,755.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,622.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,260.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,325.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,887.97
|
| Rate for Payer: Ohio Health Group HMO |
$3,313.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,534.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,843.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,048.52
|
| Rate for Payer: PHCS Commercial |
$4,241.42
|
| Rate for Payer: United Healthcare All Payer |
$3,887.97
|
|
|
WOLVERINE CUT. BALLOON 2.5*10
|
Facility
|
OP
|
$4,418.15
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,325.44 |
| Max. Negotiated Rate |
$4,241.42 |
| Rate for Payer: Aetna Commercial |
$3,401.98
|
| Rate for Payer: Anthem Medicaid |
$1,519.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,446.16
|
| Rate for Payer: Cash Price |
$2,209.07
|
| Rate for Payer: Cigna Commercial |
$3,667.06
|
| Rate for Payer: First Health Commercial |
$4,197.24
|
| Rate for Payer: Humana Commercial |
$3,755.43
|
| Rate for Payer: Humana KY Medicaid |
$1,519.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,534.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,622.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,260.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,325.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,549.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,887.97
|
| Rate for Payer: Ohio Health Group HMO |
$3,313.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,534.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,843.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,048.52
|
| Rate for Payer: PHCS Commercial |
$4,241.42
|
| Rate for Payer: United Healthcare All Payer |
$3,887.97
|
|
|
WOLVERINE CUT. BALLOON 2.5*15
|
Facility
|
IP
|
$4,418.15
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,325.44 |
| Max. Negotiated Rate |
$4,241.42 |
| Rate for Payer: Aetna Commercial |
$3,401.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,446.16
|
| Rate for Payer: Cash Price |
$2,209.07
|
| Rate for Payer: Cigna Commercial |
$3,667.06
|
| Rate for Payer: First Health Commercial |
$4,197.24
|
| Rate for Payer: Humana Commercial |
$3,755.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,622.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,260.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,325.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,887.97
|
| Rate for Payer: Ohio Health Group HMO |
$3,313.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,534.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,843.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,048.52
|
| Rate for Payer: PHCS Commercial |
$4,241.42
|
| Rate for Payer: United Healthcare All Payer |
$3,887.97
|
|
|
WOLVERINE CUT. BALLOON 2.5*15
|
Facility
|
OP
|
$4,418.15
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,325.44 |
| Max. Negotiated Rate |
$4,241.42 |
| Rate for Payer: Aetna Commercial |
$3,401.98
|
| Rate for Payer: Anthem Medicaid |
$1,519.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,446.16
|
| Rate for Payer: Cash Price |
$2,209.07
|
| Rate for Payer: Cigna Commercial |
$3,667.06
|
| Rate for Payer: First Health Commercial |
$4,197.24
|
| Rate for Payer: Humana Commercial |
$3,755.43
|
| Rate for Payer: Humana KY Medicaid |
$1,519.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,534.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,622.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,260.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,325.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,549.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,887.97
|
| Rate for Payer: Ohio Health Group HMO |
$3,313.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,534.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,843.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,048.52
|
| Rate for Payer: PHCS Commercial |
$4,241.42
|
| Rate for Payer: United Healthcare All Payer |
$3,887.97
|
|
|
WOLVERINE CUT. BALLOON 2*6
|
Facility
|
OP
|
$4,572.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,371.75 |
| Max. Negotiated Rate |
$4,389.60 |
| Rate for Payer: Aetna Commercial |
$3,520.82
|
| Rate for Payer: Anthem Medicaid |
$1,572.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,566.55
|
| Rate for Payer: Cash Price |
$2,286.25
|
| Rate for Payer: Cigna Commercial |
$3,795.18
|
| Rate for Payer: First Health Commercial |
$4,343.88
|
| Rate for Payer: Humana Commercial |
$3,886.62
|
| Rate for Payer: Humana KY Medicaid |
$1,572.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1,588.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,749.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,374.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,371.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,604.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,023.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,429.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,658.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,978.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,155.03
|
| Rate for Payer: PHCS Commercial |
$4,389.60
|
| Rate for Payer: United Healthcare All Payer |
$4,023.80
|
|
|
WOLVERINE CUT. BALLOON 2*6
|
Facility
|
IP
|
$4,572.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,371.75 |
| Max. Negotiated Rate |
$4,389.60 |
| Rate for Payer: Aetna Commercial |
$3,520.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,566.55
|
| Rate for Payer: Cash Price |
$2,286.25
|
| Rate for Payer: Cigna Commercial |
$3,795.18
|
| Rate for Payer: First Health Commercial |
$4,343.88
|
| Rate for Payer: Humana Commercial |
$3,886.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,749.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,374.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,371.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,023.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,429.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,658.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,978.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,155.03
|
| Rate for Payer: PHCS Commercial |
$4,389.60
|
| Rate for Payer: United Healthcare All Payer |
$4,023.80
|
|
|
WOLVERINE CUT. BALLOON 3*10
|
Facility
|
IP
|
$4,418.15
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,325.44 |
| Max. Negotiated Rate |
$4,241.42 |
| Rate for Payer: Aetna Commercial |
$3,401.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,446.16
|
| Rate for Payer: Cash Price |
$2,209.07
|
| Rate for Payer: Cigna Commercial |
$3,667.06
|
| Rate for Payer: First Health Commercial |
$4,197.24
|
| Rate for Payer: Humana Commercial |
$3,755.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,622.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,260.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,325.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,887.97
|
| Rate for Payer: Ohio Health Group HMO |
$3,313.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,534.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,843.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,048.52
|
| Rate for Payer: PHCS Commercial |
$4,241.42
|
| Rate for Payer: United Healthcare All Payer |
$3,887.97
|
|
|
WOLVERINE CUT. BALLOON 3*10
|
Facility
|
OP
|
$4,418.15
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,325.44 |
| Max. Negotiated Rate |
$4,241.42 |
| Rate for Payer: Aetna Commercial |
$3,401.98
|
| Rate for Payer: Anthem Medicaid |
$1,519.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,446.16
|
| Rate for Payer: Cash Price |
$2,209.07
|
| Rate for Payer: Cigna Commercial |
$3,667.06
|
| Rate for Payer: First Health Commercial |
$4,197.24
|
| Rate for Payer: Humana Commercial |
$3,755.43
|
| Rate for Payer: Humana KY Medicaid |
$1,519.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,534.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,622.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,260.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,325.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,549.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,887.97
|
| Rate for Payer: Ohio Health Group HMO |
$3,313.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,534.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,843.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,048.52
|
| Rate for Payer: PHCS Commercial |
$4,241.42
|
| Rate for Payer: United Healthcare All Payer |
$3,887.97
|
|
|
WOLVERINE CUT. BALLOON 3*15
|
Facility
|
OP
|
$4,418.15
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,325.44 |
| Max. Negotiated Rate |
$4,241.42 |
| Rate for Payer: Aetna Commercial |
$3,401.98
|
| Rate for Payer: Anthem Medicaid |
$1,519.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,446.16
|
| Rate for Payer: Cash Price |
$2,209.07
|
| Rate for Payer: Cigna Commercial |
$3,667.06
|
| Rate for Payer: First Health Commercial |
$4,197.24
|
| Rate for Payer: Humana Commercial |
$3,755.43
|
| Rate for Payer: Humana KY Medicaid |
$1,519.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,534.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,622.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,260.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,325.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,549.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,887.97
|
| Rate for Payer: Ohio Health Group HMO |
$3,313.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,534.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,843.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,048.52
|
| Rate for Payer: PHCS Commercial |
$4,241.42
|
| Rate for Payer: United Healthcare All Payer |
$3,887.97
|
|
|
WOLVERINE CUT. BALLOON 3*15
|
Facility
|
IP
|
$4,418.15
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,325.44 |
| Max. Negotiated Rate |
$4,241.42 |
| Rate for Payer: Aetna Commercial |
$3,401.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,446.16
|
| Rate for Payer: Cash Price |
$2,209.07
|
| Rate for Payer: Cigna Commercial |
$3,667.06
|
| Rate for Payer: First Health Commercial |
$4,197.24
|
| Rate for Payer: Humana Commercial |
$3,755.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,622.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,260.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,325.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,887.97
|
| Rate for Payer: Ohio Health Group HMO |
$3,313.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,534.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,843.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,048.52
|
| Rate for Payer: PHCS Commercial |
$4,241.42
|
| Rate for Payer: United Healthcare All Payer |
$3,887.97
|
|
|
WOLVERINE CUT. BALLOON 3.50*6
|
Facility
|
OP
|
$4,418.15
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,325.44 |
| Max. Negotiated Rate |
$4,241.42 |
| Rate for Payer: Aetna Commercial |
$3,401.98
|
| Rate for Payer: Anthem Medicaid |
$1,519.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,446.16
|
| Rate for Payer: Cash Price |
$2,209.07
|
| Rate for Payer: Cigna Commercial |
$3,667.06
|
| Rate for Payer: First Health Commercial |
$4,197.24
|
| Rate for Payer: Humana Commercial |
$3,755.43
|
| Rate for Payer: Humana KY Medicaid |
$1,519.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,534.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,622.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,260.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,325.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,549.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,887.97
|
| Rate for Payer: Ohio Health Group HMO |
$3,313.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,534.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,843.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,048.52
|
| Rate for Payer: PHCS Commercial |
$4,241.42
|
| Rate for Payer: United Healthcare All Payer |
$3,887.97
|
|
|
WOLVERINE CUT. BALLOON 3.50*6
|
Facility
|
IP
|
$4,418.15
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,325.44 |
| Max. Negotiated Rate |
$4,241.42 |
| Rate for Payer: Aetna Commercial |
$3,401.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,446.16
|
| Rate for Payer: Cash Price |
$2,209.07
|
| Rate for Payer: Cigna Commercial |
$3,667.06
|
| Rate for Payer: First Health Commercial |
$4,197.24
|
| Rate for Payer: Humana Commercial |
$3,755.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,622.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,260.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,325.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,887.97
|
| Rate for Payer: Ohio Health Group HMO |
$3,313.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,534.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,843.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,048.52
|
| Rate for Payer: PHCS Commercial |
$4,241.42
|
| Rate for Payer: United Healthcare All Payer |
$3,887.97
|
|
|
WOLVERINE CUT. BALLOON 3.5*10
|
Facility
|
IP
|
$4,418.15
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,325.44 |
| Max. Negotiated Rate |
$4,241.42 |
| Rate for Payer: Aetna Commercial |
$3,401.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,446.16
|
| Rate for Payer: Cash Price |
$2,209.07
|
| Rate for Payer: Cigna Commercial |
$3,667.06
|
| Rate for Payer: First Health Commercial |
$4,197.24
|
| Rate for Payer: Humana Commercial |
$3,755.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,622.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,260.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,325.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,887.97
|
| Rate for Payer: Ohio Health Group HMO |
$3,313.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,534.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,843.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,048.52
|
| Rate for Payer: PHCS Commercial |
$4,241.42
|
| Rate for Payer: United Healthcare All Payer |
$3,887.97
|
|
|
WOLVERINE CUT. BALLOON 3.5*10
|
Facility
|
OP
|
$4,418.15
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,325.44 |
| Max. Negotiated Rate |
$4,241.42 |
| Rate for Payer: Aetna Commercial |
$3,401.98
|
| Rate for Payer: Anthem Medicaid |
$1,519.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,446.16
|
| Rate for Payer: Cash Price |
$2,209.07
|
| Rate for Payer: Cigna Commercial |
$3,667.06
|
| Rate for Payer: First Health Commercial |
$4,197.24
|
| Rate for Payer: Humana Commercial |
$3,755.43
|
| Rate for Payer: Humana KY Medicaid |
$1,519.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,534.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,622.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,260.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,325.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,549.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,887.97
|
| Rate for Payer: Ohio Health Group HMO |
$3,313.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,534.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,843.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,048.52
|
| Rate for Payer: PHCS Commercial |
$4,241.42
|
| Rate for Payer: United Healthcare All Payer |
$3,887.97
|
|
|
WOLVERINE CUT. BALLOON 3.5*15
|
Facility
|
IP
|
$4,418.15
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,325.44 |
| Max. Negotiated Rate |
$4,241.42 |
| Rate for Payer: Aetna Commercial |
$3,401.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,446.16
|
| Rate for Payer: Cash Price |
$2,209.07
|
| Rate for Payer: Cigna Commercial |
$3,667.06
|
| Rate for Payer: First Health Commercial |
$4,197.24
|
| Rate for Payer: Humana Commercial |
$3,755.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,622.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,260.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,325.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,887.97
|
| Rate for Payer: Ohio Health Group HMO |
$3,313.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,534.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,843.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,048.52
|
| Rate for Payer: PHCS Commercial |
$4,241.42
|
| Rate for Payer: United Healthcare All Payer |
$3,887.97
|
|
|
WOLVERINE CUT. BALLOON 3.5*15
|
Facility
|
OP
|
$4,418.15
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,325.44 |
| Max. Negotiated Rate |
$4,241.42 |
| Rate for Payer: Aetna Commercial |
$3,401.98
|
| Rate for Payer: Anthem Medicaid |
$1,519.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,446.16
|
| Rate for Payer: Cash Price |
$2,209.07
|
| Rate for Payer: Cigna Commercial |
$3,667.06
|
| Rate for Payer: First Health Commercial |
$4,197.24
|
| Rate for Payer: Humana Commercial |
$3,755.43
|
| Rate for Payer: Humana KY Medicaid |
$1,519.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,534.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,622.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,260.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,325.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,549.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,887.97
|
| Rate for Payer: Ohio Health Group HMO |
$3,313.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,534.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,843.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,048.52
|
| Rate for Payer: PHCS Commercial |
$4,241.42
|
| Rate for Payer: United Healthcare All Payer |
$3,887.97
|
|
|
WOLVERINE CUT. BALLOON 3*6
|
Facility
|
OP
|
$4,418.15
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,325.44 |
| Max. Negotiated Rate |
$4,241.42 |
| Rate for Payer: Aetna Commercial |
$3,401.98
|
| Rate for Payer: Anthem Medicaid |
$1,519.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,446.16
|
| Rate for Payer: Cash Price |
$2,209.07
|
| Rate for Payer: Cigna Commercial |
$3,667.06
|
| Rate for Payer: First Health Commercial |
$4,197.24
|
| Rate for Payer: Humana Commercial |
$3,755.43
|
| Rate for Payer: Humana KY Medicaid |
$1,519.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,534.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,622.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,260.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,325.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,549.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,887.97
|
| Rate for Payer: Ohio Health Group HMO |
$3,313.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,534.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,843.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,048.52
|
| Rate for Payer: PHCS Commercial |
$4,241.42
|
| Rate for Payer: United Healthcare All Payer |
$3,887.97
|
|
|
WOLVERINE CUT. BALLOON 3*6
|
Facility
|
IP
|
$4,418.15
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,325.44 |
| Max. Negotiated Rate |
$4,241.42 |
| Rate for Payer: Aetna Commercial |
$3,401.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,446.16
|
| Rate for Payer: Cash Price |
$2,209.07
|
| Rate for Payer: Cigna Commercial |
$3,667.06
|
| Rate for Payer: First Health Commercial |
$4,197.24
|
| Rate for Payer: Humana Commercial |
$3,755.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,622.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,260.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,325.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,887.97
|
| Rate for Payer: Ohio Health Group HMO |
$3,313.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,534.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,843.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,048.52
|
| Rate for Payer: PHCS Commercial |
$4,241.42
|
| Rate for Payer: United Healthcare All Payer |
$3,887.97
|
|
|
WOLVERINE CUT. BALLOON 4*10
|
Facility
|
IP
|
$4,418.15
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,325.44 |
| Max. Negotiated Rate |
$4,241.42 |
| Rate for Payer: Aetna Commercial |
$3,401.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,446.16
|
| Rate for Payer: Cash Price |
$2,209.07
|
| Rate for Payer: Cigna Commercial |
$3,667.06
|
| Rate for Payer: First Health Commercial |
$4,197.24
|
| Rate for Payer: Humana Commercial |
$3,755.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,622.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,260.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,325.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,887.97
|
| Rate for Payer: Ohio Health Group HMO |
$3,313.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,534.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,843.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,048.52
|
| Rate for Payer: PHCS Commercial |
$4,241.42
|
| Rate for Payer: United Healthcare All Payer |
$3,887.97
|
|
|
WOLVERINE CUT. BALLOON 4*10
|
Facility
|
OP
|
$4,418.15
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,325.44 |
| Max. Negotiated Rate |
$4,241.42 |
| Rate for Payer: Aetna Commercial |
$3,401.98
|
| Rate for Payer: Anthem Medicaid |
$1,519.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,446.16
|
| Rate for Payer: Cash Price |
$2,209.07
|
| Rate for Payer: Cigna Commercial |
$3,667.06
|
| Rate for Payer: First Health Commercial |
$4,197.24
|
| Rate for Payer: Humana Commercial |
$3,755.43
|
| Rate for Payer: Humana KY Medicaid |
$1,519.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,534.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,622.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,260.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,325.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,549.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,887.97
|
| Rate for Payer: Ohio Health Group HMO |
$3,313.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,534.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,843.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,048.52
|
| Rate for Payer: PHCS Commercial |
$4,241.42
|
| Rate for Payer: United Healthcare All Payer |
$3,887.97
|
|
