|
CONQ FX FEM COMP SZ 16
|
Facility
|
OP
|
$5,375.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,612.50 |
| Max. Negotiated Rate |
$5,160.00 |
| Rate for Payer: Aetna Commercial |
$4,138.75
|
| Rate for Payer: Anthem Medicaid |
$1,848.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,192.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$4,461.25
|
| Rate for Payer: First Health Commercial |
$5,106.25
|
| Rate for Payer: Humana Commercial |
$4,568.75
|
| Rate for Payer: Humana KY Medicaid |
$1,848.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1,867.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,407.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,966.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,612.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,885.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,730.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,676.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,708.75
|
| Rate for Payer: PHCS Commercial |
$5,160.00
|
| Rate for Payer: United Healthcare All Payer |
$4,730.00
|
|
|
CONQ FX FEM COMP SZ 17
|
Facility
|
IP
|
$5,375.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,612.50 |
| Max. Negotiated Rate |
$5,160.00 |
| Rate for Payer: Aetna Commercial |
$4,138.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,192.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$4,461.25
|
| Rate for Payer: First Health Commercial |
$5,106.25
|
| Rate for Payer: Humana Commercial |
$4,568.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,407.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,966.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,612.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,730.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,676.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,708.75
|
| Rate for Payer: PHCS Commercial |
$5,160.00
|
| Rate for Payer: United Healthcare All Payer |
$4,730.00
|
|
|
CONQ FX FEM COMP SZ 17
|
Facility
|
OP
|
$5,375.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,612.50 |
| Max. Negotiated Rate |
$5,160.00 |
| Rate for Payer: Aetna Commercial |
$4,138.75
|
| Rate for Payer: Anthem Medicaid |
$1,848.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,192.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$4,461.25
|
| Rate for Payer: First Health Commercial |
$5,106.25
|
| Rate for Payer: Humana Commercial |
$4,568.75
|
| Rate for Payer: Humana KY Medicaid |
$1,848.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1,867.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,407.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,966.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,612.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,885.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,730.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,676.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,708.75
|
| Rate for Payer: PHCS Commercial |
$5,160.00
|
| Rate for Payer: United Healthcare All Payer |
$4,730.00
|
|
|
CONQ FX FEM COMP SZ 18
|
Facility
|
IP
|
$5,375.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,612.50 |
| Max. Negotiated Rate |
$5,160.00 |
| Rate for Payer: Aetna Commercial |
$4,138.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,192.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$4,461.25
|
| Rate for Payer: First Health Commercial |
$5,106.25
|
| Rate for Payer: Humana Commercial |
$4,568.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,407.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,966.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,612.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,730.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,676.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,708.75
|
| Rate for Payer: PHCS Commercial |
$5,160.00
|
| Rate for Payer: United Healthcare All Payer |
$4,730.00
|
|
|
CONQ FX FEM COMP SZ 18
|
Facility
|
OP
|
$5,375.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,612.50 |
| Max. Negotiated Rate |
$5,160.00 |
| Rate for Payer: Aetna Commercial |
$4,138.75
|
| Rate for Payer: Anthem Medicaid |
$1,848.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,192.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$4,461.25
|
| Rate for Payer: First Health Commercial |
$5,106.25
|
| Rate for Payer: Humana Commercial |
$4,568.75
|
| Rate for Payer: Humana KY Medicaid |
$1,848.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1,867.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,407.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,966.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,612.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,885.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,730.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,676.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,708.75
|
| Rate for Payer: PHCS Commercial |
$5,160.00
|
| Rate for Payer: United Healthcare All Payer |
$4,730.00
|
|
|
CONQ FX FEM COMP SZ 9
|
Facility
|
OP
|
$5,375.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,612.50 |
| Max. Negotiated Rate |
$5,160.00 |
| Rate for Payer: Aetna Commercial |
$4,138.75
|
| Rate for Payer: Anthem Medicaid |
$1,848.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,192.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$4,461.25
|
| Rate for Payer: First Health Commercial |
$5,106.25
|
| Rate for Payer: Humana Commercial |
$4,568.75
|
| Rate for Payer: Humana KY Medicaid |
$1,848.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1,867.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,407.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,966.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,612.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,885.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,730.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,676.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,708.75
|
| Rate for Payer: PHCS Commercial |
$5,160.00
|
| Rate for Payer: United Healthcare All Payer |
$4,730.00
|
|
|
CONQ FX FEM COMP SZ 9
|
Facility
|
IP
|
$5,375.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,612.50 |
| Max. Negotiated Rate |
$5,160.00 |
| Rate for Payer: Aetna Commercial |
$4,138.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,192.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$4,461.25
|
| Rate for Payer: First Health Commercial |
$5,106.25
|
| Rate for Payer: Humana Commercial |
$4,568.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,407.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,966.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,612.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,730.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,676.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,708.75
|
| Rate for Payer: PHCS Commercial |
$5,160.00
|
| Rate for Payer: United Healthcare All Payer |
$4,730.00
|
|
|
CONQUEST BALLOON 10*4
|
Facility
|
OP
|
$2,993.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$898.12 |
| Max. Negotiated Rate |
$2,874.00 |
| Rate for Payer: Aetna Commercial |
$2,305.19
|
| Rate for Payer: Anthem Medicaid |
$1,029.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,335.12
|
| Rate for Payer: Cash Price |
$1,496.88
|
| Rate for Payer: Cigna Commercial |
$2,484.81
|
| Rate for Payer: First Health Commercial |
$2,844.06
|
| Rate for Payer: Humana Commercial |
$2,544.69
|
| Rate for Payer: Humana KY Medicaid |
$1,029.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1,040.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,454.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,209.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$898.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,050.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,634.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,245.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,395.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,604.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,065.69
|
| Rate for Payer: PHCS Commercial |
$2,874.00
|
| Rate for Payer: United Healthcare All Payer |
$2,634.50
|
|
|
CONQUEST BALLOON 10*4
|
Facility
|
IP
|
$2,993.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$898.12 |
| Max. Negotiated Rate |
$2,874.00 |
| Rate for Payer: Aetna Commercial |
$2,305.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,335.12
|
| Rate for Payer: Cash Price |
$1,496.88
|
| Rate for Payer: Cigna Commercial |
$2,484.81
|
| Rate for Payer: First Health Commercial |
$2,844.06
|
| Rate for Payer: Humana Commercial |
$2,544.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,454.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,209.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$898.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,634.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,245.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,395.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,604.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,065.69
|
| Rate for Payer: PHCS Commercial |
$2,874.00
|
| Rate for Payer: United Healthcare All Payer |
$2,634.50
|
|
|
CONQUEST BALLOON 12*4
|
Facility
|
IP
|
$2,993.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$898.12 |
| Max. Negotiated Rate |
$2,874.00 |
| Rate for Payer: Aetna Commercial |
$2,305.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,335.12
|
| Rate for Payer: Cash Price |
$1,496.88
|
| Rate for Payer: Cigna Commercial |
$2,484.81
|
| Rate for Payer: First Health Commercial |
$2,844.06
|
| Rate for Payer: Humana Commercial |
$2,544.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,454.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,209.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$898.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,634.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,245.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,395.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,604.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,065.69
|
| Rate for Payer: PHCS Commercial |
$2,874.00
|
| Rate for Payer: United Healthcare All Payer |
$2,634.50
|
|
|
CONQUEST BALLOON 12*4
|
Facility
|
OP
|
$2,993.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$898.12 |
| Max. Negotiated Rate |
$2,874.00 |
| Rate for Payer: Aetna Commercial |
$2,305.19
|
| Rate for Payer: Anthem Medicaid |
$1,029.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,335.12
|
| Rate for Payer: Cash Price |
$1,496.88
|
| Rate for Payer: Cigna Commercial |
$2,484.81
|
| Rate for Payer: First Health Commercial |
$2,844.06
|
| Rate for Payer: Humana Commercial |
$2,544.69
|
| Rate for Payer: Humana KY Medicaid |
$1,029.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1,040.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,454.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,209.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$898.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,050.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,634.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,245.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,395.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,604.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,065.69
|
| Rate for Payer: PHCS Commercial |
$2,874.00
|
| Rate for Payer: United Healthcare All Payer |
$2,634.50
|
|
|
CONQUEST BALLOON 6*4
|
Facility
|
IP
|
$2,993.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$898.12 |
| Max. Negotiated Rate |
$2,874.00 |
| Rate for Payer: Aetna Commercial |
$2,305.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,335.12
|
| Rate for Payer: Cash Price |
$1,496.88
|
| Rate for Payer: Cigna Commercial |
$2,484.81
|
| Rate for Payer: First Health Commercial |
$2,844.06
|
| Rate for Payer: Humana Commercial |
$2,544.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,454.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,209.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$898.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,634.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,245.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,395.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,604.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,065.69
|
| Rate for Payer: PHCS Commercial |
$2,874.00
|
| Rate for Payer: United Healthcare All Payer |
$2,634.50
|
|
|
CONQUEST BALLOON 6*4
|
Facility
|
OP
|
$2,993.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$898.12 |
| Max. Negotiated Rate |
$2,874.00 |
| Rate for Payer: Aetna Commercial |
$2,305.19
|
| Rate for Payer: Anthem Medicaid |
$1,029.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,335.12
|
| Rate for Payer: Cash Price |
$1,496.88
|
| Rate for Payer: Cigna Commercial |
$2,484.81
|
| Rate for Payer: First Health Commercial |
$2,844.06
|
| Rate for Payer: Humana Commercial |
$2,544.69
|
| Rate for Payer: Humana KY Medicaid |
$1,029.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1,040.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,454.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,209.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$898.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,050.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,634.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,245.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,395.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,604.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,065.69
|
| Rate for Payer: PHCS Commercial |
$2,874.00
|
| Rate for Payer: United Healthcare All Payer |
$2,634.50
|
|
|
CONQUEST BALLOON 6*8
|
Facility
|
OP
|
$2,993.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$898.12 |
| Max. Negotiated Rate |
$2,874.00 |
| Rate for Payer: Aetna Commercial |
$2,305.19
|
| Rate for Payer: Anthem Medicaid |
$1,029.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,335.12
|
| Rate for Payer: Cash Price |
$1,496.88
|
| Rate for Payer: Cigna Commercial |
$2,484.81
|
| Rate for Payer: First Health Commercial |
$2,844.06
|
| Rate for Payer: Humana Commercial |
$2,544.69
|
| Rate for Payer: Humana KY Medicaid |
$1,029.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1,040.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,454.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,209.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$898.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,050.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,634.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,245.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,395.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,604.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,065.69
|
| Rate for Payer: PHCS Commercial |
$2,874.00
|
| Rate for Payer: United Healthcare All Payer |
$2,634.50
|
|
|
CONQUEST BALLOON 6*8
|
Facility
|
IP
|
$2,993.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$898.12 |
| Max. Negotiated Rate |
$2,874.00 |
| Rate for Payer: Aetna Commercial |
$2,305.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,335.12
|
| Rate for Payer: Cash Price |
$1,496.88
|
| Rate for Payer: Cigna Commercial |
$2,484.81
|
| Rate for Payer: First Health Commercial |
$2,844.06
|
| Rate for Payer: Humana Commercial |
$2,544.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,454.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,209.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$898.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,634.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,245.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,395.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,604.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,065.69
|
| Rate for Payer: PHCS Commercial |
$2,874.00
|
| Rate for Payer: United Healthcare All Payer |
$2,634.50
|
|
|
CONQUEST BALLOON 7*4
|
Facility
|
OP
|
$2,993.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$898.12 |
| Max. Negotiated Rate |
$2,874.00 |
| Rate for Payer: Aetna Commercial |
$2,305.19
|
| Rate for Payer: Anthem Medicaid |
$1,029.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,335.12
|
| Rate for Payer: Cash Price |
$1,496.88
|
| Rate for Payer: Cigna Commercial |
$2,484.81
|
| Rate for Payer: First Health Commercial |
$2,844.06
|
| Rate for Payer: Humana Commercial |
$2,544.69
|
| Rate for Payer: Humana KY Medicaid |
$1,029.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1,040.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,454.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,209.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$898.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,050.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,634.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,245.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,395.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,604.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,065.69
|
| Rate for Payer: PHCS Commercial |
$2,874.00
|
| Rate for Payer: United Healthcare All Payer |
$2,634.50
|
|
|
CONQUEST BALLOON 7*4
|
Facility
|
IP
|
$2,993.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$898.12 |
| Max. Negotiated Rate |
$2,874.00 |
| Rate for Payer: Aetna Commercial |
$2,305.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,335.12
|
| Rate for Payer: Cash Price |
$1,496.88
|
| Rate for Payer: Cigna Commercial |
$2,484.81
|
| Rate for Payer: First Health Commercial |
$2,844.06
|
| Rate for Payer: Humana Commercial |
$2,544.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,454.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,209.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$898.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,634.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,245.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,395.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,604.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,065.69
|
| Rate for Payer: PHCS Commercial |
$2,874.00
|
| Rate for Payer: United Healthcare All Payer |
$2,634.50
|
|
|
CONQUEST BALLOON 7*8
|
Facility
|
OP
|
$2,993.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$898.12 |
| Max. Negotiated Rate |
$2,874.00 |
| Rate for Payer: Aetna Commercial |
$2,305.19
|
| Rate for Payer: Anthem Medicaid |
$1,029.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,335.12
|
| Rate for Payer: Cash Price |
$1,496.88
|
| Rate for Payer: Cigna Commercial |
$2,484.81
|
| Rate for Payer: First Health Commercial |
$2,844.06
|
| Rate for Payer: Humana Commercial |
$2,544.69
|
| Rate for Payer: Humana KY Medicaid |
$1,029.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1,040.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,454.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,209.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$898.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,050.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,634.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,245.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,395.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,604.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,065.69
|
| Rate for Payer: PHCS Commercial |
$2,874.00
|
| Rate for Payer: United Healthcare All Payer |
$2,634.50
|
|
|
CONQUEST BALLOON 7*8
|
Facility
|
IP
|
$2,993.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$898.12 |
| Max. Negotiated Rate |
$2,874.00 |
| Rate for Payer: Aetna Commercial |
$2,305.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,335.12
|
| Rate for Payer: Cash Price |
$1,496.88
|
| Rate for Payer: Cigna Commercial |
$2,484.81
|
| Rate for Payer: First Health Commercial |
$2,844.06
|
| Rate for Payer: Humana Commercial |
$2,544.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,454.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,209.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$898.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,634.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,245.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,395.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,604.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,065.69
|
| Rate for Payer: PHCS Commercial |
$2,874.00
|
| Rate for Payer: United Healthcare All Payer |
$2,634.50
|
|
|
CONQUEST BALLOON 8*4
|
Facility
|
IP
|
$2,993.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$898.12 |
| Max. Negotiated Rate |
$2,874.00 |
| Rate for Payer: Aetna Commercial |
$2,305.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,335.12
|
| Rate for Payer: Cash Price |
$1,496.88
|
| Rate for Payer: Cigna Commercial |
$2,484.81
|
| Rate for Payer: First Health Commercial |
$2,844.06
|
| Rate for Payer: Humana Commercial |
$2,544.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,454.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,209.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$898.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,634.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,245.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,395.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,604.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,065.69
|
| Rate for Payer: PHCS Commercial |
$2,874.00
|
| Rate for Payer: United Healthcare All Payer |
$2,634.50
|
|
|
CONQUEST BALLOON 8*4
|
Facility
|
OP
|
$2,993.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$898.12 |
| Max. Negotiated Rate |
$2,874.00 |
| Rate for Payer: Aetna Commercial |
$2,305.19
|
| Rate for Payer: Anthem Medicaid |
$1,029.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,335.12
|
| Rate for Payer: Cash Price |
$1,496.88
|
| Rate for Payer: Cigna Commercial |
$2,484.81
|
| Rate for Payer: First Health Commercial |
$2,844.06
|
| Rate for Payer: Humana Commercial |
$2,544.69
|
| Rate for Payer: Humana KY Medicaid |
$1,029.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1,040.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,454.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,209.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$898.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,050.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,634.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,245.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,395.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,604.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,065.69
|
| Rate for Payer: PHCS Commercial |
$2,874.00
|
| Rate for Payer: United Healthcare All Payer |
$2,634.50
|
|
|
CONQUEST BALLOON 8*8
|
Facility
|
OP
|
$2,993.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$898.12 |
| Max. Negotiated Rate |
$2,874.00 |
| Rate for Payer: Aetna Commercial |
$2,305.19
|
| Rate for Payer: Anthem Medicaid |
$1,029.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,335.12
|
| Rate for Payer: Cash Price |
$1,496.88
|
| Rate for Payer: Cigna Commercial |
$2,484.81
|
| Rate for Payer: First Health Commercial |
$2,844.06
|
| Rate for Payer: Humana Commercial |
$2,544.69
|
| Rate for Payer: Humana KY Medicaid |
$1,029.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1,040.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,454.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,209.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$898.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,050.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,634.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,245.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,395.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,604.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,065.69
|
| Rate for Payer: PHCS Commercial |
$2,874.00
|
| Rate for Payer: United Healthcare All Payer |
$2,634.50
|
|
|
CONQUEST BALLOON 8*8
|
Facility
|
IP
|
$2,993.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$898.12 |
| Max. Negotiated Rate |
$2,874.00 |
| Rate for Payer: Aetna Commercial |
$2,305.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,335.12
|
| Rate for Payer: Cash Price |
$1,496.88
|
| Rate for Payer: Cigna Commercial |
$2,484.81
|
| Rate for Payer: First Health Commercial |
$2,844.06
|
| Rate for Payer: Humana Commercial |
$2,544.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,454.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,209.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$898.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,634.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,245.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,395.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,604.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,065.69
|
| Rate for Payer: PHCS Commercial |
$2,874.00
|
| Rate for Payer: United Healthcare All Payer |
$2,634.50
|
|
|
CONQUEST BALLOON 9*4
|
Facility
|
IP
|
$2,993.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$898.12 |
| Max. Negotiated Rate |
$2,874.00 |
| Rate for Payer: Aetna Commercial |
$2,305.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,335.12
|
| Rate for Payer: Cash Price |
$1,496.88
|
| Rate for Payer: Cigna Commercial |
$2,484.81
|
| Rate for Payer: First Health Commercial |
$2,844.06
|
| Rate for Payer: Humana Commercial |
$2,544.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,454.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,209.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$898.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,634.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,245.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,395.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,604.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,065.69
|
| Rate for Payer: PHCS Commercial |
$2,874.00
|
| Rate for Payer: United Healthcare All Payer |
$2,634.50
|
|
|
CONQUEST BALLOON 9*4
|
Facility
|
OP
|
$2,993.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$898.12 |
| Max. Negotiated Rate |
$2,874.00 |
| Rate for Payer: Aetna Commercial |
$2,305.19
|
| Rate for Payer: Anthem Medicaid |
$1,029.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,335.12
|
| Rate for Payer: Cash Price |
$1,496.88
|
| Rate for Payer: Cigna Commercial |
$2,484.81
|
| Rate for Payer: First Health Commercial |
$2,844.06
|
| Rate for Payer: Humana Commercial |
$2,544.69
|
| Rate for Payer: Humana KY Medicaid |
$1,029.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1,040.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,454.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,209.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$898.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,050.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,634.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,245.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,395.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,604.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,065.69
|
| Rate for Payer: PHCS Commercial |
$2,874.00
|
| Rate for Payer: United Healthcare All Payer |
$2,634.50
|
|
