|
COYOTE BALLOON 2*60*150 OTW
|
Facility
|
OP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem Medicaid |
$665.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Humana KY Medicaid |
$665.31
|
| Rate for Payer: Kentucky WC Medicaid |
$672.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$678.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE BALLOON 2*60*90
|
Facility
|
OP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem Medicaid |
$665.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Humana KY Medicaid |
$665.31
|
| Rate for Payer: Kentucky WC Medicaid |
$672.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$678.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE BALLOON 2*60*90
|
Facility
|
IP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE BALLOON 2*80*150 OTW
|
Facility
|
IP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE BALLOON 2*80*150 OTW
|
Facility
|
OP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem Medicaid |
$665.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Humana KY Medicaid |
$665.31
|
| Rate for Payer: Kentucky WC Medicaid |
$672.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$678.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE BALLOON 2*80*90
|
Facility
|
OP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem Medicaid |
$665.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Humana KY Medicaid |
$665.31
|
| Rate for Payer: Kentucky WC Medicaid |
$672.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$678.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE BALLOON 2*80*90
|
Facility
|
IP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE BALLOON 3*100*150 OTW
|
Facility
|
OP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem Medicaid |
$665.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Humana KY Medicaid |
$665.31
|
| Rate for Payer: Kentucky WC Medicaid |
$672.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$678.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE BALLOON 3*100*150 OTW
|
Facility
|
IP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE BALLOON 3*120*150 OTW
|
Facility
|
IP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE BALLOON 3*120*150 OTW
|
Facility
|
OP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem Medicaid |
$665.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Humana KY Medicaid |
$665.31
|
| Rate for Payer: Kentucky WC Medicaid |
$672.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$678.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE BALLOON 3*150*150 OTW
|
Facility
|
OP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem Medicaid |
$665.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Humana KY Medicaid |
$665.31
|
| Rate for Payer: Kentucky WC Medicaid |
$672.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$678.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE BALLOON 3*150*150 OTW
|
Facility
|
IP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE BALLOON 3*150*90
|
Facility
|
OP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem Medicaid |
$665.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Humana KY Medicaid |
$665.31
|
| Rate for Payer: Kentucky WC Medicaid |
$672.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$678.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE BALLOON 3*150*90
|
Facility
|
IP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE BALLOON 3*220*150 OTW
|
Facility
|
IP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE BALLOON 3*220*150 OTW
|
Facility
|
OP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem Medicaid |
$665.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Humana KY Medicaid |
$665.31
|
| Rate for Payer: Kentucky WC Medicaid |
$672.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$678.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE BALLOON 3.5*100*150 OTW
|
Facility
|
OP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem Medicaid |
$665.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Humana KY Medicaid |
$665.31
|
| Rate for Payer: Kentucky WC Medicaid |
$672.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$678.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE BALLOON 3.5*100*150 OTW
|
Facility
|
IP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE BALLOON 3.5*120*150 OTW
|
Facility
|
OP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem Medicaid |
$665.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Humana KY Medicaid |
$665.31
|
| Rate for Payer: Kentucky WC Medicaid |
$672.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$678.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE BALLOON 3.5*120*150 OTW
|
Facility
|
IP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE BALLOON 3.5*150*150 OTW
|
Facility
|
IP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE BALLOON 3.5*150*150 OTW
|
Facility
|
OP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem Medicaid |
$665.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Humana KY Medicaid |
$665.31
|
| Rate for Payer: Kentucky WC Medicaid |
$672.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$678.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE BALLOON 3.5*150*90
|
Facility
|
OP
|
$3,200.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$960.00 |
| Max. Negotiated Rate |
$3,072.00 |
| Rate for Payer: Aetna Commercial |
$2,464.00
|
| Rate for Payer: Anthem Medicaid |
$1,100.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,496.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cigna Commercial |
$2,656.00
|
| Rate for Payer: First Health Commercial |
$3,040.00
|
| Rate for Payer: Humana Commercial |
$2,720.00
|
| Rate for Payer: Humana KY Medicaid |
$1,100.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1,111.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,624.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,361.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$960.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,122.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,816.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,560.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,784.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,208.00
|
| Rate for Payer: PHCS Commercial |
$3,072.00
|
| Rate for Payer: United Healthcare All Payer |
$2,816.00
|
|
|
COYOTE BALLOON 3.5*150*90
|
Facility
|
IP
|
$3,200.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$960.00 |
| Max. Negotiated Rate |
$3,072.00 |
| Rate for Payer: Aetna Commercial |
$2,464.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,496.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cigna Commercial |
$2,656.00
|
| Rate for Payer: First Health Commercial |
$3,040.00
|
| Rate for Payer: Humana Commercial |
$2,720.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,624.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,361.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$960.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,816.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,560.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,784.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,208.00
|
| Rate for Payer: PHCS Commercial |
$3,072.00
|
| Rate for Payer: United Healthcare All Payer |
$2,816.00
|
|
