|
LPT GREAT TOE KIT W/SIZERS
|
Facility
|
IP
|
$11,238.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,461.04 |
| Max. Negotiated Rate |
$10,789.20 |
| Rate for Payer: Aetna Commercial |
$8,653.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,766.22
|
| Rate for Payer: Cash Price |
$5,619.38
|
| Rate for Payer: Cigna Commercial |
$9,328.16
|
| Rate for Payer: First Health Commercial |
$10,676.81
|
| Rate for Payer: Humana Commercial |
$9,552.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,215.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,294.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,371.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,890.10
|
| Rate for Payer: Ohio Health Group HMO |
$8,429.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,247.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,461.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,484.01
|
| Rate for Payer: PHCS Commercial |
$10,789.20
|
| Rate for Payer: United Healthcare All Payer |
$9,890.10
|
|
|
LPT GREAT TOE SZ 0 STRAIGHT
|
Facility
|
IP
|
$8,731.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,135.06 |
| Max. Negotiated Rate |
$8,382.00 |
| Rate for Payer: Aetna Commercial |
$6,723.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,810.38
|
| Rate for Payer: Cash Price |
$4,365.62
|
| Rate for Payer: Cigna Commercial |
$7,246.94
|
| Rate for Payer: First Health Commercial |
$8,294.69
|
| Rate for Payer: Humana Commercial |
$7,421.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,159.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,443.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,619.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,683.50
|
| Rate for Payer: Ohio Health Group HMO |
$6,548.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,746.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,135.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,706.69
|
| Rate for Payer: PHCS Commercial |
$8,382.00
|
| Rate for Payer: United Healthcare All Payer |
$7,683.50
|
|
|
LPT GREAT TOE SZ 0 STRAIGHT
|
Facility
|
OP
|
$8,731.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,135.06 |
| Max. Negotiated Rate |
$8,382.00 |
| Rate for Payer: Aetna Commercial |
$6,723.06
|
| Rate for Payer: Anthem Medicaid |
$3,002.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,810.38
|
| Rate for Payer: Cash Price |
$4,365.62
|
| Rate for Payer: Cigna Commercial |
$7,246.94
|
| Rate for Payer: First Health Commercial |
$8,294.69
|
| Rate for Payer: Humana Commercial |
$7,421.56
|
| Rate for Payer: Humana KY Medicaid |
$3,002.68
|
| Rate for Payer: Kentucky WC Medicaid |
$3,033.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,159.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,443.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,619.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,062.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,683.50
|
| Rate for Payer: Ohio Health Group HMO |
$6,548.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,746.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,135.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,706.69
|
| Rate for Payer: PHCS Commercial |
$8,382.00
|
| Rate for Payer: United Healthcare All Payer |
$7,683.50
|
|
|
LPT GREAT TOE SZ 1 STRAIGHT
|
Facility
|
IP
|
$8,731.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,135.06 |
| Max. Negotiated Rate |
$8,382.00 |
| Rate for Payer: Aetna Commercial |
$6,723.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,810.38
|
| Rate for Payer: Cash Price |
$4,365.62
|
| Rate for Payer: Cigna Commercial |
$7,246.94
|
| Rate for Payer: First Health Commercial |
$8,294.69
|
| Rate for Payer: Humana Commercial |
$7,421.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,159.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,443.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,619.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,683.50
|
| Rate for Payer: Ohio Health Group HMO |
$6,548.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,746.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,135.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,706.69
|
| Rate for Payer: PHCS Commercial |
$8,382.00
|
| Rate for Payer: United Healthcare All Payer |
$7,683.50
|
|
|
LPT GREAT TOE SZ 1 STRAIGHT
|
Facility
|
OP
|
$8,731.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,135.06 |
| Max. Negotiated Rate |
$8,382.00 |
| Rate for Payer: Aetna Commercial |
$6,723.06
|
| Rate for Payer: Anthem Medicaid |
$3,002.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,810.38
|
| Rate for Payer: Cash Price |
$4,365.62
|
| Rate for Payer: Cigna Commercial |
$7,246.94
|
| Rate for Payer: First Health Commercial |
$8,294.69
|
| Rate for Payer: Humana Commercial |
$7,421.56
|
| Rate for Payer: Humana KY Medicaid |
$3,002.68
|
| Rate for Payer: Kentucky WC Medicaid |
$3,033.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,159.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,443.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,619.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,062.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,683.50
|
| Rate for Payer: Ohio Health Group HMO |
$6,548.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,746.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,135.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,706.69
|
| Rate for Payer: PHCS Commercial |
$8,382.00
|
| Rate for Payer: United Healthcare All Payer |
$7,683.50
|
|
|
LSH W/T/O UT 250 G OR LESS
|
Facility
|
IP
|
$2,250.00
|
|
|
Service Code
|
HCPCS 58542
|
| Hospital Charge Code |
76102228
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$292.50 |
| Max. Negotiated Rate |
$2,160.00 |
| Rate for Payer: Aetna Commercial |
$1,732.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,755.00
|
| Rate for Payer: Cash Price |
$1,125.00
|
| Rate for Payer: Cigna Commercial |
$1,867.50
|
| Rate for Payer: First Health Commercial |
$2,137.50
|
| Rate for Payer: Humana Commercial |
$1,912.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,845.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,660.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$675.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,980.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,687.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$292.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$697.50
|
| Rate for Payer: PHCS Commercial |
$2,160.00
|
| Rate for Payer: United Healthcare All Payer |
$1,980.00
|
|
|
LSH W/T/O UT 250 G OR LESS
|
Facility
|
OP
|
$2,250.00
|
|
|
Service Code
|
HCPCS 58542
|
| Hospital Charge Code |
76102228
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$292.50 |
| Max. Negotiated Rate |
$12,462.13 |
| Rate for Payer: Aetna Commercial |
$1,732.50
|
| Rate for Payer: Anthem Medicaid |
$773.78
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8,901.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,755.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12,462.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$12,017.05
|
| Rate for Payer: Cash Price |
$1,125.00
|
| Rate for Payer: Cash Price |
$1,125.00
|
| Rate for Payer: Cigna Commercial |
$1,867.50
|
| Rate for Payer: First Health Commercial |
$2,137.50
|
| Rate for Payer: Humana Commercial |
$1,912.50
|
| Rate for Payer: Humana KY Medicaid |
$773.78
|
| Rate for Payer: Humana Medicare Advantage |
$8,901.52
|
| Rate for Payer: Kentucky WC Medicaid |
$781.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,845.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,660.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,681.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$789.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,980.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,687.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$292.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$697.50
|
| Rate for Payer: PHCS Commercial |
$2,160.00
|
| Rate for Payer: United Healthcare All Payer |
$1,980.00
|
|
|
LSH W/T/O UT 250 G OR LESS
|
Professional
|
Both
|
$2,250.00
|
|
|
Service Code
|
HCPCS 58542
|
| Hospital Charge Code |
76102228
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$684.88 |
| Max. Negotiated Rate |
$2,250.00 |
| Rate for Payer: Aetna Commercial |
$1,440.26
|
| Rate for Payer: Anthem Medicaid |
$684.88
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,250.00
|
| Rate for Payer: Cash Price |
$1,125.00
|
| Rate for Payer: Cash Price |
$1,125.00
|
| Rate for Payer: Cigna Commercial |
$1,370.47
|
| Rate for Payer: Healthspan PPO |
$1,394.54
|
| Rate for Payer: Humana Medicaid |
$684.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,249.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$698.58
|
| Rate for Payer: Molina Healthcare Passport |
$684.88
|
| Rate for Payer: Multiplan PHCS |
$1,350.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,575.00
|
| Rate for Payer: UHCCP Medicaid |
$787.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$691.73
|
|
|
LSH W/T/O UT 250 G OR LESS(P
|
Professional
|
Both
|
$2,250.00
|
|
|
Service Code
|
HCPCS 58542
|
| Hospital Charge Code |
761P2228
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$684.88 |
| Max. Negotiated Rate |
$2,250.00 |
| Rate for Payer: Aetna Commercial |
$1,440.26
|
| Rate for Payer: Anthem Medicaid |
$684.88
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,250.00
|
| Rate for Payer: Cash Price |
$1,125.00
|
| Rate for Payer: Cash Price |
$1,125.00
|
| Rate for Payer: Cigna Commercial |
$1,370.47
|
| Rate for Payer: Healthspan PPO |
$1,394.54
|
| Rate for Payer: Humana Medicaid |
$684.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,249.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$698.58
|
| Rate for Payer: Molina Healthcare Passport |
$684.88
|
| Rate for Payer: Multiplan PHCS |
$1,350.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,575.00
|
| Rate for Payer: UHCCP Medicaid |
$787.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$691.73
|
|
|
LTA KIT 1EA
|
Facility
|
OP
|
$68.20
|
|
|
Service Code
|
NDC 76329630005
|
| Hospital Charge Code |
25003189
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.87 |
| Max. Negotiated Rate |
$65.47 |
| Rate for Payer: Aetna Commercial |
$52.51
|
| Rate for Payer: Anthem Medicaid |
$23.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53.20
|
| Rate for Payer: Cash Price |
$34.10
|
| Rate for Payer: Cigna Commercial |
$56.61
|
| Rate for Payer: First Health Commercial |
$64.79
|
| Rate for Payer: Humana Commercial |
$57.97
|
| Rate for Payer: Humana KY Medicaid |
$23.45
|
| Rate for Payer: Kentucky WC Medicaid |
$23.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.02
|
| Rate for Payer: Ohio Health Group HMO |
$51.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.14
|
| Rate for Payer: PHCS Commercial |
$65.47
|
| Rate for Payer: United Healthcare All Payer |
$60.02
|
|
|
LTA KIT 1EA
|
Facility
|
IP
|
$68.20
|
|
|
Service Code
|
NDC 76329630005
|
| Hospital Charge Code |
25003189
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.87 |
| Max. Negotiated Rate |
$65.47 |
| Rate for Payer: Aetna Commercial |
$52.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53.20
|
| Rate for Payer: Cash Price |
$34.10
|
| Rate for Payer: Cigna Commercial |
$56.61
|
| Rate for Payer: First Health Commercial |
$64.79
|
| Rate for Payer: Humana Commercial |
$57.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.02
|
| Rate for Payer: Ohio Health Group HMO |
$51.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.14
|
| Rate for Payer: PHCS Commercial |
$65.47
|
| Rate for Payer: United Healthcare All Payer |
$60.02
|
|
|
LT AXILLA US
|
Professional
|
Both
|
$838.00
|
|
|
Service Code
|
HCPCS 76882
|
| Hospital Charge Code |
40200062
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$25.62 |
| Max. Negotiated Rate |
$838.00 |
| Rate for Payer: Aetna Commercial |
$47.98
|
| Rate for Payer: Anthem Medicaid |
$26.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$838.00
|
| Rate for Payer: Cash Price |
$419.00
|
| Rate for Payer: Cash Price |
$419.00
|
| Rate for Payer: Cigna Commercial |
$50.74
|
| Rate for Payer: Healthspan PPO |
$33.70
|
| Rate for Payer: Humana Medicaid |
$26.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$25.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$26.94
|
| Rate for Payer: Molina Healthcare Passport |
$26.41
|
| Rate for Payer: Multiplan PHCS |
$502.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$586.60
|
| Rate for Payer: UHCCP Medicaid |
$293.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$26.67
|
|
|
LT AXILLA US
|
Facility
|
OP
|
$838.00
|
|
|
Service Code
|
HCPCS 76882
|
| Hospital Charge Code |
40200062
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$804.48 |
| Rate for Payer: Aetna Commercial |
$645.26
|
| Rate for Payer: Anthem Medicaid |
$288.19
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$653.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$419.00
|
| Rate for Payer: Cash Price |
$419.00
|
| Rate for Payer: Cigna Commercial |
$695.54
|
| Rate for Payer: First Health Commercial |
$796.10
|
| Rate for Payer: Humana Commercial |
$712.30
|
| Rate for Payer: Humana KY Medicaid |
$288.19
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$291.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$687.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$618.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$293.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$737.44
|
| Rate for Payer: Ohio Health Group HMO |
$628.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$167.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$108.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$259.78
|
| Rate for Payer: PHCS Commercial |
$804.48
|
| Rate for Payer: United Healthcare All Payer |
$737.44
|
|
|
LT AXILLA US
|
Facility
|
IP
|
$838.00
|
|
|
Service Code
|
HCPCS 76882
|
| Hospital Charge Code |
40200062
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$108.94 |
| Max. Negotiated Rate |
$804.48 |
| Rate for Payer: Aetna Commercial |
$645.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$653.64
|
| Rate for Payer: Cash Price |
$419.00
|
| Rate for Payer: Cigna Commercial |
$695.54
|
| Rate for Payer: First Health Commercial |
$796.10
|
| Rate for Payer: Humana Commercial |
$712.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$687.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$618.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$251.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$737.44
|
| Rate for Payer: Ohio Health Group HMO |
$628.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$167.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$108.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$259.78
|
| Rate for Payer: PHCS Commercial |
$804.48
|
| Rate for Payer: United Healthcare All Payer |
$737.44
|
|
|
LT AXILLA US(P
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
HCPCS 76882
|
| Hospital Charge Code |
402P0062
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$25.62 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Aetna Commercial |
$47.98
|
| Rate for Payer: Anthem Medicaid |
$26.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$75.00
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$50.74
|
| Rate for Payer: Healthspan PPO |
$33.70
|
| Rate for Payer: Humana Medicaid |
$26.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$25.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$26.94
|
| Rate for Payer: Molina Healthcare Passport |
$26.41
|
| Rate for Payer: Multiplan PHCS |
$45.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$52.50
|
| Rate for Payer: UHCCP Medicaid |
$26.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$26.67
|
|
|
LT AXILLA US(T
|
Facility
|
OP
|
$763.00
|
|
|
Service Code
|
HCPCS 76882
|
| Hospital Charge Code |
402T0062
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$732.48 |
| Rate for Payer: Aetna Commercial |
$587.51
|
| Rate for Payer: Anthem Medicaid |
$262.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$595.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$381.50
|
| Rate for Payer: Cash Price |
$381.50
|
| Rate for Payer: Cigna Commercial |
$633.29
|
| Rate for Payer: First Health Commercial |
$724.85
|
| Rate for Payer: Humana Commercial |
$648.55
|
| Rate for Payer: Humana KY Medicaid |
$262.40
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$265.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$625.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$563.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$267.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$671.44
|
| Rate for Payer: Ohio Health Group HMO |
$572.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$236.53
|
| Rate for Payer: PHCS Commercial |
$732.48
|
| Rate for Payer: United Healthcare All Payer |
$671.44
|
|
|
LT AXILLA US(T
|
Facility
|
IP
|
$763.00
|
|
|
Service Code
|
HCPCS 76882
|
| Hospital Charge Code |
402T0062
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$99.19 |
| Max. Negotiated Rate |
$732.48 |
| Rate for Payer: Aetna Commercial |
$587.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$595.14
|
| Rate for Payer: Cash Price |
$381.50
|
| Rate for Payer: Cigna Commercial |
$633.29
|
| Rate for Payer: First Health Commercial |
$724.85
|
| Rate for Payer: Humana Commercial |
$648.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$625.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$563.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$228.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$671.44
|
| Rate for Payer: Ohio Health Group HMO |
$572.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$236.53
|
| Rate for Payer: PHCS Commercial |
$732.48
|
| Rate for Payer: United Healthcare All Payer |
$671.44
|
|
|
LT BREAST ASPIRATION
|
Facility
|
IP
|
$1,397.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
40200068
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$181.61 |
| Max. Negotiated Rate |
$1,341.12 |
| Rate for Payer: Aetna Commercial |
$1,075.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,089.66
|
| Rate for Payer: Cash Price |
$698.50
|
| Rate for Payer: Cigna Commercial |
$1,159.51
|
| Rate for Payer: First Health Commercial |
$1,327.15
|
| Rate for Payer: Humana Commercial |
$1,187.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,145.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,030.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$419.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,229.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,047.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$279.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$181.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$433.07
|
| Rate for Payer: PHCS Commercial |
$1,341.12
|
| Rate for Payer: United Healthcare All Payer |
$1,229.36
|
|
|
LT BREAST ASPIRATION
|
Facility
|
OP
|
$1,397.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
40200068
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$181.61 |
| Max. Negotiated Rate |
$1,341.12 |
| Rate for Payer: Aetna Commercial |
$1,075.69
|
| Rate for Payer: Anthem Medicaid |
$480.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,089.66
|
| Rate for Payer: Cash Price |
$698.50
|
| Rate for Payer: Cigna Commercial |
$1,159.51
|
| Rate for Payer: First Health Commercial |
$1,327.15
|
| Rate for Payer: Humana Commercial |
$1,187.45
|
| Rate for Payer: Humana KY Medicaid |
$480.43
|
| Rate for Payer: Kentucky WC Medicaid |
$485.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,145.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,030.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$419.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$490.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,229.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,047.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$279.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$181.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$433.07
|
| Rate for Payer: PHCS Commercial |
$1,341.12
|
| Rate for Payer: United Healthcare All Payer |
$1,229.36
|
|
|
LT BREAST ASPIRATION
|
Professional
|
Both
|
$1,397.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
40200068
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$42.85 |
| Max. Negotiated Rate |
$1,397.00 |
| Rate for Payer: Aetna Commercial |
$278.08
|
| Rate for Payer: Anthem Medicaid |
$70.51
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,397.00
|
| Rate for Payer: Cash Price |
$698.50
|
| Rate for Payer: Cash Price |
$698.50
|
| Rate for Payer: Cigna Commercial |
$244.99
|
| Rate for Payer: Healthspan PPO |
$260.56
|
| Rate for Payer: Humana Medicaid |
$70.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$42.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$71.92
|
| Rate for Payer: Molina Healthcare Passport |
$70.51
|
| Rate for Payer: Multiplan PHCS |
$838.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$977.90
|
| Rate for Payer: UHCCP Medicaid |
$488.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$71.22
|
|
|
LT BREAST ASPIRATION (P
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
402P0068
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$42.85 |
| Max. Negotiated Rate |
$278.08 |
| Rate for Payer: Aetna Commercial |
$278.08
|
| Rate for Payer: Anthem Medicaid |
$70.51
|
| Rate for Payer: Buckeye Medicare Advantage |
$200.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$244.99
|
| Rate for Payer: Healthspan PPO |
$260.56
|
| Rate for Payer: Humana Medicaid |
$70.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$42.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$71.92
|
| Rate for Payer: Molina Healthcare Passport |
$70.51
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.00
|
| Rate for Payer: UHCCP Medicaid |
$70.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$71.22
|
|
|
LT BREAST ASPIRATION (T
|
Facility
|
OP
|
$1,197.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
402T0068
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$155.61 |
| Max. Negotiated Rate |
$1,149.12 |
| Rate for Payer: Aetna Commercial |
$921.69
|
| Rate for Payer: Anthem Medicaid |
$411.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$933.66
|
| Rate for Payer: Cash Price |
$598.50
|
| Rate for Payer: Cigna Commercial |
$993.51
|
| Rate for Payer: First Health Commercial |
$1,137.15
|
| Rate for Payer: Humana Commercial |
$1,017.45
|
| Rate for Payer: Humana KY Medicaid |
$411.65
|
| Rate for Payer: Kentucky WC Medicaid |
$415.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$981.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$883.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$359.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$419.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,053.36
|
| Rate for Payer: Ohio Health Group HMO |
$897.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$239.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$155.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$371.07
|
| Rate for Payer: PHCS Commercial |
$1,149.12
|
| Rate for Payer: United Healthcare All Payer |
$1,053.36
|
|
|
LT BREAST ASPIRATION (T
|
Facility
|
IP
|
$1,197.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
402T0068
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$155.61 |
| Max. Negotiated Rate |
$1,149.12 |
| Rate for Payer: Aetna Commercial |
$921.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$933.66
|
| Rate for Payer: Cash Price |
$598.50
|
| Rate for Payer: Cigna Commercial |
$993.51
|
| Rate for Payer: First Health Commercial |
$1,137.15
|
| Rate for Payer: Humana Commercial |
$1,017.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$981.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$883.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$359.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,053.36
|
| Rate for Payer: Ohio Health Group HMO |
$897.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$239.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$155.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$371.07
|
| Rate for Payer: PHCS Commercial |
$1,149.12
|
| Rate for Payer: United Healthcare All Payer |
$1,053.36
|
|
|
LT BREAST LUMP US
|
Facility
|
IP
|
$862.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
40200010
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$112.06 |
| Max. Negotiated Rate |
$827.52 |
| Rate for Payer: Aetna Commercial |
$663.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$672.36
|
| Rate for Payer: Cash Price |
$431.00
|
| Rate for Payer: Cigna Commercial |
$715.46
|
| Rate for Payer: First Health Commercial |
$818.90
|
| Rate for Payer: Humana Commercial |
$732.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$706.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$636.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$258.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$758.56
|
| Rate for Payer: Ohio Health Group HMO |
$646.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$172.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$112.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$267.22
|
| Rate for Payer: PHCS Commercial |
$827.52
|
| Rate for Payer: United Healthcare All Payer |
$758.56
|
|
|
LT BREAST LUMP US
|
Professional
|
Both
|
$862.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
40200111
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$43.76 |
| Max. Negotiated Rate |
$862.00 |
| Rate for Payer: Anthem Medicaid |
$67.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$862.00
|
| Rate for Payer: Cash Price |
$431.00
|
| Rate for Payer: Cash Price |
$431.00
|
| Rate for Payer: Cigna Commercial |
$141.32
|
| Rate for Payer: Humana Medicaid |
$67.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$43.76
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$68.99
|
| Rate for Payer: Molina Healthcare Passport |
$67.64
|
| Rate for Payer: Multiplan PHCS |
$517.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$603.40
|
| Rate for Payer: UHCCP Medicaid |
$301.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$68.32
|
|
