|
LT BREAST LUMP US
|
Facility
|
OP
|
$862.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
40200010
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$78.58 |
| Max. Negotiated Rate |
$827.52 |
| Rate for Payer: Aetna Commercial |
$663.74
|
| Rate for Payer: Anthem Medicaid |
$296.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$78.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$672.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$110.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$106.08
|
| Rate for Payer: Cash Price |
$431.00
|
| 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: Humana KY Medicaid |
$296.44
|
| Rate for Payer: Humana Medicare Advantage |
$78.58
|
| Rate for Payer: Kentucky WC Medicaid |
$299.46
|
| 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 |
$94.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$302.39
|
| 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
|
Facility
|
IP
|
$862.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
40200111
|
|
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
|
Facility
|
OP
|
$862.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
40200111
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$78.58 |
| Max. Negotiated Rate |
$827.52 |
| Rate for Payer: Aetna Commercial |
$663.74
|
| Rate for Payer: Anthem Medicaid |
$296.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$78.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$672.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$110.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$106.08
|
| Rate for Payer: Cash Price |
$431.00
|
| 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: Humana KY Medicaid |
$296.44
|
| Rate for Payer: Humana Medicare Advantage |
$78.58
|
| Rate for Payer: Kentucky WC Medicaid |
$299.46
|
| 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 |
$94.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$302.39
|
| 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 |
40200010
|
|
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
|
|
|
LT BREAST LUMP US (P
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
402P0111
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$43.75 |
| Max. Negotiated Rate |
$141.32 |
| Rate for Payer: Anthem Medicaid |
$67.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$125.00
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| 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 |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.50
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$68.32
|
|
|
LT BREAST LUMP US(P
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
402P0010
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$43.75 |
| Max. Negotiated Rate |
$141.32 |
| Rate for Payer: Anthem Medicaid |
$67.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$125.00
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| 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 |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.50
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$68.32
|
|
|
LT BREAST LUMP US (T
|
Facility
|
OP
|
$737.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
402T0111
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$78.58 |
| Max. Negotiated Rate |
$707.52 |
| Rate for Payer: Aetna Commercial |
$567.49
|
| Rate for Payer: Anthem Medicaid |
$253.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$78.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$574.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$110.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$106.08
|
| Rate for Payer: Cash Price |
$368.50
|
| Rate for Payer: Cash Price |
$368.50
|
| Rate for Payer: Cigna Commercial |
$611.71
|
| Rate for Payer: First Health Commercial |
$700.15
|
| Rate for Payer: Humana Commercial |
$626.45
|
| Rate for Payer: Humana KY Medicaid |
$253.45
|
| Rate for Payer: Humana Medicare Advantage |
$78.58
|
| Rate for Payer: Kentucky WC Medicaid |
$256.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$604.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$543.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$258.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$648.56
|
| Rate for Payer: Ohio Health Group HMO |
$552.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$95.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$228.47
|
| Rate for Payer: PHCS Commercial |
$707.52
|
| Rate for Payer: United Healthcare All Payer |
$648.56
|
|
|
LT BREAST LUMP US (T
|
Facility
|
IP
|
$737.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
402T0111
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.81 |
| Max. Negotiated Rate |
$707.52 |
| Rate for Payer: Aetna Commercial |
$567.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$574.86
|
| Rate for Payer: Cash Price |
$368.50
|
| Rate for Payer: Cigna Commercial |
$611.71
|
| Rate for Payer: First Health Commercial |
$700.15
|
| Rate for Payer: Humana Commercial |
$626.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$604.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$543.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$221.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$648.56
|
| Rate for Payer: Ohio Health Group HMO |
$552.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$95.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$228.47
|
| Rate for Payer: PHCS Commercial |
$707.52
|
| Rate for Payer: United Healthcare All Payer |
$648.56
|
|
|
LT BREAST LUMP US(T
|
Facility
|
OP
|
$737.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
402T0010
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$78.58 |
| Max. Negotiated Rate |
$707.52 |
| Rate for Payer: Aetna Commercial |
$567.49
|
| Rate for Payer: Anthem Medicaid |
$253.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$78.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$574.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$110.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$106.08
|
| Rate for Payer: Cash Price |
$368.50
|
| Rate for Payer: Cash Price |
$368.50
|
| Rate for Payer: Cigna Commercial |
$611.71
|
| Rate for Payer: First Health Commercial |
$700.15
|
| Rate for Payer: Humana Commercial |
$626.45
|
| Rate for Payer: Humana KY Medicaid |
$253.45
|
| Rate for Payer: Humana Medicare Advantage |
$78.58
|
| Rate for Payer: Kentucky WC Medicaid |
$256.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$604.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$543.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$258.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$648.56
|
| Rate for Payer: Ohio Health Group HMO |
$552.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$95.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$228.47
|
| Rate for Payer: PHCS Commercial |
$707.52
|
| Rate for Payer: United Healthcare All Payer |
$648.56
|
|
|
LT BREAST LUMP US(T
|
Facility
|
IP
|
$737.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
402T0010
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.81 |
| Max. Negotiated Rate |
$707.52 |
| Rate for Payer: Aetna Commercial |
$567.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$574.86
|
| Rate for Payer: Cash Price |
$368.50
|
| Rate for Payer: Cigna Commercial |
$611.71
|
| Rate for Payer: First Health Commercial |
$700.15
|
| Rate for Payer: Humana Commercial |
$626.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$604.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$543.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$221.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$648.56
|
| Rate for Payer: Ohio Health Group HMO |
$552.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$95.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$228.47
|
| Rate for Payer: PHCS Commercial |
$707.52
|
| Rate for Payer: United Healthcare All Payer |
$648.56
|
|
|
LT BREAST US
|
Professional
|
Both
|
$862.00
|
|
|
Service Code
|
HCPCS 76641
|
| Hospital Charge Code |
40200007
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$46.90 |
| Max. Negotiated Rate |
$862.00 |
| Rate for Payer: Anthem Medicaid |
$81.80
|
| 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 |
$171.21
|
| Rate for Payer: Humana Medicaid |
$81.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$46.90
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$83.44
|
| Rate for Payer: Molina Healthcare Passport |
$81.80
|
| 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 |
$82.62
|
|
|
LT BREAST US
|
Facility
|
OP
|
$862.00
|
|
|
Service Code
|
HCPCS 76641
|
| Hospital Charge Code |
40200007
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$827.52 |
| Rate for Payer: Aetna Commercial |
$663.74
|
| Rate for Payer: Anthem Medicaid |
$296.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$672.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$431.00
|
| 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: Humana KY Medicaid |
$296.44
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$299.46
|
| 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 |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$302.39
|
| 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 US
|
Facility
|
IP
|
$862.00
|
|
|
Service Code
|
HCPCS 76641
|
| Hospital Charge Code |
40200007
|
|
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 US(P
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 76641
|
| Hospital Charge Code |
402P0007
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$43.75 |
| Max. Negotiated Rate |
$171.21 |
| Rate for Payer: Anthem Medicaid |
$81.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$125.00
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$171.21
|
| Rate for Payer: Humana Medicaid |
$81.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$46.90
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$83.44
|
| Rate for Payer: Molina Healthcare Passport |
$81.80
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.50
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$82.62
|
|
|
LT BREAST US(T
|
Facility
|
IP
|
$737.00
|
|
|
Service Code
|
HCPCS 76641
|
| Hospital Charge Code |
402T0007
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.81 |
| Max. Negotiated Rate |
$707.52 |
| Rate for Payer: Aetna Commercial |
$567.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$574.86
|
| Rate for Payer: Cash Price |
$368.50
|
| Rate for Payer: Cigna Commercial |
$611.71
|
| Rate for Payer: First Health Commercial |
$700.15
|
| Rate for Payer: Humana Commercial |
$626.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$604.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$543.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$221.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$648.56
|
| Rate for Payer: Ohio Health Group HMO |
$552.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$95.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$228.47
|
| Rate for Payer: PHCS Commercial |
$707.52
|
| Rate for Payer: United Healthcare All Payer |
$648.56
|
|
|
LT BREAST US(T
|
Facility
|
OP
|
$737.00
|
|
|
Service Code
|
HCPCS 76641
|
| Hospital Charge Code |
402T0007
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$707.52 |
| Rate for Payer: Aetna Commercial |
$567.49
|
| Rate for Payer: Anthem Medicaid |
$253.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$574.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$368.50
|
| Rate for Payer: Cash Price |
$368.50
|
| Rate for Payer: Cigna Commercial |
$611.71
|
| Rate for Payer: First Health Commercial |
$700.15
|
| Rate for Payer: Humana Commercial |
$626.45
|
| Rate for Payer: Humana KY Medicaid |
$253.45
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$256.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$604.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$543.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$258.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$648.56
|
| Rate for Payer: Ohio Health Group HMO |
$552.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$95.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$228.47
|
| Rate for Payer: PHCS Commercial |
$707.52
|
| Rate for Payer: United Healthcare All Payer |
$648.56
|
|
|
LUBRIDERM SEN SKIN 16 OZ
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 52800048856
|
| Hospital Charge Code |
25000922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Aetna Commercial |
$0.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.20
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna Commercial |
$0.21
|
| Rate for Payer: First Health Commercial |
$0.24
|
| Rate for Payer: Humana Commercial |
$0.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.22
|
| Rate for Payer: Ohio Health Group HMO |
$0.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.08
|
| Rate for Payer: PHCS Commercial |
$0.24
|
| Rate for Payer: United Healthcare All Payer |
$0.22
|
|
|
LUBRIDERM SEN SKIN 16 OZ
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 52800048856
|
| Hospital Charge Code |
25000922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Aetna Commercial |
$0.19
|
| Rate for Payer: Anthem Medicaid |
$0.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.20
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna Commercial |
$0.21
|
| Rate for Payer: First Health Commercial |
$0.24
|
| Rate for Payer: Humana Commercial |
$0.21
|
| Rate for Payer: Humana KY Medicaid |
$0.09
|
| Rate for Payer: Kentucky WC Medicaid |
$0.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.22
|
| Rate for Payer: Ohio Health Group HMO |
$0.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.08
|
| Rate for Payer: PHCS Commercial |
$0.24
|
| Rate for Payer: United Healthcare All Payer |
$0.22
|
|
|
LUMASON 25 MG/5 ML VIAL
|
Facility
|
IP
|
$650.73
|
|
|
Service Code
|
HCPCS Q9950
|
| Hospital Charge Code |
25003953
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$84.59 |
| Max. Negotiated Rate |
$624.70 |
| Rate for Payer: Aetna Commercial |
$501.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$507.57
|
| Rate for Payer: Cash Price |
$325.36
|
| Rate for Payer: Cigna Commercial |
$540.11
|
| Rate for Payer: First Health Commercial |
$618.19
|
| Rate for Payer: Humana Commercial |
$553.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$533.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$480.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$195.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$572.64
|
| Rate for Payer: Ohio Health Group HMO |
$488.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$84.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$201.73
|
| Rate for Payer: PHCS Commercial |
$624.70
|
| Rate for Payer: United Healthcare All Payer |
$572.64
|
|
|
LUMASON 25 MG/5 ML VIAL
|
Facility
|
OP
|
$650.73
|
|
|
Service Code
|
HCPCS Q9950
|
| Hospital Charge Code |
25003953
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$84.59 |
| Max. Negotiated Rate |
$624.70 |
| Rate for Payer: Aetna Commercial |
$501.06
|
| Rate for Payer: Anthem Medicaid |
$223.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$507.57
|
| Rate for Payer: Cash Price |
$325.36
|
| Rate for Payer: Cigna Commercial |
$540.11
|
| Rate for Payer: First Health Commercial |
$618.19
|
| Rate for Payer: Humana Commercial |
$553.12
|
| Rate for Payer: Humana KY Medicaid |
$223.79
|
| Rate for Payer: Kentucky WC Medicaid |
$226.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$533.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$480.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$195.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$228.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$572.64
|
| Rate for Payer: Ohio Health Group HMO |
$488.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$84.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$201.73
|
| Rate for Payer: PHCS Commercial |
$624.70
|
| Rate for Payer: United Healthcare All Payer |
$572.64
|
|
|
LUMBAR PUNCTURE
|
Facility
|
OP
|
$982.00
|
|
|
Service Code
|
HCPCS 62270
|
| Hospital Charge Code |
36001260
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$127.66 |
| Max. Negotiated Rate |
$942.72 |
| Rate for Payer: Aetna Commercial |
$756.14
|
| Rate for Payer: Anthem Medicaid |
$337.71
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$765.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Cash Price |
$491.00
|
| Rate for Payer: Cash Price |
$491.00
|
| Rate for Payer: Cigna Commercial |
$815.06
|
| Rate for Payer: First Health Commercial |
$932.90
|
| Rate for Payer: Humana Commercial |
$834.70
|
| Rate for Payer: Humana KY Medicaid |
$337.71
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Kentucky WC Medicaid |
$341.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$805.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$724.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$344.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$864.16
|
| Rate for Payer: Ohio Health Group HMO |
$736.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$196.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$304.42
|
| Rate for Payer: PHCS Commercial |
$942.72
|
| Rate for Payer: United Healthcare All Payer |
$864.16
|
|
|
LUMBAR PUNCTURE
|
Facility
|
IP
|
$982.00
|
|
|
Service Code
|
HCPCS 62270
|
| Hospital Charge Code |
36001260
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$127.66 |
| Max. Negotiated Rate |
$942.72 |
| Rate for Payer: Aetna Commercial |
$756.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$765.96
|
| Rate for Payer: Cash Price |
$491.00
|
| Rate for Payer: Cigna Commercial |
$815.06
|
| Rate for Payer: First Health Commercial |
$932.90
|
| Rate for Payer: Humana Commercial |
$834.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$805.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$724.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$294.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$864.16
|
| Rate for Payer: Ohio Health Group HMO |
$736.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$196.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$304.42
|
| Rate for Payer: PHCS Commercial |
$942.72
|
| Rate for Payer: United Healthcare All Payer |
$864.16
|
|
|
LUMBAR PUNCTURE DIAG
|
Facility
|
IP
|
$1,232.00
|
|
|
Service Code
|
HCPCS 62270
|
| Hospital Charge Code |
76102291
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$160.16 |
| Max. Negotiated Rate |
$1,182.72 |
| Rate for Payer: Aetna Commercial |
$948.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$960.96
|
| Rate for Payer: Cash Price |
$616.00
|
| Rate for Payer: Cigna Commercial |
$1,022.56
|
| Rate for Payer: First Health Commercial |
$1,170.40
|
| Rate for Payer: Humana Commercial |
$1,047.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,010.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$909.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$369.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,084.16
|
| Rate for Payer: Ohio Health Group HMO |
$924.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$246.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$160.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$381.92
|
| Rate for Payer: PHCS Commercial |
$1,182.72
|
| Rate for Payer: United Healthcare All Payer |
$1,084.16
|
|
|
LUMBAR PUNCTURE DIAG
|
Facility
|
OP
|
$982.00
|
|
|
Service Code
|
HCPCS 62270
|
| Hospital Charge Code |
45000293
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$127.66 |
| Max. Negotiated Rate |
$942.72 |
| Rate for Payer: Aetna Commercial |
$756.14
|
| Rate for Payer: Anthem Medicaid |
$337.71
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$765.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Cash Price |
$491.00
|
| Rate for Payer: Cash Price |
$491.00
|
| Rate for Payer: Cigna Commercial |
$815.06
|
| Rate for Payer: First Health Commercial |
$932.90
|
| Rate for Payer: Humana Commercial |
$834.70
|
| Rate for Payer: Humana KY Medicaid |
$337.71
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Kentucky WC Medicaid |
$341.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$805.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$724.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$344.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$864.16
|
| Rate for Payer: Ohio Health Group HMO |
$736.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$196.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$304.42
|
| Rate for Payer: PHCS Commercial |
$942.72
|
| Rate for Payer: United Healthcare All Payer |
$864.16
|
|
|
LUMBAR PUNCTURE DIAG
|
Facility
|
OP
|
$1,232.00
|
|
|
Service Code
|
HCPCS 62270
|
| Hospital Charge Code |
76102291
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$160.16 |
| Max. Negotiated Rate |
$1,182.72 |
| Rate for Payer: Aetna Commercial |
$948.64
|
| Rate for Payer: Anthem Medicaid |
$423.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$960.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Cash Price |
$616.00
|
| Rate for Payer: Cash Price |
$616.00
|
| Rate for Payer: Cigna Commercial |
$1,022.56
|
| Rate for Payer: First Health Commercial |
$1,170.40
|
| Rate for Payer: Humana Commercial |
$1,047.20
|
| Rate for Payer: Humana KY Medicaid |
$423.68
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Kentucky WC Medicaid |
$428.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,010.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$909.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$432.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,084.16
|
| Rate for Payer: Ohio Health Group HMO |
$924.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$246.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$160.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$381.92
|
| Rate for Payer: PHCS Commercial |
$1,182.72
|
| Rate for Payer: United Healthcare All Payer |
$1,084.16
|
|
