|
LPT GREAT TOE SZ 1 STRAIGHT
|
Facility
|
IP
|
$8,931.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,679.38 |
| Max. Negotiated Rate |
$8,574.00 |
| Rate for Payer: Aetna Commercial |
$6,877.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,966.38
|
| Rate for Payer: Cash Price |
$4,465.62
|
| Rate for Payer: Cigna Commercial |
$7,412.94
|
| Rate for Payer: First Health Commercial |
$8,484.69
|
| Rate for Payer: Humana Commercial |
$7,591.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,323.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,591.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,679.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,859.50
|
| Rate for Payer: Ohio Health Group HMO |
$6,698.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,145.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,770.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,162.56
|
| Rate for Payer: PHCS Commercial |
$8,574.00
|
| Rate for Payer: United Healthcare All Payer |
$7,859.50
|
|
|
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 |
$773.77 |
| Max. Negotiated Rate |
$13,467.66 |
| Rate for Payer: Aetna Commercial |
$1,732.50
|
| Rate for Payer: Anthem Medicaid |
$773.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9,619.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,755.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13,467.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$12,986.68
|
| 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 |
$773.77
|
| Rate for Payer: Humana Medicare Advantage |
$9,619.76
|
| 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 |
$11,543.71
|
| 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 |
$1,800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,957.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,552.50
|
| 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 |
$1,440.26 |
| Rate for Payer: Aetna Commercial |
$1,440.26
|
| Rate for Payer: Ambetter Exchange |
$785.94
|
| Rate for Payer: Anthem Medicaid |
$684.88
|
| Rate for Payer: Buckeye Individual/Medicaid |
$785.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$785.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$943.13
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$785.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$785.94
|
| 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 |
$1,021.72
|
| Rate for Payer: UHCCP Medicaid |
$787.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$691.73
|
| Rate for Payer: Wellcare Medicare Advantage |
$785.94
|
|
|
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 |
$675.00 |
| 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 |
$1,800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,957.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,552.50
|
| 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(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 |
$1,440.26 |
| Rate for Payer: Aetna Commercial |
$1,440.26
|
| Rate for Payer: Ambetter Exchange |
$785.94
|
| Rate for Payer: Anthem Medicaid |
$684.88
|
| Rate for Payer: Buckeye Individual/Medicaid |
$785.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$785.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$943.13
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$785.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$785.94
|
| 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 |
$1,021.72
|
| Rate for Payer: UHCCP Medicaid |
$787.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$691.73
|
| Rate for Payer: Wellcare Medicare Advantage |
$785.94
|
|
|
LTA KIT 1EA
|
Facility
|
OP
|
$68.20
|
|
|
Service Code
|
NDC 76329630005
|
| Hospital Charge Code |
25003189
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.46 |
| 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 |
$54.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.06
|
| 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 |
$20.46 |
| 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 |
$54.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.06
|
| Rate for Payer: PHCS Commercial |
$65.47
|
| Rate for Payer: United Healthcare All Payer |
$60.02
|
|
|
LT AXILLA US
|
Professional
|
Both
|
$888.00
|
|
|
Service Code
|
HCPCS 76882
|
| Hospital Charge Code |
40200062
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$25.62 |
| Max. Negotiated Rate |
$532.80 |
| Rate for Payer: Aetna Commercial |
$47.98
|
| Rate for Payer: Ambetter Exchange |
$59.06
|
| Rate for Payer: Anthem Medicaid |
$26.41
|
| Rate for Payer: Buckeye Individual/Medicaid |
$59.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$59.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$70.87
|
| Rate for Payer: Cash Price |
$444.00
|
| Rate for Payer: Cash Price |
$444.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$59.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$26.94
|
| Rate for Payer: Molina Healthcare Passport |
$26.41
|
| Rate for Payer: Multiplan PHCS |
$532.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$76.78
|
| Rate for Payer: UHCCP Medicaid |
$310.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$26.67
|
| Rate for Payer: Wellcare Medicare Advantage |
$59.06
|
|
|
LT AXILLA US
|
Facility
|
IP
|
$888.00
|
|
|
Service Code
|
HCPCS 76882
|
| Hospital Charge Code |
40200062
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$266.40 |
| Max. Negotiated Rate |
$852.48 |
| Rate for Payer: Aetna Commercial |
$683.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$692.64
|
| Rate for Payer: Cash Price |
$444.00
|
| Rate for Payer: Cigna Commercial |
$737.04
|
| Rate for Payer: First Health Commercial |
$843.60
|
| Rate for Payer: Humana Commercial |
$754.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$728.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$655.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$266.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$781.44
|
| Rate for Payer: Ohio Health Group HMO |
$666.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$710.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$772.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$612.72
|
| Rate for Payer: PHCS Commercial |
$852.48
|
| Rate for Payer: United Healthcare All Payer |
$781.44
|
|
|
LT AXILLA US
|
Facility
|
OP
|
$888.00
|
|
|
Service Code
|
HCPCS 76882
|
| Hospital Charge Code |
40200062
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$852.48 |
| Rate for Payer: Aetna Commercial |
$683.76
|
| Rate for Payer: Anthem Medicaid |
$305.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$692.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$444.00
|
| Rate for Payer: Cash Price |
$444.00
|
| Rate for Payer: Cigna Commercial |
$737.04
|
| Rate for Payer: First Health Commercial |
$843.60
|
| Rate for Payer: Humana Commercial |
$754.80
|
| Rate for Payer: Humana KY Medicaid |
$305.38
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$308.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$728.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$655.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$311.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$781.44
|
| Rate for Payer: Ohio Health Group HMO |
$666.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$710.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$772.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$612.72
|
| Rate for Payer: PHCS Commercial |
$852.48
|
| Rate for Payer: United Healthcare All Payer |
$781.44
|
|
|
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 |
$76.78 |
| Rate for Payer: Aetna Commercial |
$47.98
|
| Rate for Payer: Ambetter Exchange |
$59.06
|
| Rate for Payer: Anthem Medicaid |
$26.41
|
| Rate for Payer: Buckeye Individual/Medicaid |
$59.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$59.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$70.87
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$59.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.06
|
| 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 |
$76.78
|
| Rate for Payer: UHCCP Medicaid |
$26.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$26.67
|
| Rate for Payer: Wellcare Medicare Advantage |
$59.06
|
|
|
LT AXILLA US(T
|
Facility
|
IP
|
$813.00
|
|
|
Service Code
|
HCPCS 76882
|
| Hospital Charge Code |
402T0062
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$243.90 |
| Max. Negotiated Rate |
$780.48 |
| Rate for Payer: Aetna Commercial |
$626.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$634.14
|
| Rate for Payer: Cash Price |
$406.50
|
| Rate for Payer: Cigna Commercial |
$674.79
|
| Rate for Payer: First Health Commercial |
$772.35
|
| Rate for Payer: Humana Commercial |
$691.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$666.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$599.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$243.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$715.44
|
| Rate for Payer: Ohio Health Group HMO |
$609.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$650.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$707.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$560.97
|
| Rate for Payer: PHCS Commercial |
$780.48
|
| Rate for Payer: United Healthcare All Payer |
$715.44
|
|
|
LT AXILLA US(T
|
Facility
|
OP
|
$813.00
|
|
|
Service Code
|
HCPCS 76882
|
| Hospital Charge Code |
402T0062
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$780.48 |
| Rate for Payer: Aetna Commercial |
$626.01
|
| Rate for Payer: Anthem Medicaid |
$279.59
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$634.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$406.50
|
| Rate for Payer: Cash Price |
$406.50
|
| Rate for Payer: Cigna Commercial |
$674.79
|
| Rate for Payer: First Health Commercial |
$772.35
|
| Rate for Payer: Humana Commercial |
$691.05
|
| Rate for Payer: Humana KY Medicaid |
$279.59
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$282.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$666.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$599.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$285.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$715.44
|
| Rate for Payer: Ohio Health Group HMO |
$609.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$650.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$707.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$560.97
|
| Rate for Payer: PHCS Commercial |
$780.48
|
| Rate for Payer: United Healthcare All Payer |
$715.44
|
|
|
LT BREAST ASPIRATION
|
Facility
|
IP
|
$1,475.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
40200068
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$442.50 |
| Max. Negotiated Rate |
$1,416.00 |
| Rate for Payer: Aetna Commercial |
$1,135.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,150.50
|
| Rate for Payer: Cash Price |
$737.50
|
| Rate for Payer: Cigna Commercial |
$1,224.25
|
| Rate for Payer: First Health Commercial |
$1,401.25
|
| Rate for Payer: Humana Commercial |
$1,253.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,209.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,088.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,298.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,106.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,180.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,283.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,017.75
|
| Rate for Payer: PHCS Commercial |
$1,416.00
|
| Rate for Payer: United Healthcare All Payer |
$1,298.00
|
|
|
LT BREAST ASPIRATION
|
Professional
|
Both
|
$1,475.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
40200068
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$42.85 |
| Max. Negotiated Rate |
$885.00 |
| Rate for Payer: Aetna Commercial |
$278.08
|
| Rate for Payer: Ambetter Exchange |
$54.24
|
| Rate for Payer: Anthem Medicaid |
$70.51
|
| Rate for Payer: Buckeye Individual/Medicaid |
$54.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$54.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$65.09
|
| Rate for Payer: Cash Price |
$737.50
|
| Rate for Payer: Cash Price |
$737.50
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$54.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$71.92
|
| Rate for Payer: Molina Healthcare Passport |
$70.51
|
| Rate for Payer: Multiplan PHCS |
$885.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$70.51
|
| Rate for Payer: UHCCP Medicaid |
$516.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$71.22
|
| Rate for Payer: Wellcare Medicare Advantage |
$54.24
|
|
|
LT BREAST ASPIRATION
|
Facility
|
OP
|
$1,475.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
40200068
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$442.50 |
| Max. Negotiated Rate |
$1,416.00 |
| Rate for Payer: Aetna Commercial |
$1,135.75
|
| Rate for Payer: Anthem Medicaid |
$507.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,150.50
|
| Rate for Payer: Cash Price |
$737.50
|
| Rate for Payer: Cigna Commercial |
$1,224.25
|
| Rate for Payer: First Health Commercial |
$1,401.25
|
| Rate for Payer: Humana Commercial |
$1,253.75
|
| Rate for Payer: Humana KY Medicaid |
$507.25
|
| Rate for Payer: Kentucky WC Medicaid |
$512.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,209.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,088.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$517.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,298.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,106.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,180.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,283.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,017.75
|
| Rate for Payer: PHCS Commercial |
$1,416.00
|
| Rate for Payer: United Healthcare All Payer |
$1,298.00
|
|
|
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: Ambetter Exchange |
$54.24
|
| Rate for Payer: Anthem Medicaid |
$70.51
|
| Rate for Payer: Buckeye Individual/Medicaid |
$54.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$54.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$65.09
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$54.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.24
|
| 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 |
$70.51
|
| Rate for Payer: UHCCP Medicaid |
$70.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$71.22
|
| Rate for Payer: Wellcare Medicare Advantage |
$54.24
|
|
|
LT BREAST ASPIRATION (T
|
Facility
|
IP
|
$1,275.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
402T0068
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$382.50 |
| Max. Negotiated Rate |
$1,224.00 |
| Rate for Payer: Aetna Commercial |
$981.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$994.50
|
| Rate for Payer: Cash Price |
$637.50
|
| Rate for Payer: Cigna Commercial |
$1,058.25
|
| Rate for Payer: First Health Commercial |
$1,211.25
|
| Rate for Payer: Humana Commercial |
$1,083.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,045.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$940.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$382.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,122.00
|
| Rate for Payer: Ohio Health Group HMO |
$956.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,020.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,109.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$879.75
|
| Rate for Payer: PHCS Commercial |
$1,224.00
|
| Rate for Payer: United Healthcare All Payer |
$1,122.00
|
|
|
LT BREAST ASPIRATION (T
|
Facility
|
OP
|
$1,275.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
402T0068
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$382.50 |
| Max. Negotiated Rate |
$1,224.00 |
| Rate for Payer: Aetna Commercial |
$981.75
|
| Rate for Payer: Anthem Medicaid |
$438.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$994.50
|
| Rate for Payer: Cash Price |
$637.50
|
| Rate for Payer: Cigna Commercial |
$1,058.25
|
| Rate for Payer: First Health Commercial |
$1,211.25
|
| Rate for Payer: Humana Commercial |
$1,083.75
|
| Rate for Payer: Humana KY Medicaid |
$438.47
|
| Rate for Payer: Kentucky WC Medicaid |
$442.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,045.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$940.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$382.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$447.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,122.00
|
| Rate for Payer: Ohio Health Group HMO |
$956.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,020.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,109.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$879.75
|
| Rate for Payer: PHCS Commercial |
$1,224.00
|
| Rate for Payer: United Healthcare All Payer |
$1,122.00
|
|
|
LT BREAST LUMP US
|
Professional
|
Both
|
$910.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
40200010
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$43.76 |
| Max. Negotiated Rate |
$546.00 |
| Rate for Payer: Ambetter Exchange |
$77.00
|
| Rate for Payer: Anthem Medicaid |
$67.64
|
| Rate for Payer: Buckeye Individual/Medicaid |
$77.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$77.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$92.40
|
| Rate for Payer: Cash Price |
$455.00
|
| Rate for Payer: Cash Price |
$455.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$77.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$77.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$68.99
|
| Rate for Payer: Molina Healthcare Passport |
$67.64
|
| Rate for Payer: Multiplan PHCS |
$546.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$100.10
|
| Rate for Payer: UHCCP Medicaid |
$318.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$68.32
|
| Rate for Payer: Wellcare Medicare Advantage |
$77.00
|
|
|
LT BREAST LUMP US
|
Facility
|
OP
|
$910.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
40200010
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$873.60 |
| Rate for Payer: Aetna Commercial |
$700.70
|
| Rate for Payer: Anthem Medicaid |
$312.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$709.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$455.00
|
| Rate for Payer: Cash Price |
$455.00
|
| Rate for Payer: Cigna Commercial |
$755.30
|
| Rate for Payer: First Health Commercial |
$864.50
|
| Rate for Payer: Humana Commercial |
$773.50
|
| Rate for Payer: Humana KY Medicaid |
$312.95
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$316.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$746.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$671.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$319.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$800.80
|
| Rate for Payer: Ohio Health Group HMO |
$682.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$728.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$791.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$627.90
|
| Rate for Payer: PHCS Commercial |
$873.60
|
| Rate for Payer: United Healthcare All Payer |
$800.80
|
|
|
LT BREAST LUMP US
|
Professional
|
Both
|
$883.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
40200111
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$43.76 |
| Max. Negotiated Rate |
$529.80 |
| Rate for Payer: Ambetter Exchange |
$77.00
|
| Rate for Payer: Anthem Medicaid |
$67.64
|
| Rate for Payer: Buckeye Individual/Medicaid |
$77.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$77.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$92.40
|
| Rate for Payer: Cash Price |
$441.50
|
| Rate for Payer: Cash Price |
$441.50
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$77.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$77.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$68.99
|
| Rate for Payer: Molina Healthcare Passport |
$67.64
|
| Rate for Payer: Multiplan PHCS |
$529.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$100.10
|
| Rate for Payer: UHCCP Medicaid |
$309.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$68.32
|
| Rate for Payer: Wellcare Medicare Advantage |
$77.00
|
|
|
LT BREAST LUMP US
|
Facility
|
IP
|
$883.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
40200111
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$264.90 |
| Max. Negotiated Rate |
$847.68 |
| Rate for Payer: Aetna Commercial |
$679.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$688.74
|
| Rate for Payer: Cash Price |
$441.50
|
| Rate for Payer: Cigna Commercial |
$732.89
|
| Rate for Payer: First Health Commercial |
$838.85
|
| Rate for Payer: Humana Commercial |
$750.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$724.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$651.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$264.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$777.04
|
| Rate for Payer: Ohio Health Group HMO |
$662.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$706.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$768.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$609.27
|
| Rate for Payer: PHCS Commercial |
$847.68
|
| Rate for Payer: United Healthcare All Payer |
$777.04
|
|
|
LT BREAST LUMP US
|
Facility
|
OP
|
$883.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
40200111
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$847.68 |
| Rate for Payer: Aetna Commercial |
$679.91
|
| Rate for Payer: Anthem Medicaid |
$303.66
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$688.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$441.50
|
| Rate for Payer: Cash Price |
$441.50
|
| Rate for Payer: Cigna Commercial |
$732.89
|
| Rate for Payer: First Health Commercial |
$838.85
|
| Rate for Payer: Humana Commercial |
$750.55
|
| Rate for Payer: Humana KY Medicaid |
$303.66
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$306.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$724.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$651.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$309.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$777.04
|
| Rate for Payer: Ohio Health Group HMO |
$662.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$706.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$768.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$609.27
|
| Rate for Payer: PHCS Commercial |
$847.68
|
| Rate for Payer: United Healthcare All Payer |
$777.04
|
|
|
LT BREAST LUMP US
|
Facility
|
IP
|
$910.00
|
|
|
Service Code
|
HCPCS 76642
|
| Hospital Charge Code |
40200010
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$273.00 |
| Max. Negotiated Rate |
$873.60 |
| Rate for Payer: Aetna Commercial |
$700.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$709.80
|
| Rate for Payer: Cash Price |
$455.00
|
| Rate for Payer: Cigna Commercial |
$755.30
|
| Rate for Payer: First Health Commercial |
$864.50
|
| Rate for Payer: Humana Commercial |
$773.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$746.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$671.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$273.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$800.80
|
| Rate for Payer: Ohio Health Group HMO |
$682.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$728.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$791.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$627.90
|
| Rate for Payer: PHCS Commercial |
$873.60
|
| Rate for Payer: United Healthcare All Payer |
$800.80
|
|
