|
MASTECTOMY; PARTIAL
|
Professional
|
Both
|
$1,200.00
|
|
|
Service Code
|
HCPCS 19302
|
| Hospital Charge Code |
76100301
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$420.00 |
| Max. Negotiated Rate |
$1,269.27 |
| Rate for Payer: Aetna Commercial |
$1,269.27
|
| Rate for Payer: Anthem Medicaid |
$604.90
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,200.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$1,185.67
|
| Rate for Payer: Healthspan PPO |
$1,014.90
|
| Rate for Payer: Humana Medicaid |
$604.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,122.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$617.00
|
| Rate for Payer: Molina Healthcare Passport |
$604.90
|
| Rate for Payer: Multiplan PHCS |
$720.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$840.00
|
| Rate for Payer: UHCCP Medicaid |
$420.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$610.95
|
|
|
MASTECTOMY; PARTIAL
|
Facility
|
IP
|
$1,200.00
|
|
|
Service Code
|
HCPCS 19302
|
| Hospital Charge Code |
76100301
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$156.00 |
| Max. Negotiated Rate |
$1,152.00 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$156.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$372.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY);
|
Facility
|
OP
|
$4,614.69
|
|
|
Service Code
|
CPT 19301
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,296.21 |
| Max. Negotiated Rate |
$4,614.69 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,296.21
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,614.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,449.88
|
| Rate for Payer: Humana Medicare Advantage |
$3,296.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,955.45
|
|
|
MASTECTOMY; PARTIAL(P
|
Professional
|
Both
|
$1,200.00
|
|
|
Service Code
|
HCPCS 19302
|
| Hospital Charge Code |
761P0301
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$420.00 |
| Max. Negotiated Rate |
$1,269.27 |
| Rate for Payer: Aetna Commercial |
$1,269.27
|
| Rate for Payer: Anthem Medicaid |
$604.90
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,200.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$1,185.67
|
| Rate for Payer: Healthspan PPO |
$1,014.90
|
| Rate for Payer: Humana Medicaid |
$604.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,122.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$617.00
|
| Rate for Payer: Molina Healthcare Passport |
$604.90
|
| Rate for Payer: Multiplan PHCS |
$720.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$840.00
|
| Rate for Payer: UHCCP Medicaid |
$420.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$610.95
|
|
|
MASTECTOMY: RADICAL
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 19305
|
| Hospital Charge Code |
76100304
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$195.00 |
| Max. Negotiated Rate |
$1,440.00 |
| Rate for Payer: Aetna Commercial |
$1,155.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,245.00
|
| Rate for Payer: First Health Commercial |
$1,425.00
|
| Rate for Payer: Humana Commercial |
$1,275.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$450.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$195.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$465.00
|
| Rate for Payer: PHCS Commercial |
$1,440.00
|
| Rate for Payer: United Healthcare All Payer |
$1,320.00
|
|
|
MASTECTOMY: RADICAL
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 19305
|
| Hospital Charge Code |
76100304
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$195.00 |
| Max. Negotiated Rate |
$1,440.00 |
| Rate for Payer: Aetna Commercial |
$1,155.00
|
| Rate for Payer: Anthem Medicaid |
$515.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,245.00
|
| Rate for Payer: First Health Commercial |
$1,425.00
|
| Rate for Payer: Humana Commercial |
$1,275.00
|
| Rate for Payer: Humana KY Medicaid |
$515.85
|
| Rate for Payer: Kentucky WC Medicaid |
$521.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$450.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$526.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$195.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$465.00
|
| Rate for Payer: PHCS Commercial |
$1,440.00
|
| Rate for Payer: United Healthcare All Payer |
$1,320.00
|
|
|
MASTECTOMY: RADICAL
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 19305
|
| Hospital Charge Code |
76100304
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$525.00 |
| Max. Negotiated Rate |
$1,571.49 |
| Rate for Payer: Aetna Commercial |
$1,571.49
|
| Rate for Payer: Anthem Medicaid |
$748.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,500.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,466.18
|
| Rate for Payer: Healthspan PPO |
$1,256.55
|
| Rate for Payer: Humana Medicaid |
$748.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,422.38
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$763.23
|
| Rate for Payer: Molina Healthcare Passport |
$748.26
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,050.00
|
| Rate for Payer: UHCCP Medicaid |
$525.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$755.74
|
|
|
MASTECTOMY: RADICAL(P
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 19305
|
| Hospital Charge Code |
761P0304
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$525.00 |
| Max. Negotiated Rate |
$1,571.49 |
| Rate for Payer: Aetna Commercial |
$1,571.49
|
| Rate for Payer: Anthem Medicaid |
$748.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,500.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,466.18
|
| Rate for Payer: Healthspan PPO |
$1,256.55
|
| Rate for Payer: Humana Medicaid |
$748.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,422.38
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$763.23
|
| Rate for Payer: Molina Healthcare Passport |
$748.26
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,050.00
|
| Rate for Payer: UHCCP Medicaid |
$525.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$755.74
|
|
|
MASTECTOMY SIMPLE COMPLETE
|
Facility
|
OP
|
$1,260.00
|
|
|
Service Code
|
HCPCS 19303
|
| Hospital Charge Code |
76100302
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$163.80 |
| Max. Negotiated Rate |
$7,894.80 |
| Rate for Payer: Aetna Commercial |
$970.20
|
| Rate for Payer: Anthem Medicaid |
$433.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,639.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$982.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,894.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,612.84
|
| Rate for Payer: Cash Price |
$630.00
|
| Rate for Payer: Cash Price |
$630.00
|
| Rate for Payer: Cigna Commercial |
$1,045.80
|
| Rate for Payer: First Health Commercial |
$1,197.00
|
| Rate for Payer: Humana Commercial |
$1,071.00
|
| Rate for Payer: Humana KY Medicaid |
$433.31
|
| Rate for Payer: Humana Medicare Advantage |
$5,639.14
|
| Rate for Payer: Kentucky WC Medicaid |
$437.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,033.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$929.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,766.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$442.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,108.80
|
| Rate for Payer: Ohio Health Group HMO |
$945.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$252.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$163.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$390.60
|
| Rate for Payer: PHCS Commercial |
$1,209.60
|
| Rate for Payer: United Healthcare All Payer |
$1,108.80
|
|
|
MASTECTOMY SIMPLE COMPLETE
|
Professional
|
Both
|
$1,260.00
|
|
|
Service Code
|
HCPCS 19303
|
| Hospital Charge Code |
76100302
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$441.00 |
| Max. Negotiated Rate |
$1,345.65 |
| Rate for Payer: Aetna Commercial |
$1,345.65
|
| Rate for Payer: Anthem Medicaid |
$621.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,260.00
|
| Rate for Payer: Cash Price |
$630.00
|
| Rate for Payer: Cash Price |
$630.00
|
| Rate for Payer: Cigna Commercial |
$1,262.24
|
| Rate for Payer: Healthspan PPO |
$1,075.97
|
| Rate for Payer: Humana Medicaid |
$621.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,260.55
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$633.51
|
| Rate for Payer: Molina Healthcare Passport |
$621.09
|
| Rate for Payer: Multiplan PHCS |
$756.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$882.00
|
| Rate for Payer: UHCCP Medicaid |
$441.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$627.30
|
|
|
MASTECTOMY SIMPLE COMPLETE
|
Facility
|
IP
|
$1,260.00
|
|
|
Service Code
|
HCPCS 19303
|
| Hospital Charge Code |
76100302
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$163.80 |
| Max. Negotiated Rate |
$1,209.60 |
| Rate for Payer: Aetna Commercial |
$970.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$982.80
|
| Rate for Payer: Cash Price |
$630.00
|
| Rate for Payer: Cigna Commercial |
$1,045.80
|
| Rate for Payer: First Health Commercial |
$1,197.00
|
| Rate for Payer: Humana Commercial |
$1,071.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,033.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$929.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$378.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,108.80
|
| Rate for Payer: Ohio Health Group HMO |
$945.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$252.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$163.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$390.60
|
| Rate for Payer: PHCS Commercial |
$1,209.60
|
| Rate for Payer: United Healthcare All Payer |
$1,108.80
|
|
|
MASTECTOMY, SIMPLE, COMPLETE
|
Facility
|
OP
|
$7,894.80
|
|
|
Service Code
|
CPT 19303
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,639.14 |
| Max. Negotiated Rate |
$7,894.80 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,639.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,894.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,612.84
|
| Rate for Payer: Humana Medicare Advantage |
$5,639.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,766.97
|
|
|
MASTECTOMY SIMPLE COMPLETE(P
|
Professional
|
Both
|
$1,260.00
|
|
|
Service Code
|
HCPCS 19303
|
| Hospital Charge Code |
761P0302
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$441.00 |
| Max. Negotiated Rate |
$1,345.65 |
| Rate for Payer: Aetna Commercial |
$1,345.65
|
| Rate for Payer: Anthem Medicaid |
$621.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,260.00
|
| Rate for Payer: Cash Price |
$630.00
|
| Rate for Payer: Cash Price |
$630.00
|
| Rate for Payer: Cigna Commercial |
$1,262.24
|
| Rate for Payer: Healthspan PPO |
$1,075.97
|
| Rate for Payer: Humana Medicaid |
$621.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,260.55
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$633.51
|
| Rate for Payer: Molina Healthcare Passport |
$621.09
|
| Rate for Payer: Multiplan PHCS |
$756.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$882.00
|
| Rate for Payer: UHCCP Medicaid |
$441.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$627.30
|
|
|
MASTISOL ADHESIVE DROPERETTE
|
Facility
|
OP
|
$9.96
|
|
|
Service Code
|
NDC 496052348
|
| Hospital Charge Code |
27000182
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$7.67
|
| Rate for Payer: Anthem Medicaid |
$3.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.77
|
| Rate for Payer: Cash Price |
$4.98
|
| Rate for Payer: Cigna Commercial |
$8.27
|
| Rate for Payer: First Health Commercial |
$9.46
|
| Rate for Payer: Humana Commercial |
$8.47
|
| Rate for Payer: Humana KY Medicaid |
$3.43
|
| Rate for Payer: Kentucky WC Medicaid |
$3.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.76
|
| Rate for Payer: Ohio Health Group HMO |
$7.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.09
|
| Rate for Payer: PHCS Commercial |
$9.56
|
| Rate for Payer: United Healthcare All Payer |
$8.76
|
|
|
MASTISOL ADHESIVE DROPERETTE
|
Facility
|
IP
|
$9.96
|
|
|
Service Code
|
NDC 496052348
|
| Hospital Charge Code |
27000182
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$7.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.77
|
| Rate for Payer: Cash Price |
$4.98
|
| Rate for Payer: Cigna Commercial |
$8.27
|
| Rate for Payer: First Health Commercial |
$9.46
|
| Rate for Payer: Humana Commercial |
$8.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.76
|
| Rate for Payer: Ohio Health Group HMO |
$7.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.09
|
| Rate for Payer: PHCS Commercial |
$9.56
|
| Rate for Payer: United Healthcare All Payer |
$8.76
|
|
|
MASTISOL LIQUID
|
Facility
|
IP
|
$179.13
|
|
|
Service Code
|
NDC 496052306
|
| Hospital Charge Code |
25003741
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.29 |
| Max. Negotiated Rate |
$171.96 |
| Rate for Payer: Aetna Commercial |
$137.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$139.72
|
| Rate for Payer: Cash Price |
$89.56
|
| Rate for Payer: Cigna Commercial |
$148.68
|
| Rate for Payer: First Health Commercial |
$170.17
|
| Rate for Payer: Humana Commercial |
$152.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$146.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$132.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$157.63
|
| Rate for Payer: Ohio Health Group HMO |
$134.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$35.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.53
|
| Rate for Payer: PHCS Commercial |
$171.96
|
| Rate for Payer: United Healthcare All Payer |
$157.63
|
|
|
MASTISOL LIQUID
|
Facility
|
OP
|
$179.13
|
|
|
Service Code
|
NDC 496052306
|
| Hospital Charge Code |
25003741
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.29 |
| Max. Negotiated Rate |
$171.96 |
| Rate for Payer: Aetna Commercial |
$137.93
|
| Rate for Payer: Anthem Medicaid |
$61.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$139.72
|
| Rate for Payer: Cash Price |
$89.56
|
| Rate for Payer: Cigna Commercial |
$148.68
|
| Rate for Payer: First Health Commercial |
$170.17
|
| Rate for Payer: Humana Commercial |
$152.26
|
| Rate for Payer: Humana KY Medicaid |
$61.60
|
| Rate for Payer: Kentucky WC Medicaid |
$62.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$146.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$132.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$62.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$157.63
|
| Rate for Payer: Ohio Health Group HMO |
$134.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$35.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.53
|
| Rate for Payer: PHCS Commercial |
$171.96
|
| Rate for Payer: United Healthcare All Payer |
$157.63
|
|
|
MASTISOL LIQUID (15ML)
|
Facility
|
OP
|
$85.88
|
|
|
Service Code
|
NDC 496052315
|
| Hospital Charge Code |
27000178
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$11.16 |
| Max. Negotiated Rate |
$82.44 |
| Rate for Payer: Aetna Commercial |
$66.13
|
| Rate for Payer: Anthem Medicaid |
$29.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.99
|
| Rate for Payer: Cash Price |
$42.94
|
| Rate for Payer: Cigna Commercial |
$71.28
|
| Rate for Payer: First Health Commercial |
$81.59
|
| Rate for Payer: Humana Commercial |
$73.00
|
| Rate for Payer: Humana KY Medicaid |
$29.53
|
| Rate for Payer: Kentucky WC Medicaid |
$29.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$70.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$63.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.57
|
| Rate for Payer: Ohio Health Group HMO |
$64.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.62
|
| Rate for Payer: PHCS Commercial |
$82.44
|
| Rate for Payer: United Healthcare All Payer |
$75.57
|
|
|
MASTISOL LIQUID (15ML)
|
Facility
|
IP
|
$85.88
|
|
|
Service Code
|
NDC 496052315
|
| Hospital Charge Code |
27000178
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$11.16 |
| Max. Negotiated Rate |
$82.44 |
| Rate for Payer: Aetna Commercial |
$66.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.99
|
| Rate for Payer: Cash Price |
$42.94
|
| Rate for Payer: Cigna Commercial |
$71.28
|
| Rate for Payer: First Health Commercial |
$81.59
|
| Rate for Payer: Humana Commercial |
$73.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$70.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$63.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.57
|
| Rate for Payer: Ohio Health Group HMO |
$64.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.62
|
| Rate for Payer: PHCS Commercial |
$82.44
|
| Rate for Payer: United Healthcare All Payer |
$75.57
|
|
|
MASTOID CLEANING
|
Professional
|
Both
|
$461.00
|
|
|
Service Code
|
HCPCS 69220
|
| Hospital Charge Code |
76102414
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$26.08 |
| Max. Negotiated Rate |
$461.00 |
| Rate for Payer: Aetna Commercial |
$90.37
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$26.08
|
| Rate for Payer: Anthem Medicaid |
$32.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$461.00
|
| Rate for Payer: Cash Price |
$230.50
|
| Rate for Payer: Cash Price |
$230.50
|
| Rate for Payer: Cigna Commercial |
$183.60
|
| Rate for Payer: Healthspan PPO |
$165.15
|
| Rate for Payer: Humana Medicaid |
$32.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$79.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$32.93
|
| Rate for Payer: Molina Healthcare Passport |
$32.28
|
| Rate for Payer: Multiplan PHCS |
$276.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$322.70
|
| Rate for Payer: UHCCP Medicaid |
$27.38
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$32.60
|
|
|
MASTOID CLEANING
|
Facility
|
OP
|
$461.00
|
|
|
Service Code
|
HCPCS 69220
|
| Hospital Charge Code |
76102414
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$59.93 |
| Max. Negotiated Rate |
$442.56 |
| Rate for Payer: Aetna Commercial |
$354.97
|
| Rate for Payer: Anthem Medicaid |
$158.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$359.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$230.50
|
| Rate for Payer: Cash Price |
$230.50
|
| Rate for Payer: Cigna Commercial |
$382.63
|
| Rate for Payer: First Health Commercial |
$437.95
|
| Rate for Payer: Humana Commercial |
$391.85
|
| Rate for Payer: Humana KY Medicaid |
$158.54
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$160.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$378.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$340.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$161.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$405.68
|
| Rate for Payer: Ohio Health Group HMO |
$345.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$142.91
|
| Rate for Payer: PHCS Commercial |
$442.56
|
| Rate for Payer: United Healthcare All Payer |
$405.68
|
|
|
MASTOID CLEANING
|
Facility
|
IP
|
$461.00
|
|
|
Service Code
|
HCPCS 69220
|
| Hospital Charge Code |
76102414
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$59.93 |
| Max. Negotiated Rate |
$442.56 |
| Rate for Payer: Aetna Commercial |
$354.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$359.58
|
| Rate for Payer: Cash Price |
$230.50
|
| Rate for Payer: Cigna Commercial |
$382.63
|
| Rate for Payer: First Health Commercial |
$437.95
|
| Rate for Payer: Humana Commercial |
$391.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$378.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$340.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$138.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$405.68
|
| Rate for Payer: Ohio Health Group HMO |
$345.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$142.91
|
| Rate for Payer: PHCS Commercial |
$442.56
|
| Rate for Payer: United Healthcare All Payer |
$405.68
|
|
|
MASTOID CLEANING(P
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 69220
|
| Hospital Charge Code |
761P2414
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$26.08 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna Commercial |
$90.37
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$26.08
|
| Rate for Payer: Anthem Medicaid |
$32.28
|
| 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 |
$183.60
|
| Rate for Payer: Healthspan PPO |
$165.15
|
| Rate for Payer: Humana Medicaid |
$32.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$79.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$32.93
|
| Rate for Payer: Molina Healthcare Passport |
$32.28
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.00
|
| Rate for Payer: UHCCP Medicaid |
$27.38
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$32.60
|
|
|
MASTOID CLEANING(T
|
Facility
|
IP
|
$261.00
|
|
|
Service Code
|
HCPCS 69220
|
| Hospital Charge Code |
761T2414
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$33.93 |
| Max. Negotiated Rate |
$250.56 |
| Rate for Payer: Aetna Commercial |
$200.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$203.58
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cigna Commercial |
$216.63
|
| Rate for Payer: First Health Commercial |
$247.95
|
| Rate for Payer: Humana Commercial |
$221.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$214.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$192.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$229.68
|
| Rate for Payer: Ohio Health Group HMO |
$195.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.91
|
| Rate for Payer: PHCS Commercial |
$250.56
|
| Rate for Payer: United Healthcare All Payer |
$229.68
|
|
|
MASTOID CLEANING(T
|
Facility
|
OP
|
$261.00
|
|
|
Service Code
|
HCPCS 69220
|
| Hospital Charge Code |
761T2414
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$33.93 |
| Max. Negotiated Rate |
$250.56 |
| Rate for Payer: Aetna Commercial |
$200.97
|
| Rate for Payer: Anthem Medicaid |
$89.76
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$203.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cigna Commercial |
$216.63
|
| Rate for Payer: First Health Commercial |
$247.95
|
| Rate for Payer: Humana Commercial |
$221.85
|
| Rate for Payer: Humana KY Medicaid |
$89.76
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$90.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$214.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$192.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$91.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$229.68
|
| Rate for Payer: Ohio Health Group HMO |
$195.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.91
|
| Rate for Payer: PHCS Commercial |
$250.56
|
| Rate for Payer: United Healthcare All Payer |
$229.68
|
|
