|
MASTOIDECTOMY; COMPLETE
|
Facility
|
IP
|
$2,300.00
|
|
|
Service Code
|
HCPCS 69502
|
| Hospital Charge Code |
76102423
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$299.00 |
| Max. Negotiated Rate |
$2,208.00 |
| Rate for Payer: Aetna Commercial |
$1,771.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,794.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$1,909.00
|
| Rate for Payer: First Health Commercial |
$2,185.00
|
| Rate for Payer: Humana Commercial |
$1,955.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,886.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,697.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$690.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,024.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,725.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$460.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$299.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$713.00
|
| Rate for Payer: PHCS Commercial |
$2,208.00
|
| Rate for Payer: United Healthcare All Payer |
$2,024.00
|
|
|
MASTOIDECTOMY; COMPLETE
|
Facility
|
OP
|
$2,300.00
|
|
|
Service Code
|
HCPCS 69502
|
| Hospital Charge Code |
76102423
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$299.00 |
| Max. Negotiated Rate |
$7,089.80 |
| Rate for Payer: Aetna Commercial |
$1,771.00
|
| Rate for Payer: Anthem Medicaid |
$790.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,064.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,794.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,089.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,836.59
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$1,909.00
|
| Rate for Payer: First Health Commercial |
$2,185.00
|
| Rate for Payer: Humana Commercial |
$1,955.00
|
| Rate for Payer: Humana KY Medicaid |
$790.97
|
| Rate for Payer: Humana Medicare Advantage |
$5,064.14
|
| Rate for Payer: Kentucky WC Medicaid |
$799.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,886.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,697.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,076.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$806.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,024.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,725.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$460.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$299.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$713.00
|
| Rate for Payer: PHCS Commercial |
$2,208.00
|
| Rate for Payer: United Healthcare All Payer |
$2,024.00
|
|
|
MASTOIDECTOMY; COMPLETE
|
Professional
|
Both
|
$2,300.00
|
|
|
Service Code
|
HCPCS 69502
|
| Hospital Charge Code |
76102423
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$744.52 |
| Max. Negotiated Rate |
$2,300.00 |
| Rate for Payer: Aetna Commercial |
$1,392.02
|
| Rate for Payer: Anthem Medicaid |
$744.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,300.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$1,371.44
|
| Rate for Payer: Healthspan PPO |
$1,234.79
|
| Rate for Payer: Humana Medicaid |
$744.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,245.69
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$759.41
|
| Rate for Payer: Molina Healthcare Passport |
$744.52
|
| Rate for Payer: Multiplan PHCS |
$1,380.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,610.00
|
| Rate for Payer: UHCCP Medicaid |
$805.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$751.97
|
|
|
MASTOIDECTOMY; COMPLETE(P
|
Professional
|
Both
|
$2,300.00
|
|
|
Service Code
|
HCPCS 69502
|
| Hospital Charge Code |
761P2423
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$744.52 |
| Max. Negotiated Rate |
$2,300.00 |
| Rate for Payer: Aetna Commercial |
$1,392.02
|
| Rate for Payer: Anthem Medicaid |
$744.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,300.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$1,371.44
|
| Rate for Payer: Healthspan PPO |
$1,234.79
|
| Rate for Payer: Humana Medicaid |
$744.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,245.69
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$759.41
|
| Rate for Payer: Molina Healthcare Passport |
$744.52
|
| Rate for Payer: Multiplan PHCS |
$1,380.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,610.00
|
| Rate for Payer: UHCCP Medicaid |
$805.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$751.97
|
|
|
MASTOID SURGERY REVISION
|
Facility
|
OP
|
$1,260.00
|
|
|
Service Code
|
HCPCS 69602
|
| Hospital Charge Code |
76102425
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$163.80 |
| Max. Negotiated Rate |
$7,089.80 |
| Rate for Payer: Aetna Commercial |
$970.20
|
| Rate for Payer: Anthem Medicaid |
$433.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,064.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$982.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,089.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,836.59
|
| 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 |
$5,064.14
|
| 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 |
$6,076.97
|
| 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
|
|
|
MASTOID SURGERY REVISION
|
Professional
|
Both
|
$1,260.00
|
|
|
Service Code
|
HCPCS 69602
|
| Hospital Charge Code |
76102425
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$441.00 |
| Max. Negotiated Rate |
$1,559.41 |
| Rate for Payer: Aetna Commercial |
$1,559.41
|
| Rate for Payer: Anthem Medicaid |
$865.08
|
| 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 |
$1,534.35
|
| Rate for Payer: Healthspan PPO |
$1,383.26
|
| Rate for Payer: Humana Medicaid |
$865.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,393.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$882.38
|
| Rate for Payer: Molina Healthcare Passport |
$865.08
|
| 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 |
$873.73
|
|
|
MASTOID SURGERY REVISION
|
Professional
|
Both
|
$1,225.00
|
|
|
Service Code
|
HCPCS 69601
|
| Hospital Charge Code |
76102705
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$428.75 |
| Max. Negotiated Rate |
$1,500.21 |
| Rate for Payer: Aetna Commercial |
$1,500.21
|
| Rate for Payer: Anthem Medicaid |
$789.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,225.00
|
| Rate for Payer: Cash Price |
$612.50
|
| Rate for Payer: Cash Price |
$612.50
|
| Rate for Payer: Cigna Commercial |
$1,480.49
|
| Rate for Payer: Healthspan PPO |
$1,330.75
|
| Rate for Payer: Humana Medicaid |
$789.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,339.95
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$804.79
|
| Rate for Payer: Molina Healthcare Passport |
$789.01
|
| Rate for Payer: Multiplan PHCS |
$735.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$857.50
|
| Rate for Payer: UHCCP Medicaid |
$428.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$796.90
|
|
|
MASTOID SURGERY REVISION
|
Facility
|
IP
|
$1,260.00
|
|
|
Service Code
|
HCPCS 69602
|
| Hospital Charge Code |
76102425
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$163.80 |
| Max. Negotiated Rate |
$1,209.60 |
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,033.20
|
| 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 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
|
|
|
MASTOID SURGERY REVISION(P
|
Professional
|
Both
|
$1,260.00
|
|
|
Service Code
|
HCPCS 69602
|
| Hospital Charge Code |
761P2425
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$441.00 |
| Max. Negotiated Rate |
$1,559.41 |
| Rate for Payer: Aetna Commercial |
$1,559.41
|
| Rate for Payer: Anthem Medicaid |
$865.08
|
| 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 |
$1,534.35
|
| Rate for Payer: Healthspan PPO |
$1,383.26
|
| Rate for Payer: Humana Medicaid |
$865.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,393.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$882.38
|
| Rate for Payer: Molina Healthcare Passport |
$865.08
|
| 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 |
$873.73
|
|
|
MASTOPEXY
|
Professional
|
Both
|
$2,100.00
|
|
|
Service Code
|
HCPCS 19316
|
| Hospital Charge Code |
76100306
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$698.93 |
| Max. Negotiated Rate |
$2,100.00 |
| Rate for Payer: Aetna Commercial |
$1,132.21
|
| Rate for Payer: Anthem Medicaid |
$698.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,100.00
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cigna Commercial |
$1,087.07
|
| Rate for Payer: Healthspan PPO |
$905.31
|
| Rate for Payer: Humana Medicaid |
$698.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$991.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$712.91
|
| Rate for Payer: Molina Healthcare Passport |
$698.93
|
| Rate for Payer: Multiplan PHCS |
$1,260.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,470.00
|
| Rate for Payer: UHCCP Medicaid |
$735.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$705.92
|
|
|
MASTOPEXY
|
Facility
|
IP
|
$2,100.00
|
|
|
Service Code
|
HCPCS 19316
|
| Hospital Charge Code |
76100306
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$273.00 |
| Max. Negotiated Rate |
$2,016.00 |
| Rate for Payer: Aetna Commercial |
$1,617.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,638.00
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cigna Commercial |
$1,743.00
|
| Rate for Payer: First Health Commercial |
$1,995.00
|
| Rate for Payer: Humana Commercial |
$1,785.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,722.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,549.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$630.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,848.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,575.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$420.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$273.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$651.00
|
| Rate for Payer: PHCS Commercial |
$2,016.00
|
| Rate for Payer: United Healthcare All Payer |
$1,848.00
|
|
|
MASTOPEXY
|
Facility
|
OP
|
$2,100.00
|
|
|
Service Code
|
HCPCS 19316
|
| Hospital Charge Code |
76100306
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$273.00 |
| Max. Negotiated Rate |
$7,894.80 |
| Rate for Payer: Aetna Commercial |
$1,617.00
|
| Rate for Payer: Anthem Medicaid |
$722.19
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,639.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,638.00
|
| 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 |
$1,050.00
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cigna Commercial |
$1,743.00
|
| Rate for Payer: First Health Commercial |
$1,995.00
|
| Rate for Payer: Humana Commercial |
$1,785.00
|
| Rate for Payer: Humana KY Medicaid |
$722.19
|
| Rate for Payer: Humana Medicare Advantage |
$5,639.14
|
| Rate for Payer: Kentucky WC Medicaid |
$729.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,722.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,549.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,766.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$736.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,848.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,575.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$420.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$273.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$651.00
|
| Rate for Payer: PHCS Commercial |
$2,016.00
|
| Rate for Payer: United Healthcare All Payer |
$1,848.00
|
|
|
MASTOPEXY - FULL
|
Professional
|
Both
|
$1,250.00
|
|
| Hospital Charge Code |
22200054
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$437.50 |
| Max. Negotiated Rate |
$1,250.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$1,250.00
|
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Multiplan PHCS |
$750.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$875.00
|
| Rate for Payer: UHCCP Medicaid |
$437.50
|
|
|
MASTOPEXY-FULL -80
|
Professional
|
Both
|
$625.00
|
|
| Hospital Charge Code |
22200380
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$218.75 |
| Max. Negotiated Rate |
$625.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$625.00
|
| Rate for Payer: Cash Price |
$312.50
|
| Rate for Payer: Multiplan PHCS |
$375.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$437.50
|
| Rate for Payer: UHCCP Medicaid |
$218.75
|
|
|
MASTOPEXY(P
|
Professional
|
Both
|
$2,100.00
|
|
|
Service Code
|
HCPCS 19316
|
| Hospital Charge Code |
761P0306
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$698.93 |
| Max. Negotiated Rate |
$2,100.00 |
| Rate for Payer: Aetna Commercial |
$1,132.21
|
| Rate for Payer: Anthem Medicaid |
$698.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,100.00
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cigna Commercial |
$1,087.07
|
| Rate for Payer: Healthspan PPO |
$905.31
|
| Rate for Payer: Humana Medicaid |
$698.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$991.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$712.91
|
| Rate for Payer: Molina Healthcare Passport |
$698.93
|
| Rate for Payer: Multiplan PHCS |
$1,260.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,470.00
|
| Rate for Payer: UHCCP Medicaid |
$735.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$705.92
|
|
|
MASTOTOMY WEXP OR DRAINABSCSDP
|
Facility
|
OP
|
$2,138.00
|
|
|
Service Code
|
HCPCS 19020
|
| Hospital Charge Code |
761T0276
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$277.94 |
| Max. Negotiated Rate |
$2,052.48 |
| Rate for Payer: Aetna Commercial |
$1,646.26
|
| Rate for Payer: Anthem Medicaid |
$735.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,667.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$1,069.00
|
| Rate for Payer: Cash Price |
$1,069.00
|
| Rate for Payer: Cigna Commercial |
$1,774.54
|
| Rate for Payer: First Health Commercial |
$2,031.10
|
| Rate for Payer: Humana Commercial |
$1,817.30
|
| Rate for Payer: Humana KY Medicaid |
$735.26
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$742.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,753.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,577.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$750.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,881.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,603.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$427.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$277.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$662.78
|
| Rate for Payer: PHCS Commercial |
$2,052.48
|
| Rate for Payer: United Healthcare All Payer |
$1,881.44
|
|
|
MASTOTOMY WEXP OR DRAINABSCSDP
|
Facility
|
IP
|
$2,138.00
|
|
|
Service Code
|
HCPCS 19020
|
| Hospital Charge Code |
45000084
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$277.94 |
| Max. Negotiated Rate |
$2,052.48 |
| Rate for Payer: Aetna Commercial |
$1,646.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,667.64
|
| Rate for Payer: Cash Price |
$1,069.00
|
| Rate for Payer: Cigna Commercial |
$1,774.54
|
| Rate for Payer: First Health Commercial |
$2,031.10
|
| Rate for Payer: Humana Commercial |
$1,817.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,753.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,577.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$641.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,881.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,603.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$427.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$277.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$662.78
|
| Rate for Payer: PHCS Commercial |
$2,052.48
|
| Rate for Payer: United Healthcare All Payer |
$1,881.44
|
|
|
MASTOTOMY WEXP OR DRAINABSCSDP
|
Professional
|
Both
|
$2,676.00
|
|
|
Service Code
|
HCPCS 19020
|
| Hospital Charge Code |
76100276
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.24 |
| Max. Negotiated Rate |
$2,676.00 |
| Rate for Payer: Aetna Commercial |
$406.37
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$161.09
|
| Rate for Payer: Anthem Medicaid |
$143.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,676.00
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$376.07
|
| Rate for Payer: Healthspan PPO |
$476.85
|
| Rate for Payer: Humana Medicaid |
$143.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$373.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$146.10
|
| Rate for Payer: Molina Healthcare Passport |
$143.24
|
| Rate for Payer: Multiplan PHCS |
$1,605.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,873.20
|
| Rate for Payer: UHCCP Medicaid |
$169.14
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$144.67
|
|
|
MASTOTOMY WEXP OR DRAINABSCSDP
|
Facility
|
IP
|
$2,676.00
|
|
|
Service Code
|
HCPCS 19020
|
| Hospital Charge Code |
76100276
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$347.88 |
| Max. Negotiated Rate |
$2,568.96 |
| Rate for Payer: Aetna Commercial |
$2,060.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,087.28
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$2,221.08
|
| Rate for Payer: First Health Commercial |
$2,542.20
|
| Rate for Payer: Humana Commercial |
$2,274.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,194.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,974.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$802.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,354.88
|
| Rate for Payer: Ohio Health Group HMO |
$2,007.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$535.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$347.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$829.56
|
| Rate for Payer: PHCS Commercial |
$2,568.96
|
| Rate for Payer: United Healthcare All Payer |
$2,354.88
|
|
|
MASTOTOMY WEXP OR DRAINABSCSDP
|
Facility
|
OP
|
$2,138.00
|
|
|
Service Code
|
HCPCS 19020
|
| Hospital Charge Code |
45000084
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$277.94 |
| Max. Negotiated Rate |
$2,052.48 |
| Rate for Payer: Aetna Commercial |
$1,646.26
|
| Rate for Payer: Anthem Medicaid |
$735.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,667.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$1,069.00
|
| Rate for Payer: Cash Price |
$1,069.00
|
| Rate for Payer: Cigna Commercial |
$1,774.54
|
| Rate for Payer: First Health Commercial |
$2,031.10
|
| Rate for Payer: Humana Commercial |
$1,817.30
|
| Rate for Payer: Humana KY Medicaid |
$735.26
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$742.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,753.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,577.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$750.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,881.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,603.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$427.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$277.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$662.78
|
| Rate for Payer: PHCS Commercial |
$2,052.48
|
| Rate for Payer: United Healthcare All Payer |
$1,881.44
|
|
|
MASTOTOMY WEXP OR DRAINABSCSDP
|
Facility
|
IP
|
$2,138.00
|
|
|
Service Code
|
HCPCS 19020
|
| Hospital Charge Code |
761T0276
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$277.94 |
| Max. Negotiated Rate |
$2,052.48 |
| Rate for Payer: Aetna Commercial |
$1,646.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,667.64
|
| Rate for Payer: Cash Price |
$1,069.00
|
| Rate for Payer: Cigna Commercial |
$1,774.54
|
| Rate for Payer: First Health Commercial |
$2,031.10
|
| Rate for Payer: Humana Commercial |
$1,817.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,753.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,577.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$641.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,881.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,603.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$427.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$277.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$662.78
|
| Rate for Payer: PHCS Commercial |
$2,052.48
|
| Rate for Payer: United Healthcare All Payer |
$1,881.44
|
|
|
MASTOTOMY WEXP OR DRAINABSCSDP
|
Facility
|
OP
|
$2,676.00
|
|
|
Service Code
|
HCPCS 19020
|
| Hospital Charge Code |
76100276
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$347.88 |
| Max. Negotiated Rate |
$2,568.96 |
| Rate for Payer: Aetna Commercial |
$2,060.52
|
| Rate for Payer: Anthem Medicaid |
$920.28
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,087.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$2,221.08
|
| Rate for Payer: First Health Commercial |
$2,542.20
|
| Rate for Payer: Humana Commercial |
$2,274.60
|
| Rate for Payer: Humana KY Medicaid |
$920.28
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$929.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,194.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,974.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$938.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,354.88
|
| Rate for Payer: Ohio Health Group HMO |
$2,007.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$535.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$347.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$829.56
|
| Rate for Payer: PHCS Commercial |
$2,568.96
|
| Rate for Payer: United Healthcare All Payer |
$2,354.88
|
|
|
MASTOTOMY WEXP OR DRAINABSCSDP
|
Professional
|
Both
|
$538.00
|
|
|
Service Code
|
HCPCS 19020
|
| Hospital Charge Code |
761P0276
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.24 |
| Max. Negotiated Rate |
$538.00 |
| Rate for Payer: Aetna Commercial |
$406.37
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$161.09
|
| Rate for Payer: Anthem Medicaid |
$143.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$538.00
|
| Rate for Payer: Cash Price |
$269.00
|
| Rate for Payer: Cash Price |
$269.00
|
| Rate for Payer: Cigna Commercial |
$376.07
|
| Rate for Payer: Healthspan PPO |
$476.85
|
| Rate for Payer: Humana Medicaid |
$143.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$373.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$146.10
|
| Rate for Payer: Molina Healthcare Passport |
$143.24
|
| Rate for Payer: Multiplan PHCS |
$322.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$376.60
|
| Rate for Payer: UHCCP Medicaid |
$169.14
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$144.67
|
|
|
MATERNA 1:60 (PRENATAL VI 1TAB
|
Facility
|
OP
|
$4.23
|
|
|
Service Code
|
NDC 904531360
|
| Hospital Charge Code |
25000943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.06 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem Medicaid |
$1.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.51
|
| Rate for Payer: First Health Commercial |
$4.02
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Humana KY Medicaid |
$1.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.72
|
| Rate for Payer: Ohio Health Group HMO |
$3.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.06
|
| Rate for Payer: United Healthcare All Payer |
$3.72
|
|
|
MATERNA 1:60 (PRENATAL VI 1TAB
|
Facility
|
IP
|
$4.23
|
|
|
Service Code
|
NDC 904531360
|
| Hospital Charge Code |
25000943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.06 |
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.72
|
| Rate for Payer: Ohio Health Group HMO |
$3.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.06
|
| Rate for Payer: United Healthcare All Payer |
$3.72
|
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.51
|
| Rate for Payer: First Health Commercial |
$4.02
|
|
