|
MAMMO BREAST SPEC-1 VW (SURG(P
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 76098
|
| Hospital Charge Code |
320P0184
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$50.73 |
| Rate for Payer: Aetna Commercial |
$30.64
|
| Rate for Payer: Ambetter Exchange |
$39.02
|
| Rate for Payer: Anthem Medicaid |
$18.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$39.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$39.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$46.82
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$33.67
|
| Rate for Payer: Healthspan PPO |
$28.71
|
| Rate for Payer: Humana Medicaid |
$18.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$10.38
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$39.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.02
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$18.64
|
| Rate for Payer: Molina Healthcare Passport |
$18.27
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$50.73
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$18.45
|
| Rate for Payer: Wellcare Medicare Advantage |
$39.02
|
|
|
MAMMO BREAST SPEC-1 VW (SURG(T
|
Facility
|
IP
|
$730.00
|
|
|
Service Code
|
HCPCS 76098
|
| Hospital Charge Code |
320T0184
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$219.00 |
| Max. Negotiated Rate |
$700.80 |
| Rate for Payer: Aetna Commercial |
$562.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$569.40
|
| Rate for Payer: Cash Price |
$365.00
|
| Rate for Payer: Cigna Commercial |
$605.90
|
| Rate for Payer: First Health Commercial |
$693.50
|
| Rate for Payer: Humana Commercial |
$620.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$598.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$538.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$219.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$642.40
|
| Rate for Payer: Ohio Health Group HMO |
$547.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$584.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$635.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$503.70
|
| Rate for Payer: PHCS Commercial |
$700.80
|
| Rate for Payer: United Healthcare All Payer |
$642.40
|
|
|
MAMMO BREAST SPEC-1 VW (SURG(T
|
Facility
|
OP
|
$730.00
|
|
|
Service Code
|
HCPCS 76098
|
| Hospital Charge Code |
320T0184
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$251.05 |
| Max. Negotiated Rate |
$709.27 |
| Rate for Payer: Aetna Commercial |
$562.10
|
| Rate for Payer: Anthem Medicaid |
$251.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$506.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$569.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$709.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$683.94
|
| Rate for Payer: Cash Price |
$365.00
|
| Rate for Payer: Cash Price |
$365.00
|
| Rate for Payer: Cigna Commercial |
$605.90
|
| Rate for Payer: First Health Commercial |
$693.50
|
| Rate for Payer: Humana Commercial |
$620.50
|
| Rate for Payer: Humana KY Medicaid |
$251.05
|
| Rate for Payer: Humana Medicare Advantage |
$506.62
|
| Rate for Payer: Kentucky WC Medicaid |
$253.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$598.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$538.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$607.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$256.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$642.40
|
| Rate for Payer: Ohio Health Group HMO |
$547.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$584.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$635.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$503.70
|
| Rate for Payer: PHCS Commercial |
$700.80
|
| Rate for Payer: United Healthcare All Payer |
$642.40
|
|
|
MAMMO BRST LOC DEV PERC 1STLES
|
Facility
|
OP
|
$2,178.00
|
|
|
Service Code
|
HCPCS 19281
|
| Hospital Charge Code |
76100292
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$749.01 |
| Max. Negotiated Rate |
$2,095.90 |
| Rate for Payer: Aetna Commercial |
$1,677.06
|
| Rate for Payer: Anthem Medicaid |
$749.01
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,698.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,095.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,021.04
|
| Rate for Payer: Cash Price |
$1,089.00
|
| Rate for Payer: Cash Price |
$1,089.00
|
| Rate for Payer: Cigna Commercial |
$1,807.74
|
| Rate for Payer: First Health Commercial |
$2,069.10
|
| Rate for Payer: Humana Commercial |
$1,851.30
|
| Rate for Payer: Humana KY Medicaid |
$749.01
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$756.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,785.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,607.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$764.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,916.64
|
| Rate for Payer: Ohio Health Group HMO |
$1,633.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,742.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,894.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,502.82
|
| Rate for Payer: PHCS Commercial |
$2,090.88
|
| Rate for Payer: United Healthcare All Payer |
$1,916.64
|
|
|
MAMMO BRST LOC DEV PERC 1STLES
|
Facility
|
IP
|
$2,178.00
|
|
|
Service Code
|
HCPCS 19281
|
| Hospital Charge Code |
76100292
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$653.40 |
| Max. Negotiated Rate |
$2,090.88 |
| Rate for Payer: Aetna Commercial |
$1,677.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,698.84
|
| Rate for Payer: Cash Price |
$1,089.00
|
| Rate for Payer: Cigna Commercial |
$1,807.74
|
| Rate for Payer: First Health Commercial |
$2,069.10
|
| Rate for Payer: Humana Commercial |
$1,851.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,785.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,607.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$653.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,916.64
|
| Rate for Payer: Ohio Health Group HMO |
$1,633.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,742.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,894.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,502.82
|
| Rate for Payer: PHCS Commercial |
$2,090.88
|
| Rate for Payer: United Healthcare All Payer |
$1,916.64
|
|
|
MAMMO BRST LOC DEV PERC 1STLES
|
Facility
|
OP
|
$1,953.00
|
|
|
Service Code
|
HCPCS 19281
|
| Hospital Charge Code |
761T0292
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$671.64 |
| Max. Negotiated Rate |
$2,095.90 |
| Rate for Payer: Aetna Commercial |
$1,503.81
|
| Rate for Payer: Anthem Medicaid |
$671.64
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,523.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,095.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,021.04
|
| Rate for Payer: Cash Price |
$976.50
|
| Rate for Payer: Cash Price |
$976.50
|
| Rate for Payer: Cigna Commercial |
$1,620.99
|
| Rate for Payer: First Health Commercial |
$1,855.35
|
| Rate for Payer: Humana Commercial |
$1,660.05
|
| Rate for Payer: Humana KY Medicaid |
$671.64
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$678.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,601.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,441.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$685.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,718.64
|
| Rate for Payer: Ohio Health Group HMO |
$1,464.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,562.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,699.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,347.57
|
| Rate for Payer: PHCS Commercial |
$1,874.88
|
| Rate for Payer: United Healthcare All Payer |
$1,718.64
|
|
|
MAMMO BRST LOC DEV PERC 1STLES
|
Facility
|
IP
|
$1,953.00
|
|
|
Service Code
|
HCPCS 19281
|
| Hospital Charge Code |
761T0292
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$585.90 |
| Max. Negotiated Rate |
$1,874.88 |
| Rate for Payer: Aetna Commercial |
$1,503.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,523.34
|
| Rate for Payer: Cash Price |
$976.50
|
| Rate for Payer: Cigna Commercial |
$1,620.99
|
| Rate for Payer: First Health Commercial |
$1,855.35
|
| Rate for Payer: Humana Commercial |
$1,660.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,601.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,441.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$585.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,718.64
|
| Rate for Payer: Ohio Health Group HMO |
$1,464.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,562.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,699.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,347.57
|
| Rate for Payer: PHCS Commercial |
$1,874.88
|
| Rate for Payer: United Healthcare All Payer |
$1,718.64
|
|
|
MAMMO BRST LOC DEV PERC 1STLES
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 19281
|
| Hospital Charge Code |
761P0292
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$78.75 |
| Max. Negotiated Rate |
$385.31 |
| Rate for Payer: Ambetter Exchange |
$91.88
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$78.75
|
| Rate for Payer: Anthem Medicaid |
$184.53
|
| Rate for Payer: Buckeye Individual/Medicaid |
$91.88
|
| Rate for Payer: Buckeye Medicare Advantage |
$91.88
|
| Rate for Payer: CareSource Just4Me Medicare |
$110.26
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$385.31
|
| Rate for Payer: Healthspan PPO |
$299.08
|
| Rate for Payer: Humana Medicaid |
$184.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$132.38
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$91.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$91.88
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$188.22
|
| Rate for Payer: Molina Healthcare Passport |
$184.53
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$119.44
|
| Rate for Payer: UHCCP Medicaid |
$82.69
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$186.38
|
| Rate for Payer: Wellcare Medicare Advantage |
$91.88
|
|
|
MAMMO BRST LOC DEV PERC 1STLES
|
Professional
|
Both
|
$2,178.00
|
|
|
Service Code
|
HCPCS 19281
|
| Hospital Charge Code |
76100292
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$78.75 |
| Max. Negotiated Rate |
$1,306.80 |
| Rate for Payer: Ambetter Exchange |
$91.88
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$78.75
|
| Rate for Payer: Anthem Medicaid |
$184.53
|
| Rate for Payer: Buckeye Individual/Medicaid |
$91.88
|
| Rate for Payer: Buckeye Medicare Advantage |
$91.88
|
| Rate for Payer: CareSource Just4Me Medicare |
$110.26
|
| Rate for Payer: Cash Price |
$1,089.00
|
| Rate for Payer: Cash Price |
$1,089.00
|
| Rate for Payer: Cigna Commercial |
$385.31
|
| Rate for Payer: Healthspan PPO |
$299.08
|
| Rate for Payer: Humana Medicaid |
$184.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$132.38
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$91.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$91.88
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$188.22
|
| Rate for Payer: Molina Healthcare Passport |
$184.53
|
| Rate for Payer: Multiplan PHCS |
$1,306.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$119.44
|
| Rate for Payer: UHCCP Medicaid |
$82.69
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$186.38
|
| Rate for Payer: Wellcare Medicare Advantage |
$91.88
|
|
|
MAMMO BRST LOCDEVPERC EAADDLES
|
Facility
|
IP
|
$1,379.00
|
|
|
Service Code
|
HCPCS 19282
|
| Hospital Charge Code |
76100293
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$413.70 |
| Max. Negotiated Rate |
$1,323.84 |
| Rate for Payer: Aetna Commercial |
$1,061.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,075.62
|
| Rate for Payer: Cash Price |
$689.50
|
| Rate for Payer: Cigna Commercial |
$1,144.57
|
| Rate for Payer: First Health Commercial |
$1,310.05
|
| Rate for Payer: Humana Commercial |
$1,172.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,130.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,017.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,213.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,034.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,103.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,199.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$951.51
|
| Rate for Payer: PHCS Commercial |
$1,323.84
|
| Rate for Payer: United Healthcare All Payer |
$1,213.52
|
|
|
MAMMO BRST LOCDEVPERC EAADDLES
|
Facility
|
IP
|
$1,279.00
|
|
|
Service Code
|
HCPCS 19282
|
| Hospital Charge Code |
761T0293
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$383.70 |
| Max. Negotiated Rate |
$1,227.84 |
| Rate for Payer: Aetna Commercial |
$984.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$997.62
|
| Rate for Payer: Cash Price |
$639.50
|
| Rate for Payer: Cigna Commercial |
$1,061.57
|
| Rate for Payer: First Health Commercial |
$1,215.05
|
| Rate for Payer: Humana Commercial |
$1,087.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,048.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$943.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$383.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,125.52
|
| Rate for Payer: Ohio Health Group HMO |
$959.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,023.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,112.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$882.51
|
| Rate for Payer: PHCS Commercial |
$1,227.84
|
| Rate for Payer: United Healthcare All Payer |
$1,125.52
|
|
|
MAMMO BRST LOCDEVPERC EAADDLES
|
Professional
|
Both
|
$1,379.00
|
|
|
Service Code
|
HCPCS 19282
|
| Hospital Charge Code |
76100293
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$39.27 |
| Max. Negotiated Rate |
$827.40 |
| Rate for Payer: Ambetter Exchange |
$45.92
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$39.27
|
| Rate for Payer: Anthem Medicaid |
$126.86
|
| Rate for Payer: Buckeye Individual/Medicaid |
$45.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$45.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$55.10
|
| Rate for Payer: Cash Price |
$689.50
|
| Rate for Payer: Cash Price |
$689.50
|
| Rate for Payer: Cigna Commercial |
$265.70
|
| Rate for Payer: Healthspan PPO |
$205.25
|
| Rate for Payer: Humana Medicaid |
$126.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$62.86
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$45.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$129.40
|
| Rate for Payer: Molina Healthcare Passport |
$126.86
|
| Rate for Payer: Multiplan PHCS |
$827.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$59.70
|
| Rate for Payer: UHCCP Medicaid |
$41.23
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$128.13
|
| Rate for Payer: Wellcare Medicare Advantage |
$45.92
|
|
|
MAMMO BRST LOCDEVPERC EAADDLES
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 19282
|
| Hospital Charge Code |
761P0293
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$39.27 |
| Max. Negotiated Rate |
$265.70 |
| Rate for Payer: Ambetter Exchange |
$45.92
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$39.27
|
| Rate for Payer: Anthem Medicaid |
$126.86
|
| Rate for Payer: Buckeye Individual/Medicaid |
$45.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$45.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$55.10
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$265.70
|
| Rate for Payer: Healthspan PPO |
$205.25
|
| Rate for Payer: Humana Medicaid |
$126.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$62.86
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$45.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$129.40
|
| Rate for Payer: Molina Healthcare Passport |
$126.86
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$59.70
|
| Rate for Payer: UHCCP Medicaid |
$41.23
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$128.13
|
| Rate for Payer: Wellcare Medicare Advantage |
$45.92
|
|
|
MAMMO BRST LOCDEVPERC EAADDLES
|
Facility
|
OP
|
$1,279.00
|
|
|
Service Code
|
HCPCS 19282
|
| Hospital Charge Code |
761T0293
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$383.70 |
| Max. Negotiated Rate |
$1,227.84 |
| Rate for Payer: Aetna Commercial |
$984.83
|
| Rate for Payer: Anthem Medicaid |
$439.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$997.62
|
| Rate for Payer: Cash Price |
$639.50
|
| Rate for Payer: Cigna Commercial |
$1,061.57
|
| Rate for Payer: First Health Commercial |
$1,215.05
|
| Rate for Payer: Humana Commercial |
$1,087.15
|
| Rate for Payer: Humana KY Medicaid |
$439.85
|
| Rate for Payer: Kentucky WC Medicaid |
$444.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,048.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$943.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$383.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$448.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,125.52
|
| Rate for Payer: Ohio Health Group HMO |
$959.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,023.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,112.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$882.51
|
| Rate for Payer: PHCS Commercial |
$1,227.84
|
| Rate for Payer: United Healthcare All Payer |
$1,125.52
|
|
|
MAMMO BRST LOCDEVPERC EAADDLES
|
Facility
|
OP
|
$1,379.00
|
|
|
Service Code
|
HCPCS 19282
|
| Hospital Charge Code |
76100293
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$413.70 |
| Max. Negotiated Rate |
$1,323.84 |
| Rate for Payer: Aetna Commercial |
$1,061.83
|
| Rate for Payer: Anthem Medicaid |
$474.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,075.62
|
| Rate for Payer: Cash Price |
$689.50
|
| Rate for Payer: Cigna Commercial |
$1,144.57
|
| Rate for Payer: First Health Commercial |
$1,310.05
|
| Rate for Payer: Humana Commercial |
$1,172.15
|
| Rate for Payer: Humana KY Medicaid |
$474.24
|
| Rate for Payer: Kentucky WC Medicaid |
$479.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,130.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,017.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$483.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,213.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,034.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,103.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,199.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$951.51
|
| Rate for Payer: PHCS Commercial |
$1,323.84
|
| Rate for Payer: United Healthcare All Payer |
$1,213.52
|
|
|
MAMMOSITE BALLOON
|
Facility
|
IP
|
$1,866.20
|
|
|
Service Code
|
HCPCS C1728
|
| Hospital Charge Code |
27000012
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$559.86 |
| Max. Negotiated Rate |
$1,791.55 |
| Rate for Payer: Aetna Commercial |
$1,436.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,455.64
|
| Rate for Payer: Cash Price |
$933.10
|
| Rate for Payer: Cigna Commercial |
$1,548.95
|
| Rate for Payer: First Health Commercial |
$1,772.89
|
| Rate for Payer: Humana Commercial |
$1,586.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,530.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,377.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$559.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,642.26
|
| Rate for Payer: Ohio Health Group HMO |
$1,399.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,492.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,623.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,287.68
|
| Rate for Payer: PHCS Commercial |
$1,791.55
|
| Rate for Payer: United Healthcare All Payer |
$1,642.26
|
|
|
MAMMOSITE BALLOON
|
Facility
|
OP
|
$1,866.20
|
|
|
Service Code
|
HCPCS C1728
|
| Hospital Charge Code |
27000012
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$559.86 |
| Max. Negotiated Rate |
$1,791.55 |
| Rate for Payer: Aetna Commercial |
$1,436.97
|
| Rate for Payer: Anthem Medicaid |
$641.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,455.64
|
| Rate for Payer: Cash Price |
$933.10
|
| Rate for Payer: Cigna Commercial |
$1,548.95
|
| Rate for Payer: First Health Commercial |
$1,772.89
|
| Rate for Payer: Humana Commercial |
$1,586.27
|
| Rate for Payer: Humana KY Medicaid |
$641.79
|
| Rate for Payer: Kentucky WC Medicaid |
$648.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,530.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,377.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$559.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$654.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,642.26
|
| Rate for Payer: Ohio Health Group HMO |
$1,399.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,492.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,623.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,287.68
|
| Rate for Payer: PHCS Commercial |
$1,791.55
|
| Rate for Payer: United Healthcare All Payer |
$1,642.26
|
|
|
MANDIBLES COMPLETE 4V
|
Professional
|
Both
|
$581.00
|
|
|
Service Code
|
HCPCS 70110
|
| Hospital Charge Code |
32000011
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$15.54 |
| Max. Negotiated Rate |
$348.60 |
| Rate for Payer: Aetna Commercial |
$59.74
|
| Rate for Payer: Ambetter Exchange |
$39.40
|
| Rate for Payer: Anthem Medicaid |
$27.84
|
| Rate for Payer: Buckeye Individual/Medicaid |
$39.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$39.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$47.28
|
| Rate for Payer: Cash Price |
$290.50
|
| Rate for Payer: Cash Price |
$290.50
|
| Rate for Payer: Cigna Commercial |
$55.53
|
| Rate for Payer: Healthspan PPO |
$55.98
|
| Rate for Payer: Humana Medicaid |
$27.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$15.54
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$39.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$28.40
|
| Rate for Payer: Molina Healthcare Passport |
$27.84
|
| Rate for Payer: Multiplan PHCS |
$348.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$51.22
|
| Rate for Payer: UHCCP Medicaid |
$203.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$28.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$39.40
|
|
|
MANDIBLES COMPLETE 4V
|
Facility
|
OP
|
$581.00
|
|
|
Service Code
|
HCPCS 70110
|
| Hospital Charge Code |
32000011
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$557.76 |
| Rate for Payer: Aetna Commercial |
$447.37
|
| Rate for Payer: Anthem Medicaid |
$199.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$453.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$290.50
|
| Rate for Payer: Cash Price |
$290.50
|
| Rate for Payer: Cigna Commercial |
$482.23
|
| Rate for Payer: First Health Commercial |
$551.95
|
| Rate for Payer: Humana Commercial |
$493.85
|
| Rate for Payer: Humana KY Medicaid |
$199.81
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$201.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$476.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$428.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$203.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$511.28
|
| Rate for Payer: Ohio Health Group HMO |
$435.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$464.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$505.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$400.89
|
| Rate for Payer: PHCS Commercial |
$557.76
|
| Rate for Payer: United Healthcare All Payer |
$511.28
|
|
|
MANDIBLES COMPLETE 4V
|
Facility
|
IP
|
$581.00
|
|
|
Service Code
|
HCPCS 70110
|
| Hospital Charge Code |
32000011
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$174.30 |
| Max. Negotiated Rate |
$557.76 |
| Rate for Payer: Aetna Commercial |
$447.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$453.18
|
| Rate for Payer: Cash Price |
$290.50
|
| Rate for Payer: Cigna Commercial |
$482.23
|
| Rate for Payer: First Health Commercial |
$551.95
|
| Rate for Payer: Humana Commercial |
$493.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$476.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$428.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$174.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$511.28
|
| Rate for Payer: Ohio Health Group HMO |
$435.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$464.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$505.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$400.89
|
| Rate for Payer: PHCS Commercial |
$557.76
|
| Rate for Payer: United Healthcare All Payer |
$511.28
|
|
|
MANDIBLES COMPLETE 4V(P
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
HCPCS 70110
|
| Hospital Charge Code |
320P0011
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$15.54 |
| Max. Negotiated Rate |
$59.74 |
| Rate for Payer: Aetna Commercial |
$59.74
|
| Rate for Payer: Ambetter Exchange |
$39.40
|
| Rate for Payer: Anthem Medicaid |
$27.84
|
| Rate for Payer: Buckeye Individual/Medicaid |
$39.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$39.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$47.28
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$55.53
|
| Rate for Payer: Healthspan PPO |
$55.98
|
| Rate for Payer: Humana Medicaid |
$27.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$15.54
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$39.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$28.40
|
| Rate for Payer: Molina Healthcare Passport |
$27.84
|
| Rate for Payer: Multiplan PHCS |
$45.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$51.22
|
| Rate for Payer: UHCCP Medicaid |
$26.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$28.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$39.40
|
|
|
MANDIBLES COMPLETE 4V(T
|
Facility
|
IP
|
$506.00
|
|
|
Service Code
|
HCPCS 70110
|
| Hospital Charge Code |
320T0011
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$151.80 |
| Max. Negotiated Rate |
$485.76 |
| Rate for Payer: Aetna Commercial |
$389.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$394.68
|
| Rate for Payer: Cash Price |
$253.00
|
| Rate for Payer: Cigna Commercial |
$419.98
|
| Rate for Payer: First Health Commercial |
$480.70
|
| Rate for Payer: Humana Commercial |
$430.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$414.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$373.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$151.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$445.28
|
| Rate for Payer: Ohio Health Group HMO |
$379.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$404.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$440.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$349.14
|
| Rate for Payer: PHCS Commercial |
$485.76
|
| Rate for Payer: United Healthcare All Payer |
$445.28
|
|
|
MANDIBLES COMPLETE 4V(T
|
Facility
|
OP
|
$506.00
|
|
|
Service Code
|
HCPCS 70110
|
| Hospital Charge Code |
320T0011
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$485.76 |
| Rate for Payer: Aetna Commercial |
$389.62
|
| Rate for Payer: Anthem Medicaid |
$174.01
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$394.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$253.00
|
| Rate for Payer: Cash Price |
$253.00
|
| Rate for Payer: Cigna Commercial |
$419.98
|
| Rate for Payer: First Health Commercial |
$480.70
|
| Rate for Payer: Humana Commercial |
$430.10
|
| Rate for Payer: Humana KY Medicaid |
$174.01
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$175.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$414.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$373.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$177.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$445.28
|
| Rate for Payer: Ohio Health Group HMO |
$379.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$404.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$440.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$349.14
|
| Rate for Payer: PHCS Commercial |
$485.76
|
| Rate for Payer: United Healthcare All Payer |
$445.28
|
|
|
MANIPULATE ELBOW W ANESTHESIA
|
Facility
|
OP
|
$635.00
|
|
|
Service Code
|
HCPCS 24300
|
| Hospital Charge Code |
76100517
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$218.38 |
| Max. Negotiated Rate |
$2,070.25 |
| Rate for Payer: Aetna Commercial |
$488.95
|
| Rate for Payer: Anthem Medicaid |
$218.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,478.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$495.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,070.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,996.31
|
| Rate for Payer: Cash Price |
$317.50
|
| Rate for Payer: Cash Price |
$317.50
|
| Rate for Payer: Cigna Commercial |
$527.05
|
| Rate for Payer: First Health Commercial |
$603.25
|
| Rate for Payer: Humana Commercial |
$539.75
|
| Rate for Payer: Humana KY Medicaid |
$218.38
|
| Rate for Payer: Humana Medicare Advantage |
$1,478.75
|
| Rate for Payer: Kentucky WC Medicaid |
$220.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$520.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$468.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,774.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$222.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$558.80
|
| Rate for Payer: Ohio Health Group HMO |
$476.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$508.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$552.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$438.15
|
| Rate for Payer: PHCS Commercial |
$609.60
|
| Rate for Payer: United Healthcare All Payer |
$558.80
|
|
|
MANIPULATE ELBOW W ANESTHESIA
|
Professional
|
Both
|
$635.00
|
|
|
Service Code
|
HCPCS 24300
|
| Hospital Charge Code |
76100517
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$222.25 |
| Max. Negotiated Rate |
$621.07 |
| Rate for Payer: Aetna Commercial |
$551.69
|
| Rate for Payer: Ambetter Exchange |
$420.03
|
| Rate for Payer: Anthem Medicaid |
$261.85
|
| Rate for Payer: Buckeye Individual/Medicaid |
$420.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$420.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$504.04
|
| Rate for Payer: Cash Price |
$317.50
|
| Rate for Payer: Cash Price |
$317.50
|
| Rate for Payer: Cigna Commercial |
$621.07
|
| Rate for Payer: Healthspan PPO |
$499.71
|
| Rate for Payer: Humana Medicaid |
$261.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$487.54
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$420.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$420.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$267.09
|
| Rate for Payer: Molina Healthcare Passport |
$261.85
|
| Rate for Payer: Multiplan PHCS |
$381.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$546.04
|
| Rate for Payer: UHCCP Medicaid |
$222.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$264.47
|
| Rate for Payer: Wellcare Medicare Advantage |
$420.03
|
|
