|
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: Ambetter Exchange |
$914.57
|
| Rate for Payer: Anthem Medicaid |
$621.09
|
| Rate for Payer: Buckeye Individual/Medicaid |
$914.57
|
| Rate for Payer: Buckeye Medicare Advantage |
$914.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,097.48
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$914.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$914.57
|
| 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 |
$1,188.94
|
| Rate for Payer: UHCCP Medicaid |
$441.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$627.30
|
| Rate for Payer: Wellcare Medicare Advantage |
$914.57
|
|
|
MASTISOL ADHESIVE DROPERETTE
|
Facility
|
OP
|
$9.96
|
|
|
Service Code
|
NDC 496052348
|
| Hospital Charge Code |
27000182
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.99 |
| 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 |
$7.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.87
|
| 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 |
$2.99 |
| 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 |
$7.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.87
|
| 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 |
$53.74 |
| 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 |
$143.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$155.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$123.60
|
| 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 |
$53.74 |
| 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 |
$143.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$155.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$123.60
|
| 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 |
$25.76 |
| 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 |
$68.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$59.26
|
| 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 |
$25.76 |
| 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 |
$68.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$59.26
|
| Rate for Payer: PHCS Commercial |
$82.44
|
| Rate for Payer: United Healthcare All Payer |
$75.57
|
|
|
MASTOID CLEANING
|
Professional
|
Both
|
$478.00
|
|
|
Service Code
|
HCPCS 69220
|
| Hospital Charge Code |
76102414
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$26.08 |
| Max. Negotiated Rate |
$286.80 |
| Rate for Payer: Aetna Commercial |
$90.37
|
| Rate for Payer: Ambetter Exchange |
$48.87
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$26.08
|
| Rate for Payer: Anthem Medicaid |
$38.98
|
| Rate for Payer: Buckeye Individual/Medicaid |
$48.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$48.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$58.64
|
| Rate for Payer: Cash Price |
$239.00
|
| Rate for Payer: Cash Price |
$239.00
|
| Rate for Payer: Cigna Commercial |
$183.60
|
| Rate for Payer: Healthspan PPO |
$165.15
|
| Rate for Payer: Humana Medicaid |
$38.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$79.24
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$48.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$39.76
|
| Rate for Payer: Molina Healthcare Passport |
$38.98
|
| Rate for Payer: Multiplan PHCS |
$286.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$63.53
|
| Rate for Payer: UHCCP Medicaid |
$27.38
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$39.37
|
| Rate for Payer: Wellcare Medicare Advantage |
$48.87
|
|
|
MASTOID CLEANING
|
Facility
|
OP
|
$478.00
|
|
|
Service Code
|
HCPCS 69220
|
| Hospital Charge Code |
76102414
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$164.38 |
| Max. Negotiated Rate |
$458.88 |
| Rate for Payer: Aetna Commercial |
$368.06
|
| Rate for Payer: Anthem Medicaid |
$164.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$372.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$239.00
|
| Rate for Payer: Cash Price |
$239.00
|
| Rate for Payer: Cigna Commercial |
$396.74
|
| Rate for Payer: First Health Commercial |
$454.10
|
| Rate for Payer: Humana Commercial |
$406.30
|
| Rate for Payer: Humana KY Medicaid |
$164.38
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$166.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$391.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$352.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$167.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$420.64
|
| Rate for Payer: Ohio Health Group HMO |
$358.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$382.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$415.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$329.82
|
| Rate for Payer: PHCS Commercial |
$458.88
|
| Rate for Payer: United Healthcare All Payer |
$420.64
|
|
|
MASTOID CLEANING
|
Facility
|
IP
|
$478.00
|
|
|
Service Code
|
HCPCS 69220
|
| Hospital Charge Code |
76102414
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.40 |
| Max. Negotiated Rate |
$458.88 |
| Rate for Payer: Aetna Commercial |
$368.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$372.84
|
| Rate for Payer: Cash Price |
$239.00
|
| Rate for Payer: Cigna Commercial |
$396.74
|
| Rate for Payer: First Health Commercial |
$454.10
|
| Rate for Payer: Humana Commercial |
$406.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$391.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$352.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$143.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$420.64
|
| Rate for Payer: Ohio Health Group HMO |
$358.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$382.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$415.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$329.82
|
| Rate for Payer: PHCS Commercial |
$458.88
|
| Rate for Payer: United Healthcare All Payer |
$420.64
|
|
|
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 |
$183.60 |
| Rate for Payer: Aetna Commercial |
$90.37
|
| Rate for Payer: Ambetter Exchange |
$48.87
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$26.08
|
| Rate for Payer: Anthem Medicaid |
$38.98
|
| Rate for Payer: Buckeye Individual/Medicaid |
$48.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$48.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$58.64
|
| 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 |
$38.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$79.24
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$48.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$39.76
|
| Rate for Payer: Molina Healthcare Passport |
$38.98
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$63.53
|
| Rate for Payer: UHCCP Medicaid |
$27.38
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$39.37
|
| Rate for Payer: Wellcare Medicare Advantage |
$48.87
|
|
|
MASTOID CLEANING(T
|
Facility
|
IP
|
$278.00
|
|
|
Service Code
|
HCPCS 69220
|
| Hospital Charge Code |
761T2414
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$83.40 |
| Max. Negotiated Rate |
$266.88 |
| Rate for Payer: Aetna Commercial |
$214.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$216.84
|
| Rate for Payer: Cash Price |
$139.00
|
| Rate for Payer: Cigna Commercial |
$230.74
|
| Rate for Payer: First Health Commercial |
$264.10
|
| Rate for Payer: Humana Commercial |
$236.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$227.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$205.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$83.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$244.64
|
| Rate for Payer: Ohio Health Group HMO |
$208.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$222.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$241.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$191.82
|
| Rate for Payer: PHCS Commercial |
$266.88
|
| Rate for Payer: United Healthcare All Payer |
$244.64
|
|
|
MASTOID CLEANING(T
|
Facility
|
OP
|
$278.00
|
|
|
Service Code
|
HCPCS 69220
|
| Hospital Charge Code |
761T2414
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$95.60 |
| Max. Negotiated Rate |
$266.88 |
| Rate for Payer: Aetna Commercial |
$214.06
|
| Rate for Payer: Anthem Medicaid |
$95.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$216.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$139.00
|
| Rate for Payer: Cash Price |
$139.00
|
| Rate for Payer: Cigna Commercial |
$230.74
|
| Rate for Payer: First Health Commercial |
$264.10
|
| Rate for Payer: Humana Commercial |
$236.30
|
| Rate for Payer: Humana KY Medicaid |
$95.60
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$96.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$227.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$205.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$97.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$244.64
|
| Rate for Payer: Ohio Health Group HMO |
$208.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$222.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$241.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$191.82
|
| Rate for Payer: PHCS Commercial |
$266.88
|
| Rate for Payer: United Healthcare All Payer |
$244.64
|
|
|
MASTOIDECTOMY; COMPLETE
|
Facility
|
OP
|
$2,300.00
|
|
|
Service Code
|
HCPCS 69502
|
| Hospital Charge Code |
76102423
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$790.97 |
| Max. Negotiated Rate |
$7,652.33 |
| Rate for Payer: Aetna Commercial |
$1,771.00
|
| Rate for Payer: Anthem Medicaid |
$790.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,465.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,794.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,652.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,379.03
|
| 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 |
$5,465.95
|
| 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 |
$6,559.14
|
| 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 |
$1,840.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,001.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,587.00
|
| 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 |
$1,392.02 |
| Rate for Payer: Aetna Commercial |
$1,392.02
|
| Rate for Payer: Ambetter Exchange |
$877.53
|
| Rate for Payer: Anthem Medicaid |
$744.52
|
| Rate for Payer: Buckeye Individual/Medicaid |
$877.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$877.53
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,053.04
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$877.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$877.53
|
| 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 |
$1,140.79
|
| Rate for Payer: UHCCP Medicaid |
$805.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$751.97
|
| Rate for Payer: Wellcare Medicare Advantage |
$877.53
|
|
|
MASTOIDECTOMY; COMPLETE
|
Facility
|
IP
|
$2,300.00
|
|
|
Service Code
|
HCPCS 69502
|
| Hospital Charge Code |
76102423
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$690.00 |
| 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 |
$1,840.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,001.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,587.00
|
| Rate for Payer: PHCS Commercial |
$2,208.00
|
| Rate for Payer: United Healthcare All Payer |
$2,024.00
|
|
|
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 |
$1,392.02 |
| Rate for Payer: Aetna Commercial |
$1,392.02
|
| Rate for Payer: Ambetter Exchange |
$877.53
|
| Rate for Payer: Anthem Medicaid |
$744.52
|
| Rate for Payer: Buckeye Individual/Medicaid |
$877.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$877.53
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,053.04
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$877.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$877.53
|
| 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 |
$1,140.79
|
| Rate for Payer: UHCCP Medicaid |
$805.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$751.97
|
| Rate for Payer: Wellcare Medicare Advantage |
$877.53
|
|
|
MASTOID SURGERY REVISION
|
Facility
|
OP
|
$1,260.00
|
|
|
Service Code
|
HCPCS 69602
|
| Hospital Charge Code |
76102425
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$433.31 |
| Max. Negotiated Rate |
$7,652.33 |
| Rate for Payer: Aetna Commercial |
$970.20
|
| Rate for Payer: Anthem Medicaid |
$433.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,465.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$982.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,652.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,379.03
|
| 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 |
$5,465.95
|
| 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 |
$6,559.14
|
| 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 |
$1,008.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,096.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$869.40
|
| Rate for Payer: PHCS Commercial |
$1,209.60
|
| Rate for Payer: United Healthcare All Payer |
$1,108.80
|
|
|
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: Ambetter Exchange |
$945.77
|
| Rate for Payer: Anthem Medicaid |
$789.01
|
| Rate for Payer: Buckeye Individual/Medicaid |
$945.77
|
| Rate for Payer: Buckeye Medicare Advantage |
$945.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,134.92
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$945.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$945.77
|
| 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 |
$1,229.50
|
| Rate for Payer: UHCCP Medicaid |
$428.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$796.90
|
| Rate for Payer: Wellcare Medicare Advantage |
$945.77
|
|
|
MASTOID SURGERY REVISION
|
Facility
|
IP
|
$1,260.00
|
|
|
Service Code
|
HCPCS 69602
|
| Hospital Charge Code |
76102425
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$378.00 |
| 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 |
$1,008.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,096.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$869.40
|
| 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: Ambetter Exchange |
$1,007.78
|
| Rate for Payer: Anthem Medicaid |
$865.08
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,007.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,007.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,209.34
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$1,007.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,007.78
|
| 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 |
$1,310.11
|
| Rate for Payer: UHCCP Medicaid |
$441.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$873.73
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,007.78
|
|
|
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: Ambetter Exchange |
$1,007.78
|
| Rate for Payer: Anthem Medicaid |
$865.08
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,007.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,007.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,209.34
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$1,007.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,007.78
|
| 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 |
$1,310.11
|
| Rate for Payer: UHCCP Medicaid |
$441.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$873.73
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,007.78
|
|
|
MASTOPEXY
|
Facility
|
OP
|
$2,100.00
|
|
|
Service Code
|
HCPCS 19316
|
| Hospital Charge Code |
76100306
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$722.19 |
| Max. Negotiated Rate |
$8,435.98 |
| Rate for Payer: Aetna Commercial |
$1,617.00
|
| Rate for Payer: Anthem Medicaid |
$722.19
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,025.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,638.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,435.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,134.69
|
| 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 |
$6,025.70
|
| 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 |
$7,230.84
|
| 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 |
$1,680.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,827.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,449.00
|
| Rate for Payer: PHCS Commercial |
$2,016.00
|
| Rate for Payer: United Healthcare All Payer |
$1,848.00
|
|
|
MASTOPEXY
|
Facility
|
IP
|
$2,100.00
|
|
|
Service Code
|
HCPCS 19316
|
| Hospital Charge Code |
76100306
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$630.00 |
| 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 |
$1,680.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,827.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,449.00
|
| Rate for Payer: PHCS Commercial |
$2,016.00
|
| Rate for Payer: United Healthcare All Payer |
$1,848.00
|
|
|
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 |
$1,260.00 |
| Rate for Payer: Aetna Commercial |
$1,132.21
|
| Rate for Payer: Ambetter Exchange |
$749.40
|
| Rate for Payer: Anthem Medicaid |
$698.93
|
| Rate for Payer: Buckeye Individual/Medicaid |
$749.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$749.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$899.28
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$749.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$749.40
|
| 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 |
$974.22
|
| Rate for Payer: UHCCP Medicaid |
$735.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$705.92
|
| Rate for Payer: Wellcare Medicare Advantage |
$749.40
|
|
