|
REM. OF INTACT MAMMARY IMPLANT
|
Professional
|
Both
|
$900.00
|
|
|
Service Code
|
HCPCS 19328
|
| Hospital Charge Code |
761P0309
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$274.70 |
| Max. Negotiated Rate |
$702.17 |
| Rate for Payer: Aetna Commercial |
$702.17
|
| Rate for Payer: Ambetter Exchange |
$525.03
|
| Rate for Payer: Anthem Medicaid |
$274.70
|
| Rate for Payer: Buckeye Individual/Medicaid |
$525.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$525.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$630.04
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$667.17
|
| Rate for Payer: Healthspan PPO |
$561.45
|
| Rate for Payer: Humana Medicaid |
$274.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$630.96
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$525.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$280.19
|
| Rate for Payer: Molina Healthcare Passport |
$274.70
|
| Rate for Payer: Multiplan PHCS |
$540.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$682.54
|
| Rate for Payer: UHCCP Medicaid |
$315.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$277.45
|
| Rate for Payer: Wellcare Medicare Advantage |
$525.03
|
|
|
REM. OF INTACT MAMMARY IMPLANT
|
Facility
|
OP
|
$900.00
|
|
|
Service Code
|
HCPCS 19328
|
| Hospital Charge Code |
76100309
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$309.51 |
| Max. Negotiated Rate |
$4,953.45 |
| Rate for Payer: Aetna Commercial |
$693.00
|
| Rate for Payer: Anthem Medicaid |
$309.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,538.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$702.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,953.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,776.54
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$747.00
|
| Rate for Payer: First Health Commercial |
$855.00
|
| Rate for Payer: Humana Commercial |
$765.00
|
| Rate for Payer: Humana KY Medicaid |
$309.51
|
| Rate for Payer: Humana Medicare Advantage |
$3,538.18
|
| Rate for Payer: Kentucky WC Medicaid |
$312.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$738.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$664.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,245.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$315.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$792.00
|
| Rate for Payer: Ohio Health Group HMO |
$675.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$720.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$783.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$621.00
|
| Rate for Payer: PHCS Commercial |
$864.00
|
| Rate for Payer: United Healthcare All Payer |
$792.00
|
|
|
REM. OF INTACT MAMMARY IMPLANT
|
Facility
|
IP
|
$900.00
|
|
|
Service Code
|
HCPCS 19328
|
| Hospital Charge Code |
76100309
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$270.00 |
| Max. Negotiated Rate |
$864.00 |
| Rate for Payer: Aetna Commercial |
$693.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$702.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$747.00
|
| Rate for Payer: First Health Commercial |
$855.00
|
| Rate for Payer: Humana Commercial |
$765.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$738.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$664.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$270.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$792.00
|
| Rate for Payer: Ohio Health Group HMO |
$675.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$720.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$783.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$621.00
|
| Rate for Payer: PHCS Commercial |
$864.00
|
| Rate for Payer: United Healthcare All Payer |
$792.00
|
|
|
REM. OF INTACT MAMMARY IMPLANT
|
Professional
|
Both
|
$900.00
|
|
|
Service Code
|
HCPCS 19328
|
| Hospital Charge Code |
76100309
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$274.70 |
| Max. Negotiated Rate |
$702.17 |
| Rate for Payer: Aetna Commercial |
$702.17
|
| Rate for Payer: Ambetter Exchange |
$525.03
|
| Rate for Payer: Anthem Medicaid |
$274.70
|
| Rate for Payer: Buckeye Individual/Medicaid |
$525.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$525.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$630.04
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$667.17
|
| Rate for Payer: Healthspan PPO |
$561.45
|
| Rate for Payer: Humana Medicaid |
$274.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$630.96
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$525.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$280.19
|
| Rate for Payer: Molina Healthcare Passport |
$274.70
|
| Rate for Payer: Multiplan PHCS |
$540.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$682.54
|
| Rate for Payer: UHCCP Medicaid |
$315.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$277.45
|
| Rate for Payer: Wellcare Medicare Advantage |
$525.03
|
|
|
REMOT AFTLOAD HDR 2-12 CHANEL
|
Facility
|
OP
|
$6,586.00
|
|
|
Service Code
|
HCPCS 77771
|
| Hospital Charge Code |
33300033
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$641.07 |
| Max. Negotiated Rate |
$6,322.56 |
| Rate for Payer: Aetna Commercial |
$5,071.22
|
| Rate for Payer: Anthem Medicaid |
$2,264.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$641.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,137.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$897.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$865.44
|
| Rate for Payer: Cash Price |
$3,293.00
|
| Rate for Payer: Cash Price |
$3,293.00
|
| Rate for Payer: Cigna Commercial |
$5,466.38
|
| Rate for Payer: First Health Commercial |
$6,256.70
|
| Rate for Payer: Humana Commercial |
$5,598.10
|
| Rate for Payer: Humana KY Medicaid |
$2,264.93
|
| Rate for Payer: Humana Medicare Advantage |
$641.07
|
| Rate for Payer: Kentucky WC Medicaid |
$2,287.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,400.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,860.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$769.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,310.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,795.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,939.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,268.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,729.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,544.34
|
| Rate for Payer: PHCS Commercial |
$6,322.56
|
| Rate for Payer: United Healthcare All Payer |
$5,795.68
|
|
|
REMOT AFTLOAD HDR 2-12 CHANEL
|
Professional
|
Both
|
$6,586.00
|
|
|
Service Code
|
HCPCS 77771
|
| Hospital Charge Code |
33300033
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$247.61 |
| Max. Negotiated Rate |
$3,951.60 |
| Rate for Payer: Ambetter Exchange |
$553.37
|
| Rate for Payer: Anthem Medicaid |
$450.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$553.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$553.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$664.04
|
| Rate for Payer: Cash Price |
$3,293.00
|
| Rate for Payer: Cash Price |
$3,293.00
|
| Rate for Payer: Cigna Commercial |
$942.31
|
| Rate for Payer: Humana Medicaid |
$450.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$247.61
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$553.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$553.37
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$459.11
|
| Rate for Payer: Molina Healthcare Passport |
$450.11
|
| Rate for Payer: Multiplan PHCS |
$3,951.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$719.38
|
| Rate for Payer: UHCCP Medicaid |
$2,305.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$454.61
|
| Rate for Payer: Wellcare Medicare Advantage |
$553.37
|
|
|
REMOT AFTLOAD HDR 2-12 CHANEL
|
Facility
|
IP
|
$6,586.00
|
|
|
Service Code
|
HCPCS 77771
|
| Hospital Charge Code |
33300033
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$1,975.80 |
| Max. Negotiated Rate |
$6,322.56 |
| Rate for Payer: Aetna Commercial |
$5,071.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,137.08
|
| Rate for Payer: Cash Price |
$3,293.00
|
| Rate for Payer: Cigna Commercial |
$5,466.38
|
| Rate for Payer: First Health Commercial |
$6,256.70
|
| Rate for Payer: Humana Commercial |
$5,598.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,400.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,860.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,975.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,795.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,939.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,268.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,729.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,544.34
|
| Rate for Payer: PHCS Commercial |
$6,322.56
|
| Rate for Payer: United Healthcare All Payer |
$5,795.68
|
|
|
REMOT AFTLOAD HDR 2-12 CHANE(P
|
Professional
|
Both
|
$415.00
|
|
|
Service Code
|
HCPCS 77771
|
| Hospital Charge Code |
333P0033
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$145.25 |
| Max. Negotiated Rate |
$942.31 |
| Rate for Payer: Ambetter Exchange |
$553.37
|
| Rate for Payer: Anthem Medicaid |
$450.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$553.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$553.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$664.04
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cigna Commercial |
$942.31
|
| Rate for Payer: Humana Medicaid |
$450.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$247.61
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$553.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$553.37
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$459.11
|
| Rate for Payer: Molina Healthcare Passport |
$450.11
|
| Rate for Payer: Multiplan PHCS |
$249.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$719.38
|
| Rate for Payer: UHCCP Medicaid |
$145.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$454.61
|
| Rate for Payer: Wellcare Medicare Advantage |
$553.37
|
|
|
REMOT AFTLOAD HDR 2-12 CHANE(T
|
Facility
|
OP
|
$6,171.00
|
|
|
Service Code
|
HCPCS 77771
|
| Hospital Charge Code |
333T0033
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$641.07 |
| Max. Negotiated Rate |
$5,924.16 |
| Rate for Payer: Aetna Commercial |
$4,751.67
|
| Rate for Payer: Anthem Medicaid |
$2,122.21
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$641.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,813.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$897.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$865.44
|
| Rate for Payer: Cash Price |
$3,085.50
|
| Rate for Payer: Cash Price |
$3,085.50
|
| Rate for Payer: Cigna Commercial |
$5,121.93
|
| Rate for Payer: First Health Commercial |
$5,862.45
|
| Rate for Payer: Humana Commercial |
$5,245.35
|
| Rate for Payer: Humana KY Medicaid |
$2,122.21
|
| Rate for Payer: Humana Medicare Advantage |
$641.07
|
| Rate for Payer: Kentucky WC Medicaid |
$2,143.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,060.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,554.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$769.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,164.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,430.48
|
| Rate for Payer: Ohio Health Group HMO |
$4,628.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,936.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,368.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,257.99
|
| Rate for Payer: PHCS Commercial |
$5,924.16
|
| Rate for Payer: United Healthcare All Payer |
$5,430.48
|
|
|
REMOT AFTLOAD HDR 2-12 CHANE(T
|
Facility
|
IP
|
$6,171.00
|
|
|
Service Code
|
HCPCS 77771
|
| Hospital Charge Code |
333T0033
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$1,851.30 |
| Max. Negotiated Rate |
$5,924.16 |
| Rate for Payer: Aetna Commercial |
$4,751.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,813.38
|
| Rate for Payer: Cash Price |
$3,085.50
|
| Rate for Payer: Cigna Commercial |
$5,121.93
|
| Rate for Payer: First Health Commercial |
$5,862.45
|
| Rate for Payer: Humana Commercial |
$5,245.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,060.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,554.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,851.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,430.48
|
| Rate for Payer: Ohio Health Group HMO |
$4,628.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,936.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,368.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,257.99
|
| Rate for Payer: PHCS Commercial |
$5,924.16
|
| Rate for Payer: United Healthcare All Payer |
$5,430.48
|
|
|
REMOT AFTLOAD HDR ICHANEL
|
Professional
|
Both
|
$4,384.00
|
|
|
Service Code
|
HCPCS 77770
|
| Hospital Charge Code |
33300032
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$127.13 |
| Max. Negotiated Rate |
$2,630.40 |
| Rate for Payer: Ambetter Exchange |
$315.20
|
| Rate for Payer: Anthem Medicaid |
$241.28
|
| Rate for Payer: Buckeye Individual/Medicaid |
$315.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$315.20
|
| Rate for Payer: CareSource Just4Me Medicare |
$378.24
|
| Rate for Payer: Cash Price |
$2,192.00
|
| Rate for Payer: Cash Price |
$2,192.00
|
| Rate for Payer: Cigna Commercial |
$506.00
|
| Rate for Payer: Humana Medicaid |
$241.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$127.13
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$315.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$315.20
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$246.11
|
| Rate for Payer: Molina Healthcare Passport |
$241.28
|
| Rate for Payer: Multiplan PHCS |
$2,630.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$409.76
|
| Rate for Payer: UHCCP Medicaid |
$1,534.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$243.69
|
| Rate for Payer: Wellcare Medicare Advantage |
$315.20
|
|
|
REMOT AFTLOAD HDR ICHANEL
|
Facility
|
IP
|
$4,384.00
|
|
|
Service Code
|
HCPCS 77770
|
| Hospital Charge Code |
33300032
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$1,315.20 |
| Max. Negotiated Rate |
$4,208.64 |
| Rate for Payer: Aetna Commercial |
$3,375.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,419.52
|
| Rate for Payer: Cash Price |
$2,192.00
|
| Rate for Payer: Cigna Commercial |
$3,638.72
|
| Rate for Payer: First Health Commercial |
$4,164.80
|
| Rate for Payer: Humana Commercial |
$3,726.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,594.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,235.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,315.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,857.92
|
| Rate for Payer: Ohio Health Group HMO |
$3,288.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,507.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,814.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,024.96
|
| Rate for Payer: PHCS Commercial |
$4,208.64
|
| Rate for Payer: United Healthcare All Payer |
$3,857.92
|
|
|
REMOT AFTLOAD HDR ICHANEL
|
Facility
|
OP
|
$4,384.00
|
|
|
Service Code
|
HCPCS 77770
|
| Hospital Charge Code |
33300032
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$641.07 |
| Max. Negotiated Rate |
$4,208.64 |
| Rate for Payer: Aetna Commercial |
$3,375.68
|
| Rate for Payer: Anthem Medicaid |
$1,507.66
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$641.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,419.52
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$897.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$865.44
|
| Rate for Payer: Cash Price |
$2,192.00
|
| Rate for Payer: Cash Price |
$2,192.00
|
| Rate for Payer: Cigna Commercial |
$3,638.72
|
| Rate for Payer: First Health Commercial |
$4,164.80
|
| Rate for Payer: Humana Commercial |
$3,726.40
|
| Rate for Payer: Humana KY Medicaid |
$1,507.66
|
| Rate for Payer: Humana Medicare Advantage |
$641.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,523.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,594.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,235.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$769.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,537.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,857.92
|
| Rate for Payer: Ohio Health Group HMO |
$3,288.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,507.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,814.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,024.96
|
| Rate for Payer: PHCS Commercial |
$4,208.64
|
| Rate for Payer: United Healthcare All Payer |
$3,857.92
|
|
|
REMOT AFTLOAD HDR ICHANEL(P
|
Professional
|
Both
|
$375.00
|
|
|
Service Code
|
HCPCS 77770
|
| Hospital Charge Code |
333P0032
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$127.13 |
| Max. Negotiated Rate |
$506.00 |
| Rate for Payer: Ambetter Exchange |
$315.20
|
| Rate for Payer: Anthem Medicaid |
$241.28
|
| Rate for Payer: Buckeye Individual/Medicaid |
$315.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$315.20
|
| Rate for Payer: CareSource Just4Me Medicare |
$378.24
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cigna Commercial |
$506.00
|
| Rate for Payer: Humana Medicaid |
$241.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$127.13
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$315.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$315.20
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$246.11
|
| Rate for Payer: Molina Healthcare Passport |
$241.28
|
| Rate for Payer: Multiplan PHCS |
$225.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$409.76
|
| Rate for Payer: UHCCP Medicaid |
$131.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$243.69
|
| Rate for Payer: Wellcare Medicare Advantage |
$315.20
|
|
|
REMOT AFTLOAD HDR ICHANEL(T
|
Facility
|
OP
|
$4,009.00
|
|
|
Service Code
|
HCPCS 77770
|
| Hospital Charge Code |
333T0032
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$641.07 |
| Max. Negotiated Rate |
$3,848.64 |
| Rate for Payer: Aetna Commercial |
$3,086.93
|
| Rate for Payer: Anthem Medicaid |
$1,378.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$641.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,127.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$897.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$865.44
|
| Rate for Payer: Cash Price |
$2,004.50
|
| Rate for Payer: Cash Price |
$2,004.50
|
| Rate for Payer: Cigna Commercial |
$3,327.47
|
| Rate for Payer: First Health Commercial |
$3,808.55
|
| Rate for Payer: Humana Commercial |
$3,407.65
|
| Rate for Payer: Humana KY Medicaid |
$1,378.70
|
| Rate for Payer: Humana Medicare Advantage |
$641.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,392.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,287.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,958.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$769.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,406.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,527.92
|
| Rate for Payer: Ohio Health Group HMO |
$3,006.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,207.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,487.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,766.21
|
| Rate for Payer: PHCS Commercial |
$3,848.64
|
| Rate for Payer: United Healthcare All Payer |
$3,527.92
|
|
|
REMOT AFTLOAD HDR ICHANEL(T
|
Facility
|
IP
|
$4,009.00
|
|
|
Service Code
|
HCPCS 77770
|
| Hospital Charge Code |
333T0032
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$1,202.70 |
| Max. Negotiated Rate |
$3,848.64 |
| Rate for Payer: Aetna Commercial |
$3,086.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,127.02
|
| Rate for Payer: Cash Price |
$2,004.50
|
| Rate for Payer: Cigna Commercial |
$3,327.47
|
| Rate for Payer: First Health Commercial |
$3,808.55
|
| Rate for Payer: Humana Commercial |
$3,407.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,287.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,958.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,202.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,527.92
|
| Rate for Payer: Ohio Health Group HMO |
$3,006.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,207.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,487.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,766.21
|
| Rate for Payer: PHCS Commercial |
$3,848.64
|
| Rate for Payer: United Healthcare All Payer |
$3,527.92
|
|
|
REMOTE 30 DAY ECG REV/REPORT
|
Facility
|
IP
|
$52.00
|
|
|
Service Code
|
HCPCS 93228
|
| Hospital Charge Code |
48000074
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$49.92 |
| Rate for Payer: Aetna Commercial |
$40.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$40.56
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Cigna Commercial |
$43.16
|
| Rate for Payer: First Health Commercial |
$49.40
|
| Rate for Payer: Humana Commercial |
$44.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$42.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$38.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$45.76
|
| Rate for Payer: Ohio Health Group HMO |
$39.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$41.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$45.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.88
|
| Rate for Payer: PHCS Commercial |
$49.92
|
| Rate for Payer: United Healthcare All Payer |
$45.76
|
|
|
REMOTE 30 DAY ECG REV/REPORT
|
Facility
|
OP
|
$52.00
|
|
|
Service Code
|
HCPCS 93228
|
| Hospital Charge Code |
48000074
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$49.92 |
| Rate for Payer: Aetna Commercial |
$40.04
|
| Rate for Payer: Anthem Medicaid |
$17.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$40.56
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Cigna Commercial |
$43.16
|
| Rate for Payer: First Health Commercial |
$49.40
|
| Rate for Payer: Humana Commercial |
$44.20
|
| Rate for Payer: Humana KY Medicaid |
$17.88
|
| Rate for Payer: Kentucky WC Medicaid |
$18.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$42.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$38.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$18.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$45.76
|
| Rate for Payer: Ohio Health Group HMO |
$39.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$41.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$45.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.88
|
| Rate for Payer: PHCS Commercial |
$49.92
|
| Rate for Payer: United Healthcare All Payer |
$45.76
|
|
|
REMOTE 30 DAY ECG REV/REPORT
|
Professional
|
Both
|
$52.00
|
|
|
Service Code
|
HCPCS 93228
|
| Hospital Charge Code |
48000074
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$43.00 |
| Rate for Payer: Aetna Commercial |
$42.57
|
| Rate for Payer: Ambetter Exchange |
$23.60
|
| Rate for Payer: Anthem Medicaid |
$21.07
|
| Rate for Payer: Buckeye Individual/Medicaid |
$23.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$23.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$28.32
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Cigna Commercial |
$43.00
|
| Rate for Payer: Healthspan PPO |
$40.02
|
| Rate for Payer: Humana Medicaid |
$21.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$34.36
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$23.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$21.49
|
| Rate for Payer: Molina Healthcare Passport |
$21.07
|
| Rate for Payer: Multiplan PHCS |
$31.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$30.68
|
| Rate for Payer: UHCCP Medicaid |
$18.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$21.28
|
| Rate for Payer: Wellcare Medicare Advantage |
$23.60
|
|
|
REMOVAL ANAL SETON OTH MRK
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 46030
|
| Hospital Charge Code |
76103017
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$47.64 |
| Max. Negotiated Rate |
$155.65 |
| Rate for Payer: Aetna Commercial |
$123.84
|
| Rate for Payer: Ambetter Exchange |
$82.41
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$52.12
|
| Rate for Payer: Anthem Medicaid |
$47.64
|
| Rate for Payer: Buckeye Individual/Medicaid |
$82.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$82.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$98.89
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$155.65
|
| Rate for Payer: Healthspan PPO |
$147.31
|
| Rate for Payer: Humana Medicaid |
$47.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$111.92
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$82.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$82.41
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$48.59
|
| Rate for Payer: Molina Healthcare Passport |
$47.64
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$107.13
|
| Rate for Payer: UHCCP Medicaid |
$54.73
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$48.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$82.41
|
|
|
REMOVAL ARTERY CLOT; FEMORAL
|
Facility
|
OP
|
$2,500.00
|
|
|
Service Code
|
HCPCS 34201
|
| Hospital Charge Code |
76101340
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$859.75 |
| Max. Negotiated Rate |
$6,992.66 |
| Rate for Payer: Aetna Commercial |
$1,925.00
|
| Rate for Payer: Anthem Medicaid |
$859.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,994.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,950.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,992.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,742.93
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$2,075.00
|
| Rate for Payer: First Health Commercial |
$2,375.00
|
| Rate for Payer: Humana Commercial |
$2,125.00
|
| Rate for Payer: Humana KY Medicaid |
$859.75
|
| Rate for Payer: Humana Medicare Advantage |
$4,994.76
|
| Rate for Payer: Kentucky WC Medicaid |
$868.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,050.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,845.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,993.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$877.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,200.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,875.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,175.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,725.00
|
| Rate for Payer: PHCS Commercial |
$2,400.00
|
| Rate for Payer: United Healthcare All Payer |
$2,200.00
|
|
|
REMOVAL ARTERY CLOT; FEMORAL
|
Professional
|
Both
|
$2,500.00
|
|
|
Service Code
|
HCPCS 34201
|
| Hospital Charge Code |
76101340
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$517.89 |
| Max. Negotiated Rate |
$1,695.15 |
| Rate for Payer: Aetna Commercial |
$1,695.15
|
| Rate for Payer: Ambetter Exchange |
$957.46
|
| Rate for Payer: Anthem Medicaid |
$517.89
|
| Rate for Payer: Buckeye Individual/Medicaid |
$957.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$957.46
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,148.95
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$1,552.51
|
| Rate for Payer: Healthspan PPO |
$1,666.66
|
| Rate for Payer: Humana Medicaid |
$517.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,400.22
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$957.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$957.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$528.25
|
| Rate for Payer: Molina Healthcare Passport |
$517.89
|
| Rate for Payer: Multiplan PHCS |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,244.70
|
| Rate for Payer: UHCCP Medicaid |
$875.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$523.07
|
| Rate for Payer: Wellcare Medicare Advantage |
$957.46
|
|
|
REMOVAL ARTERY CLOT; FEMORAL
|
Facility
|
IP
|
$2,500.00
|
|
|
Service Code
|
HCPCS 34201
|
| Hospital Charge Code |
76101340
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$750.00 |
| Max. Negotiated Rate |
$2,400.00 |
| Rate for Payer: Aetna Commercial |
$1,925.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,950.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$2,075.00
|
| Rate for Payer: First Health Commercial |
$2,375.00
|
| Rate for Payer: Humana Commercial |
$2,125.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,050.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,845.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$750.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,200.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,875.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,175.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,725.00
|
| Rate for Payer: PHCS Commercial |
$2,400.00
|
| Rate for Payer: United Healthcare All Payer |
$2,200.00
|
|
|
REMOVAL ARTERY CLOT; FEMORAL(P
|
Professional
|
Both
|
$2,500.00
|
|
|
Service Code
|
HCPCS 34201
|
| Hospital Charge Code |
761P1340
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$517.89 |
| Max. Negotiated Rate |
$1,695.15 |
| Rate for Payer: Aetna Commercial |
$1,695.15
|
| Rate for Payer: Ambetter Exchange |
$957.46
|
| Rate for Payer: Anthem Medicaid |
$517.89
|
| Rate for Payer: Buckeye Individual/Medicaid |
$957.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$957.46
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,148.95
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$1,552.51
|
| Rate for Payer: Healthspan PPO |
$1,666.66
|
| Rate for Payer: Humana Medicaid |
$517.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,400.22
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$957.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$957.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$528.25
|
| Rate for Payer: Molina Healthcare Passport |
$517.89
|
| Rate for Payer: Multiplan PHCS |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,244.70
|
| Rate for Payer: UHCCP Medicaid |
$875.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$523.07
|
| Rate for Payer: Wellcare Medicare Advantage |
$957.46
|
|
|
REMOVAL BILIARY DRG CATH
|
Professional
|
Both
|
$430.00
|
|
|
Service Code
|
HCPCS 47537
|
| Hospital Charge Code |
360P1273
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$80.86 |
| Max. Negotiated Rate |
$308.43 |
| Rate for Payer: Ambetter Exchange |
$89.40
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$80.86
|
| Rate for Payer: Anthem Medicaid |
$302.38
|
| Rate for Payer: Buckeye Individual/Medicaid |
$89.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$89.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$107.28
|
| Rate for Payer: Cash Price |
$215.00
|
| Rate for Payer: Cash Price |
$215.00
|
| Rate for Payer: Cigna Commercial |
$166.41
|
| Rate for Payer: Humana Medicaid |
$302.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$140.38
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$89.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$89.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$308.43
|
| Rate for Payer: Molina Healthcare Passport |
$302.38
|
| Rate for Payer: Multiplan PHCS |
$258.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$116.22
|
| Rate for Payer: UHCCP Medicaid |
$84.90
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$305.40
|
| Rate for Payer: Wellcare Medicare Advantage |
$89.40
|
|
