|
REMOVE BLADDER STONE
|
Professional
|
Both
|
$1,900.00
|
|
|
Service Code
|
HCPCS 52318
|
| Hospital Charge Code |
76102099
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$443.98 |
| Max. Negotiated Rate |
$1,140.00 |
| Rate for Payer: Aetna Commercial |
$792.49
|
| Rate for Payer: Ambetter Exchange |
$443.98
|
| Rate for Payer: Anthem Medicaid |
$499.73
|
| Rate for Payer: Buckeye Individual/Medicaid |
$443.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$443.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$532.78
|
| Rate for Payer: Cash Price |
$950.00
|
| Rate for Payer: Cash Price |
$950.00
|
| Rate for Payer: Cigna Commercial |
$709.79
|
| Rate for Payer: Healthspan PPO |
$633.66
|
| Rate for Payer: Humana Medicaid |
$499.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$650.18
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$443.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$443.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$509.72
|
| Rate for Payer: Molina Healthcare Passport |
$499.73
|
| Rate for Payer: Multiplan PHCS |
$1,140.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$577.17
|
| Rate for Payer: UHCCP Medicaid |
$665.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$504.73
|
| Rate for Payer: Wellcare Medicare Advantage |
$443.98
|
|
|
REMOVE BLADDER STONE(P
|
Professional
|
Both
|
$1,870.00
|
|
|
Service Code
|
HCPCS 52317
|
| Hospital Charge Code |
761P2098
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$173.90 |
| Max. Negotiated Rate |
$1,193.83 |
| Rate for Payer: Aetna Commercial |
$581.58
|
| Rate for Payer: Ambetter Exchange |
$325.48
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$173.90
|
| Rate for Payer: Anthem Medicaid |
$377.55
|
| Rate for Payer: Buckeye Individual/Medicaid |
$325.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$325.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$390.58
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$519.96
|
| Rate for Payer: Healthspan PPO |
$1,193.83
|
| Rate for Payer: Humana Medicaid |
$377.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$477.30
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$325.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$325.48
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$385.10
|
| Rate for Payer: Molina Healthcare Passport |
$377.55
|
| Rate for Payer: Multiplan PHCS |
$1,122.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$423.12
|
| Rate for Payer: UHCCP Medicaid |
$182.59
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$381.33
|
| Rate for Payer: Wellcare Medicare Advantage |
$325.48
|
|
|
REMOVE BLADDER STONE(P
|
Professional
|
Both
|
$1,900.00
|
|
|
Service Code
|
HCPCS 52318
|
| Hospital Charge Code |
761P2099
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$443.98 |
| Max. Negotiated Rate |
$1,140.00 |
| Rate for Payer: Aetna Commercial |
$792.49
|
| Rate for Payer: Ambetter Exchange |
$443.98
|
| Rate for Payer: Anthem Medicaid |
$499.73
|
| Rate for Payer: Buckeye Individual/Medicaid |
$443.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$443.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$532.78
|
| Rate for Payer: Cash Price |
$950.00
|
| Rate for Payer: Cash Price |
$950.00
|
| Rate for Payer: Cigna Commercial |
$709.79
|
| Rate for Payer: Healthspan PPO |
$633.66
|
| Rate for Payer: Humana Medicaid |
$499.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$650.18
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$443.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$443.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$509.72
|
| Rate for Payer: Molina Healthcare Passport |
$499.73
|
| Rate for Payer: Multiplan PHCS |
$1,140.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$577.17
|
| Rate for Payer: UHCCP Medicaid |
$665.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$504.73
|
| Rate for Payer: Wellcare Medicare Advantage |
$443.98
|
|
|
REMOVE BONE FIXATION DEVICE
|
Facility
|
OP
|
$6,535.00
|
|
|
Service Code
|
HCPCS 20694
|
| Hospital Charge Code |
76100354
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,478.75 |
| Max. Negotiated Rate |
$6,273.60 |
| Rate for Payer: Aetna Commercial |
$5,031.95
|
| Rate for Payer: Anthem Medicaid |
$2,247.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,478.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,097.30
|
| 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 |
$3,267.50
|
| Rate for Payer: Cash Price |
$3,267.50
|
| Rate for Payer: Cigna Commercial |
$5,424.05
|
| Rate for Payer: First Health Commercial |
$6,208.25
|
| Rate for Payer: Humana Commercial |
$5,554.75
|
| Rate for Payer: Humana KY Medicaid |
$2,247.39
|
| Rate for Payer: Humana Medicare Advantage |
$1,478.75
|
| Rate for Payer: Kentucky WC Medicaid |
$2,270.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,358.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,822.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,774.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,292.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,750.80
|
| Rate for Payer: Ohio Health Group HMO |
$4,901.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,228.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,685.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,509.15
|
| Rate for Payer: PHCS Commercial |
$6,273.60
|
| Rate for Payer: United Healthcare All Payer |
$5,750.80
|
|
|
REMOVE BONE FIXATION DEVICE
|
Professional
|
Both
|
$6,535.00
|
|
|
Service Code
|
HCPCS 20694
|
| Hospital Charge Code |
76100354
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$174.24 |
| Max. Negotiated Rate |
$3,921.00 |
| Rate for Payer: Aetna Commercial |
$491.02
|
| Rate for Payer: Ambetter Exchange |
$326.32
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$174.24
|
| Rate for Payer: Anthem Medicaid |
$191.50
|
| Rate for Payer: Buckeye Individual/Medicaid |
$326.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$326.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$391.58
|
| Rate for Payer: Cash Price |
$3,267.50
|
| Rate for Payer: Cash Price |
$3,267.50
|
| Rate for Payer: Cigna Commercial |
$542.12
|
| Rate for Payer: Healthspan PPO |
$545.59
|
| Rate for Payer: Humana Medicaid |
$191.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$415.05
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$326.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$326.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$195.33
|
| Rate for Payer: Molina Healthcare Passport |
$191.50
|
| Rate for Payer: Multiplan PHCS |
$3,921.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$424.22
|
| Rate for Payer: UHCCP Medicaid |
$182.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$193.41
|
| Rate for Payer: Wellcare Medicare Advantage |
$326.32
|
|
|
REMOVE BONE FIXATION DEVICE
|
Facility
|
IP
|
$6,535.00
|
|
|
Service Code
|
HCPCS 20694
|
| Hospital Charge Code |
76100354
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,960.50 |
| Max. Negotiated Rate |
$6,273.60 |
| Rate for Payer: Aetna Commercial |
$5,031.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,097.30
|
| Rate for Payer: Cash Price |
$3,267.50
|
| Rate for Payer: Cigna Commercial |
$5,424.05
|
| Rate for Payer: First Health Commercial |
$6,208.25
|
| Rate for Payer: Humana Commercial |
$5,554.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,358.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,822.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,960.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,750.80
|
| Rate for Payer: Ohio Health Group HMO |
$4,901.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,228.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,685.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,509.15
|
| Rate for Payer: PHCS Commercial |
$6,273.60
|
| Rate for Payer: United Healthcare All Payer |
$5,750.80
|
|
|
REMOVE BONE FIXATION DEVICE(P
|
Professional
|
Both
|
$775.00
|
|
|
Service Code
|
HCPCS 20694
|
| Hospital Charge Code |
761P0354
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$174.24 |
| Max. Negotiated Rate |
$545.59 |
| Rate for Payer: Aetna Commercial |
$491.02
|
| Rate for Payer: Ambetter Exchange |
$326.32
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$174.24
|
| Rate for Payer: Anthem Medicaid |
$191.50
|
| Rate for Payer: Buckeye Individual/Medicaid |
$326.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$326.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$391.58
|
| Rate for Payer: Cash Price |
$387.50
|
| Rate for Payer: Cash Price |
$387.50
|
| Rate for Payer: Cigna Commercial |
$542.12
|
| Rate for Payer: Healthspan PPO |
$545.59
|
| Rate for Payer: Humana Medicaid |
$191.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$415.05
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$326.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$326.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$195.33
|
| Rate for Payer: Molina Healthcare Passport |
$191.50
|
| Rate for Payer: Multiplan PHCS |
$465.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$424.22
|
| Rate for Payer: UHCCP Medicaid |
$182.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$193.41
|
| Rate for Payer: Wellcare Medicare Advantage |
$326.32
|
|
|
REMOVE BONE FIXATION DEVICE(T
|
Facility
|
IP
|
$5,760.00
|
|
|
Service Code
|
HCPCS 20694
|
| Hospital Charge Code |
761T0354
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,728.00 |
| Max. Negotiated Rate |
$5,529.60 |
| Rate for Payer: Aetna Commercial |
$4,435.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,492.80
|
| Rate for Payer: Cash Price |
$2,880.00
|
| Rate for Payer: Cigna Commercial |
$4,780.80
|
| Rate for Payer: First Health Commercial |
$5,472.00
|
| Rate for Payer: Humana Commercial |
$4,896.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,723.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,250.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,728.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,068.80
|
| Rate for Payer: Ohio Health Group HMO |
$4,320.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,608.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,011.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,974.40
|
| Rate for Payer: PHCS Commercial |
$5,529.60
|
| Rate for Payer: United Healthcare All Payer |
$5,068.80
|
|
|
REMOVE BONE FIXATION DEVICE(T
|
Facility
|
OP
|
$5,760.00
|
|
|
Service Code
|
HCPCS 20694
|
| Hospital Charge Code |
761T0354
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,478.75 |
| Max. Negotiated Rate |
$5,529.60 |
| Rate for Payer: Aetna Commercial |
$4,435.20
|
| Rate for Payer: Anthem Medicaid |
$1,980.86
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,478.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,492.80
|
| 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 |
$2,880.00
|
| Rate for Payer: Cash Price |
$2,880.00
|
| Rate for Payer: Cigna Commercial |
$4,780.80
|
| Rate for Payer: First Health Commercial |
$5,472.00
|
| Rate for Payer: Humana Commercial |
$4,896.00
|
| Rate for Payer: Humana KY Medicaid |
$1,980.86
|
| Rate for Payer: Humana Medicare Advantage |
$1,478.75
|
| Rate for Payer: Kentucky WC Medicaid |
$2,001.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,723.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,250.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,774.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,020.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,068.80
|
| Rate for Payer: Ohio Health Group HMO |
$4,320.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,608.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,011.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,974.40
|
| Rate for Payer: PHCS Commercial |
$5,529.60
|
| Rate for Payer: United Healthcare All Payer |
$5,068.80
|
|
|
REMOVE BY LIGAT INT HEM GRP
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 46945
|
| Hospital Charge Code |
76101941
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$175.80 |
| Max. Negotiated Rate |
$415.44 |
| Rate for Payer: Aetna Commercial |
$287.43
|
| Rate for Payer: Ambetter Exchange |
$319.57
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$175.80
|
| Rate for Payer: Anthem Medicaid |
$260.96
|
| Rate for Payer: Buckeye Individual/Medicaid |
$319.57
|
| Rate for Payer: Buckeye Medicare Advantage |
$319.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$383.48
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$325.38
|
| Rate for Payer: Healthspan PPO |
$311.00
|
| Rate for Payer: Humana Medicaid |
$260.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$269.86
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$319.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$319.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$266.18
|
| Rate for Payer: Molina Healthcare Passport |
$260.96
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$415.44
|
| Rate for Payer: UHCCP Medicaid |
$184.59
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$263.57
|
| Rate for Payer: Wellcare Medicare Advantage |
$319.57
|
|
|
REMOVE BY LIGAT INT HEM GRP
|
Facility
|
OP
|
$450.00
|
|
|
Service Code
|
HCPCS 46945
|
| Hospital Charge Code |
76101941
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$154.75 |
| Max. Negotiated Rate |
$3,547.47 |
| Rate for Payer: Aetna Commercial |
$346.50
|
| Rate for Payer: Anthem Medicaid |
$154.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,533.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$351.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,547.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,420.78
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$373.50
|
| Rate for Payer: First Health Commercial |
$427.50
|
| Rate for Payer: Humana Commercial |
$382.50
|
| Rate for Payer: Humana KY Medicaid |
$154.75
|
| Rate for Payer: Humana Medicare Advantage |
$2,533.91
|
| Rate for Payer: Kentucky WC Medicaid |
$156.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$369.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$332.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,040.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$157.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$396.00
|
| Rate for Payer: Ohio Health Group HMO |
$337.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$360.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$391.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$310.50
|
| Rate for Payer: PHCS Commercial |
$432.00
|
| Rate for Payer: United Healthcare All Payer |
$396.00
|
|
|
REMOVE BY LIGAT INT HEM GRP
|
Facility
|
IP
|
$450.00
|
|
|
Service Code
|
HCPCS 46945
|
| Hospital Charge Code |
76101941
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$135.00 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna Commercial |
$346.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$351.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$373.50
|
| Rate for Payer: First Health Commercial |
$427.50
|
| Rate for Payer: Humana Commercial |
$382.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$369.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$332.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$135.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$396.00
|
| Rate for Payer: Ohio Health Group HMO |
$337.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$360.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$391.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$310.50
|
| Rate for Payer: PHCS Commercial |
$432.00
|
| Rate for Payer: United Healthcare All Payer |
$396.00
|
|
|
REMOVE BY LIGAT INT HEM GRP(P
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 46945
|
| Hospital Charge Code |
761P1941
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$175.80 |
| Max. Negotiated Rate |
$415.44 |
| Rate for Payer: Aetna Commercial |
$287.43
|
| Rate for Payer: Ambetter Exchange |
$319.57
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$175.80
|
| Rate for Payer: Anthem Medicaid |
$260.96
|
| Rate for Payer: Buckeye Individual/Medicaid |
$319.57
|
| Rate for Payer: Buckeye Medicare Advantage |
$319.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$383.48
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$325.38
|
| Rate for Payer: Healthspan PPO |
$311.00
|
| Rate for Payer: Humana Medicaid |
$260.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$269.86
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$319.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$319.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$266.18
|
| Rate for Payer: Molina Healthcare Passport |
$260.96
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$415.44
|
| Rate for Payer: UHCCP Medicaid |
$184.59
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$263.57
|
| Rate for Payer: Wellcare Medicare Advantage |
$319.57
|
|
|
REMOVE CONTRACEPTIVE CAPSULE
|
Facility
|
IP
|
$1,269.00
|
|
|
Service Code
|
HCPCS 11976
|
| Hospital Charge Code |
76100115
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$380.70 |
| Max. Negotiated Rate |
$1,218.24 |
| Rate for Payer: Aetna Commercial |
$977.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$989.82
|
| Rate for Payer: Cash Price |
$634.50
|
| Rate for Payer: Cigna Commercial |
$1,053.27
|
| Rate for Payer: First Health Commercial |
$1,205.55
|
| Rate for Payer: Humana Commercial |
$1,078.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,040.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$936.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$380.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,116.72
|
| Rate for Payer: Ohio Health Group HMO |
$951.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,015.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,104.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$875.61
|
| Rate for Payer: PHCS Commercial |
$1,218.24
|
| Rate for Payer: United Healthcare All Payer |
$1,116.72
|
|
|
REMOVE CONTRACEPTIVE CAPSULE
|
Professional
|
Both
|
$1,269.00
|
|
|
Service Code
|
HCPCS 11976
|
| Hospital Charge Code |
76100115
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$52.05 |
| Max. Negotiated Rate |
$761.40 |
| Rate for Payer: Aetna Commercial |
$147.15
|
| Rate for Payer: Ambetter Exchange |
$87.60
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$52.05
|
| Rate for Payer: Anthem Medicaid |
$93.85
|
| Rate for Payer: Buckeye Individual/Medicaid |
$87.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$87.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$105.12
|
| Rate for Payer: Cash Price |
$634.50
|
| Rate for Payer: Cash Price |
$634.50
|
| Rate for Payer: Cigna Commercial |
$201.21
|
| Rate for Payer: Healthspan PPO |
$170.73
|
| Rate for Payer: Humana Medicaid |
$93.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$121.67
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$87.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$95.73
|
| Rate for Payer: Molina Healthcare Passport |
$93.85
|
| Rate for Payer: Multiplan PHCS |
$761.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$113.88
|
| Rate for Payer: UHCCP Medicaid |
$54.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$94.79
|
| Rate for Payer: Wellcare Medicare Advantage |
$87.60
|
|
|
REMOVE CONTRACEPTIVE CAPSULE
|
Facility
|
OP
|
$1,269.00
|
|
|
Service Code
|
HCPCS 11976
|
| Hospital Charge Code |
76100115
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$436.41 |
| Max. Negotiated Rate |
$1,218.24 |
| Rate for Payer: Aetna Commercial |
$977.13
|
| Rate for Payer: Anthem Medicaid |
$436.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$650.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$989.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$910.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$877.63
|
| Rate for Payer: Cash Price |
$634.50
|
| Rate for Payer: Cash Price |
$634.50
|
| Rate for Payer: Cigna Commercial |
$1,053.27
|
| Rate for Payer: First Health Commercial |
$1,205.55
|
| Rate for Payer: Humana Commercial |
$1,078.65
|
| Rate for Payer: Humana KY Medicaid |
$436.41
|
| Rate for Payer: Humana Medicare Advantage |
$650.10
|
| Rate for Payer: Kentucky WC Medicaid |
$440.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,040.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$936.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$780.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$445.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,116.72
|
| Rate for Payer: Ohio Health Group HMO |
$951.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,015.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,104.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$875.61
|
| Rate for Payer: PHCS Commercial |
$1,218.24
|
| Rate for Payer: United Healthcare All Payer |
$1,116.72
|
|
|
REMOVE CONTRACEPTIVE CAPSUL(P
|
Professional
|
Both
|
$395.00
|
|
|
Service Code
|
HCPCS 11976
|
| Hospital Charge Code |
761P0115
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$52.05 |
| Max. Negotiated Rate |
$237.00 |
| Rate for Payer: Aetna Commercial |
$147.15
|
| Rate for Payer: Ambetter Exchange |
$87.60
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$52.05
|
| Rate for Payer: Anthem Medicaid |
$93.85
|
| Rate for Payer: Buckeye Individual/Medicaid |
$87.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$87.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$105.12
|
| Rate for Payer: Cash Price |
$197.50
|
| Rate for Payer: Cash Price |
$197.50
|
| Rate for Payer: Cigna Commercial |
$201.21
|
| Rate for Payer: Healthspan PPO |
$170.73
|
| Rate for Payer: Humana Medicaid |
$93.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$121.67
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$87.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$95.73
|
| Rate for Payer: Molina Healthcare Passport |
$93.85
|
| Rate for Payer: Multiplan PHCS |
$237.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$113.88
|
| Rate for Payer: UHCCP Medicaid |
$54.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$94.79
|
| Rate for Payer: Wellcare Medicare Advantage |
$87.60
|
|
|
REMOVE CONTRACEPTIVE CAPSUL(T
|
Facility
|
OP
|
$874.00
|
|
|
Service Code
|
HCPCS 11976
|
| Hospital Charge Code |
761T0115
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$300.57 |
| Max. Negotiated Rate |
$910.14 |
| Rate for Payer: Aetna Commercial |
$672.98
|
| Rate for Payer: Anthem Medicaid |
$300.57
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$650.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$681.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$910.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$877.63
|
| Rate for Payer: Cash Price |
$437.00
|
| Rate for Payer: Cash Price |
$437.00
|
| Rate for Payer: Cigna Commercial |
$725.42
|
| Rate for Payer: First Health Commercial |
$830.30
|
| Rate for Payer: Humana Commercial |
$742.90
|
| Rate for Payer: Humana KY Medicaid |
$300.57
|
| Rate for Payer: Humana Medicare Advantage |
$650.10
|
| Rate for Payer: Kentucky WC Medicaid |
$303.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$716.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$645.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$780.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$306.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$769.12
|
| Rate for Payer: Ohio Health Group HMO |
$655.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$699.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$760.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$603.06
|
| Rate for Payer: PHCS Commercial |
$839.04
|
| Rate for Payer: United Healthcare All Payer |
$769.12
|
|
|
REMOVE CONTRACEPTIVE CAPSUL(T
|
Facility
|
IP
|
$874.00
|
|
|
Service Code
|
HCPCS 11976
|
| Hospital Charge Code |
761T0115
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$262.20 |
| Max. Negotiated Rate |
$839.04 |
| Rate for Payer: Aetna Commercial |
$672.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$681.72
|
| Rate for Payer: Cash Price |
$437.00
|
| Rate for Payer: Cigna Commercial |
$725.42
|
| Rate for Payer: First Health Commercial |
$830.30
|
| Rate for Payer: Humana Commercial |
$742.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$716.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$645.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$262.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$769.12
|
| Rate for Payer: Ohio Health Group HMO |
$655.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$699.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$760.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$603.06
|
| Rate for Payer: PHCS Commercial |
$839.04
|
| Rate for Payer: United Healthcare All Payer |
$769.12
|
|
|
REMOVE CVA DEVICE OBSTRUCT
|
Facility
|
OP
|
$925.00
|
|
|
Service Code
|
HCPCS 75901
|
| Hospital Charge Code |
32000377
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$277.50 |
| Max. Negotiated Rate |
$888.00 |
| Rate for Payer: Aetna Commercial |
$712.25
|
| Rate for Payer: Anthem Medicaid |
$318.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$721.50
|
| Rate for Payer: Cash Price |
$462.50
|
| Rate for Payer: Cigna Commercial |
$767.75
|
| Rate for Payer: First Health Commercial |
$878.75
|
| Rate for Payer: Humana Commercial |
$786.25
|
| Rate for Payer: Humana KY Medicaid |
$318.11
|
| Rate for Payer: Kentucky WC Medicaid |
$321.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$758.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$682.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$277.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$324.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$814.00
|
| Rate for Payer: Ohio Health Group HMO |
$693.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$740.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$804.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$638.25
|
| Rate for Payer: PHCS Commercial |
$888.00
|
| Rate for Payer: United Healthcare All Payer |
$814.00
|
|
|
REMOVE CVA DEVICE OBSTRUCT
|
Facility
|
IP
|
$925.00
|
|
|
Service Code
|
HCPCS 75901
|
| Hospital Charge Code |
32000377
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$277.50 |
| Max. Negotiated Rate |
$888.00 |
| Rate for Payer: Aetna Commercial |
$712.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$721.50
|
| Rate for Payer: Cash Price |
$462.50
|
| Rate for Payer: Cigna Commercial |
$767.75
|
| Rate for Payer: First Health Commercial |
$878.75
|
| Rate for Payer: Humana Commercial |
$786.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$758.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$682.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$277.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$814.00
|
| Rate for Payer: Ohio Health Group HMO |
$693.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$740.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$804.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$638.25
|
| Rate for Payer: PHCS Commercial |
$888.00
|
| Rate for Payer: United Healthcare All Payer |
$814.00
|
|
|
REMOVE DRUG IMPLANT DEVICE
|
Facility
|
IP
|
$1,632.00
|
|
|
Service Code
|
HCPCS 11982
|
| Hospital Charge Code |
76100118
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$489.60 |
| Max. Negotiated Rate |
$1,566.72 |
| Rate for Payer: Aetna Commercial |
$1,256.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,272.96
|
| Rate for Payer: Cash Price |
$816.00
|
| Rate for Payer: Cigna Commercial |
$1,354.56
|
| Rate for Payer: First Health Commercial |
$1,550.40
|
| Rate for Payer: Humana Commercial |
$1,387.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,338.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,204.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$489.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,436.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,224.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,305.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,419.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,126.08
|
| Rate for Payer: PHCS Commercial |
$1,566.72
|
| Rate for Payer: United Healthcare All Payer |
$1,436.16
|
|
|
REMOVE DRUG IMPLANT DEVICE
|
Facility
|
OP
|
$1,632.00
|
|
|
Service Code
|
HCPCS 11982
|
| Hospital Charge Code |
76100118
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$368.70 |
| Max. Negotiated Rate |
$1,566.72 |
| Rate for Payer: Aetna Commercial |
$1,256.64
|
| Rate for Payer: Anthem Medicaid |
$561.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$368.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,272.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$497.75
|
| Rate for Payer: Cash Price |
$816.00
|
| Rate for Payer: Cash Price |
$816.00
|
| Rate for Payer: Cigna Commercial |
$1,354.56
|
| Rate for Payer: First Health Commercial |
$1,550.40
|
| Rate for Payer: Humana Commercial |
$1,387.20
|
| Rate for Payer: Humana KY Medicaid |
$561.24
|
| Rate for Payer: Humana Medicare Advantage |
$368.70
|
| Rate for Payer: Kentucky WC Medicaid |
$566.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,338.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,204.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$572.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,436.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,224.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,305.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,419.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,126.08
|
| Rate for Payer: PHCS Commercial |
$1,566.72
|
| Rate for Payer: United Healthcare All Payer |
$1,436.16
|
|
|
REMOVE DRUG IMPLANT DEVICE
|
Professional
|
Both
|
$1,632.00
|
|
|
Service Code
|
HCPCS 11982
|
| Hospital Charge Code |
76100118
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$49.51 |
| Max. Negotiated Rate |
$979.20 |
| Rate for Payer: Aetna Commercial |
$156.61
|
| Rate for Payer: Ambetter Exchange |
$69.00
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$49.51
|
| Rate for Payer: Anthem Medicaid |
$99.36
|
| Rate for Payer: Buckeye Individual/Medicaid |
$69.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$69.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$82.80
|
| Rate for Payer: Cash Price |
$816.00
|
| Rate for Payer: Cash Price |
$816.00
|
| Rate for Payer: Cigna Commercial |
$212.72
|
| Rate for Payer: Healthspan PPO |
$178.71
|
| Rate for Payer: Humana Medicaid |
$99.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$124.65
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$69.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$69.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$101.35
|
| Rate for Payer: Molina Healthcare Passport |
$99.36
|
| Rate for Payer: Multiplan PHCS |
$979.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$89.70
|
| Rate for Payer: UHCCP Medicaid |
$51.99
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$100.35
|
| Rate for Payer: Wellcare Medicare Advantage |
$69.00
|
|
|
REMOVE DRUG IMPLANT DEVICE(P
|
Professional
|
Both
|
$390.00
|
|
|
Service Code
|
HCPCS 11982
|
| Hospital Charge Code |
761P0118
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$49.51 |
| Max. Negotiated Rate |
$234.00 |
| Rate for Payer: Aetna Commercial |
$156.61
|
| Rate for Payer: Ambetter Exchange |
$69.00
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$49.51
|
| Rate for Payer: Anthem Medicaid |
$99.36
|
| Rate for Payer: Buckeye Individual/Medicaid |
$69.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$69.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$82.80
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cigna Commercial |
$212.72
|
| Rate for Payer: Healthspan PPO |
$178.71
|
| Rate for Payer: Humana Medicaid |
$99.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$124.65
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$69.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$69.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$101.35
|
| Rate for Payer: Molina Healthcare Passport |
$99.36
|
| Rate for Payer: Multiplan PHCS |
$234.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$89.70
|
| Rate for Payer: UHCCP Medicaid |
$51.99
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$100.35
|
| Rate for Payer: Wellcare Medicare Advantage |
$69.00
|
|
