|
Bikini Extended Lsr Hair Remvl
|
Professional
|
Both
|
$250.00
|
|
| Hospital Charge Code |
22200186
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$87.50 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
|
|
Bikini Ext LsrHairRem-PP#1 50%
|
Professional
|
Both
|
$319.00
|
|
| Hospital Charge Code |
22200350
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$111.65 |
| Max. Negotiated Rate |
$319.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$319.00
|
| Rate for Payer: Cash Price |
$159.50
|
| Rate for Payer: Multiplan PHCS |
$191.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$223.30
|
| Rate for Payer: UHCCP Medicaid |
$111.65
|
|
|
Bikini Full Laser Hair Removal
|
Professional
|
Both
|
$375.00
|
|
| Hospital Charge Code |
22200187
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$131.25 |
| Max. Negotiated Rate |
$375.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$375.00
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Multiplan PHCS |
$225.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$262.50
|
| Rate for Payer: UHCCP Medicaid |
$131.25
|
|
|
Bikini FulLsr HairRem-PP#1 50%
|
Professional
|
Both
|
$478.00
|
|
| Hospital Charge Code |
22200351
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$167.30 |
| Max. Negotiated Rate |
$478.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$478.00
|
| Rate for Payer: Cash Price |
$239.00
|
| Rate for Payer: Multiplan PHCS |
$286.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$334.60
|
| Rate for Payer: UHCCP Medicaid |
$167.30
|
|
|
Bikini Line Only LsrHair Rem
|
Professional
|
Both
|
$200.00
|
|
| Hospital Charge Code |
22200222
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$200.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.00
|
| Rate for Payer: UHCCP Medicaid |
$70.00
|
|
|
BikniExt LsrHairRem-PP#2/3 25%
|
Professional
|
Both
|
$159.00
|
|
| Hospital Charge Code |
22200466
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$55.65 |
| Max. Negotiated Rate |
$159.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$159.00
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Multiplan PHCS |
$95.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$111.30
|
| Rate for Payer: UHCCP Medicaid |
$55.65
|
|
|
Bikni FulLsrHairRem-PP#2/3 25%
|
Professional
|
Both
|
$239.00
|
|
| Hospital Charge Code |
22200467
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$83.65 |
| Max. Negotiated Rate |
$239.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$239.00
|
| Rate for Payer: Cash Price |
$119.50
|
| Rate for Payer: Multiplan PHCS |
$143.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$167.30
|
| Rate for Payer: UHCCP Medicaid |
$83.65
|
|
|
BikniLine LsrHairRem-PP#1 50%
|
Professional
|
Both
|
$256.00
|
|
| Hospital Charge Code |
22200223
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$89.60 |
| Max. Negotiated Rate |
$256.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$256.00
|
| Rate for Payer: Cash Price |
$128.00
|
| Rate for Payer: Multiplan PHCS |
$153.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$179.20
|
| Rate for Payer: UHCCP Medicaid |
$89.60
|
|
|
BikniLne LsrHairRem-PP#2/3 25%
|
Professional
|
Both
|
$127.00
|
|
| Hospital Charge Code |
22200477
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$44.45 |
| Max. Negotiated Rate |
$127.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$127.00
|
| Rate for Payer: Cash Price |
$63.50
|
| Rate for Payer: Multiplan PHCS |
$76.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$88.90
|
| Rate for Payer: UHCCP Medicaid |
$44.45
|
|
|
BI LAPAROSCOP OVARIAN DRILLING
|
Facility
|
IP
|
$1,700.00
|
|
|
Service Code
|
HCPCS 58679
|
| Hospital Charge Code |
76102937
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$221.00 |
| Max. Negotiated Rate |
$1,632.00 |
| Rate for Payer: Aetna Commercial |
$1,309.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,326.00
|
| Rate for Payer: Cash Price |
$850.00
|
| Rate for Payer: Cigna Commercial |
$1,411.00
|
| Rate for Payer: First Health Commercial |
$1,615.00
|
| Rate for Payer: Humana Commercial |
$1,445.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,394.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,254.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$510.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,496.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$221.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$527.00
|
| Rate for Payer: PHCS Commercial |
$1,632.00
|
| Rate for Payer: United Healthcare All Payer |
$1,496.00
|
|
|
BI LAPAROSCOP OVARIAN DRILLING
|
Facility
|
OP
|
$1,700.00
|
|
|
Service Code
|
HCPCS 58679
|
| Hospital Charge Code |
76102937
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$221.00 |
| Max. Negotiated Rate |
$6,985.45 |
| Rate for Payer: Aetna Commercial |
$1,309.00
|
| Rate for Payer: Anthem Medicaid |
$584.63
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,989.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,326.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,985.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,735.97
|
| Rate for Payer: Cash Price |
$850.00
|
| Rate for Payer: Cash Price |
$850.00
|
| Rate for Payer: Cigna Commercial |
$1,411.00
|
| Rate for Payer: First Health Commercial |
$1,615.00
|
| Rate for Payer: Humana Commercial |
$1,445.00
|
| Rate for Payer: Humana KY Medicaid |
$584.63
|
| Rate for Payer: Humana Medicare Advantage |
$4,989.61
|
| Rate for Payer: Kentucky WC Medicaid |
$590.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,394.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,254.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,987.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$596.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,496.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$221.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$527.00
|
| Rate for Payer: PHCS Commercial |
$1,632.00
|
| Rate for Payer: United Healthcare All Payer |
$1,496.00
|
|
|
BI LAPAROSCOP OVARIAN DRILLING
|
Professional
|
Both
|
$1,700.00
|
|
|
Service Code
|
HCPCS 58679
|
| Hospital Charge Code |
76102937
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1,700.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$1,700.00
|
| Rate for Payer: Cash Price |
$850.00
|
| Rate for Payer: Cash Price |
$850.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$1,020.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,190.00
|
| Rate for Payer: UHCCP Medicaid |
$595.00
|
|
|
BILAT DIAGNOSITIC W/CAD
|
Facility
|
IP
|
$851.00
|
|
|
Service Code
|
HCPCS 77066
|
| Hospital Charge Code |
40100010
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$110.63 |
| Max. Negotiated Rate |
$816.96 |
| Rate for Payer: Aetna Commercial |
$655.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$663.78
|
| Rate for Payer: Cash Price |
$425.50
|
| Rate for Payer: Cigna Commercial |
$706.33
|
| Rate for Payer: First Health Commercial |
$808.45
|
| Rate for Payer: Humana Commercial |
$723.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$697.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$628.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$255.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$748.88
|
| Rate for Payer: Ohio Health Group HMO |
$638.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$170.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$263.81
|
| Rate for Payer: PHCS Commercial |
$816.96
|
| Rate for Payer: United Healthcare All Payer |
$748.88
|
|
|
BILAT DIAGNOSITIC W/CAD
|
Professional
|
Both
|
$851.00
|
|
|
Service Code
|
HCPCS 77066
|
| Hospital Charge Code |
40100010
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$59.05 |
| Max. Negotiated Rate |
$851.00 |
| Rate for Payer: Anthem Medicaid |
$126.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$851.00
|
| Rate for Payer: Cash Price |
$425.50
|
| Rate for Payer: Cash Price |
$425.50
|
| Rate for Payer: Cigna Commercial |
$266.31
|
| Rate for Payer: Humana Medicaid |
$126.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$59.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$128.68
|
| Rate for Payer: Molina Healthcare Passport |
$126.16
|
| Rate for Payer: Multiplan PHCS |
$510.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$595.70
|
| Rate for Payer: UHCCP Medicaid |
$297.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$127.42
|
|
|
BILAT DIAGNOSITIC W/CAD
|
Facility
|
OP
|
$851.00
|
|
|
Service Code
|
HCPCS 77066
|
| Hospital Charge Code |
40100010
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$110.63 |
| Max. Negotiated Rate |
$816.96 |
| Rate for Payer: Aetna Commercial |
$655.27
|
| Rate for Payer: Anthem Medicaid |
$292.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$663.78
|
| Rate for Payer: Cash Price |
$425.50
|
| Rate for Payer: Cigna Commercial |
$706.33
|
| Rate for Payer: First Health Commercial |
$808.45
|
| Rate for Payer: Humana Commercial |
$723.35
|
| Rate for Payer: Humana KY Medicaid |
$292.66
|
| Rate for Payer: Kentucky WC Medicaid |
$295.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$697.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$628.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$255.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$298.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$748.88
|
| Rate for Payer: Ohio Health Group HMO |
$638.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$170.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$263.81
|
| Rate for Payer: PHCS Commercial |
$816.96
|
| Rate for Payer: United Healthcare All Payer |
$748.88
|
|
|
BILAT DIAGNOSITIC W/CAD(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 77066
|
| Hospital Charge Code |
401P0010
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$59.05 |
| Max. Negotiated Rate |
$266.31 |
| Rate for Payer: Anthem Medicaid |
$126.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$266.31
|
| Rate for Payer: Humana Medicaid |
$126.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$59.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$128.68
|
| Rate for Payer: Molina Healthcare Passport |
$126.16
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$127.42
|
|
|
BILAT DIAGNOSITIC W/CAD(T
|
Facility
|
IP
|
$601.00
|
|
|
Service Code
|
HCPCS 77066
|
| Hospital Charge Code |
401T0010
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$78.13 |
| Max. Negotiated Rate |
$576.96 |
| Rate for Payer: Aetna Commercial |
$462.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.78
|
| Rate for Payer: Cash Price |
$300.50
|
| Rate for Payer: Cigna Commercial |
$498.83
|
| Rate for Payer: First Health Commercial |
$570.95
|
| Rate for Payer: Humana Commercial |
$510.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$443.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.88
|
| Rate for Payer: Ohio Health Group HMO |
$450.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$186.31
|
| Rate for Payer: PHCS Commercial |
$576.96
|
| Rate for Payer: United Healthcare All Payer |
$528.88
|
|
|
BILAT DIAGNOSITIC W/CAD(T
|
Facility
|
OP
|
$601.00
|
|
|
Service Code
|
HCPCS 77066
|
| Hospital Charge Code |
401T0010
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$78.13 |
| Max. Negotiated Rate |
$576.96 |
| Rate for Payer: Aetna Commercial |
$462.77
|
| Rate for Payer: Anthem Medicaid |
$206.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.78
|
| Rate for Payer: Cash Price |
$300.50
|
| Rate for Payer: Cigna Commercial |
$498.83
|
| Rate for Payer: First Health Commercial |
$570.95
|
| Rate for Payer: Humana Commercial |
$510.85
|
| Rate for Payer: Humana KY Medicaid |
$206.68
|
| Rate for Payer: Kentucky WC Medicaid |
$208.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$443.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$210.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.88
|
| Rate for Payer: Ohio Health Group HMO |
$450.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$186.31
|
| Rate for Payer: PHCS Commercial |
$576.96
|
| Rate for Payer: United Healthcare All Payer |
$528.88
|
|
|
BILATERAL BROW LIFT IN OFC
|
Professional
|
Both
|
$2,000.00
|
|
| Hospital Charge Code |
22200723
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$700.00 |
| Max. Negotiated Rate |
$2,000.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$2,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Multiplan PHCS |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,400.00
|
| Rate for Payer: UHCCP Medicaid |
$700.00
|
|
|
BILATERAL EXTREMITY S & I
|
Facility
|
IP
|
$4,680.00
|
|
|
Service Code
|
HCPCS 75716
|
| Hospital Charge Code |
32000157
|
|
Hospital Revenue Code
|
323
|
| Min. Negotiated Rate |
$608.40 |
| Max. Negotiated Rate |
$4,492.80 |
| Rate for Payer: Cash Price |
$2,340.00
|
| Rate for Payer: Aetna Commercial |
$3,603.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,650.40
|
| Rate for Payer: Cigna Commercial |
$3,884.40
|
| Rate for Payer: First Health Commercial |
$4,446.00
|
| Rate for Payer: Humana Commercial |
$3,978.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,837.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,453.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,404.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,118.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,510.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$936.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$608.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,450.80
|
| Rate for Payer: PHCS Commercial |
$4,492.80
|
| Rate for Payer: United Healthcare All Payer |
$4,118.40
|
|
|
BILATERAL EXTREMITY S & I
|
Facility
|
OP
|
$4,680.00
|
|
|
Service Code
|
HCPCS 75716
|
| Hospital Charge Code |
32000157
|
|
Hospital Revenue Code
|
323
|
| Min. Negotiated Rate |
$608.40 |
| Max. Negotiated Rate |
$4,492.80 |
| Rate for Payer: Aetna Commercial |
$3,603.60
|
| Rate for Payer: Anthem Medicaid |
$1,609.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,756.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,650.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,858.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,721.13
|
| Rate for Payer: Cash Price |
$2,340.00
|
| Rate for Payer: Cash Price |
$2,340.00
|
| Rate for Payer: Cigna Commercial |
$3,884.40
|
| Rate for Payer: First Health Commercial |
$4,446.00
|
| Rate for Payer: Humana Commercial |
$3,978.00
|
| Rate for Payer: Humana KY Medicaid |
$1,609.45
|
| Rate for Payer: Humana Medicare Advantage |
$2,756.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,625.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,837.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,453.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,307.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,641.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,118.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,510.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$936.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$608.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,450.80
|
| Rate for Payer: PHCS Commercial |
$4,492.80
|
| Rate for Payer: United Healthcare All Payer |
$4,118.40
|
|
|
BILATERAL EXTREMITY S & I
|
Professional
|
Both
|
$4,680.00
|
|
|
Service Code
|
HCPCS 75716
|
| Hospital Charge Code |
32000157
|
|
Hospital Revenue Code
|
323
|
| Min. Negotiated Rate |
$84.63 |
| Max. Negotiated Rate |
$4,680.00 |
| Rate for Payer: Aetna Commercial |
$495.07
|
| Rate for Payer: Anthem Medicaid |
$396.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,680.00
|
| Rate for Payer: Cash Price |
$2,340.00
|
| Rate for Payer: Cash Price |
$2,340.00
|
| Rate for Payer: Cigna Commercial |
$714.85
|
| Rate for Payer: Healthspan PPO |
$463.89
|
| Rate for Payer: Humana Medicaid |
$396.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$84.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$404.47
|
| Rate for Payer: Molina Healthcare Passport |
$396.54
|
| Rate for Payer: Multiplan PHCS |
$2,808.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,276.00
|
| Rate for Payer: UHCCP Medicaid |
$1,638.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$400.51
|
|
|
BILATERAL EXTREMITY S & I(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 75716
|
| Hospital Charge Code |
320P0157
|
|
Hospital Revenue Code
|
323
|
| Min. Negotiated Rate |
$84.63 |
| Max. Negotiated Rate |
$714.85 |
| Rate for Payer: Aetna Commercial |
$495.07
|
| Rate for Payer: Anthem Medicaid |
$396.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$714.85
|
| Rate for Payer: Healthspan PPO |
$463.89
|
| Rate for Payer: Humana Medicaid |
$396.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$84.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$404.47
|
| Rate for Payer: Molina Healthcare Passport |
$396.54
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$400.51
|
|
|
BILATERAL EXTREMITY S & I(T
|
Facility
|
OP
|
$4,430.00
|
|
|
Service Code
|
HCPCS 75716
|
| Hospital Charge Code |
320T0157
|
|
Hospital Revenue Code
|
323
|
| Min. Negotiated Rate |
$575.90 |
| Max. Negotiated Rate |
$4,252.80 |
| Rate for Payer: Aetna Commercial |
$3,411.10
|
| Rate for Payer: Anthem Medicaid |
$1,523.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,756.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,455.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,858.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,721.13
|
| Rate for Payer: Cash Price |
$2,215.00
|
| Rate for Payer: Cash Price |
$2,215.00
|
| Rate for Payer: Cigna Commercial |
$3,676.90
|
| Rate for Payer: First Health Commercial |
$4,208.50
|
| Rate for Payer: Humana Commercial |
$3,765.50
|
| Rate for Payer: Humana KY Medicaid |
$1,523.48
|
| Rate for Payer: Humana Medicare Advantage |
$2,756.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,538.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,632.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,269.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,307.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,554.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,898.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,322.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$886.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$575.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,373.30
|
| Rate for Payer: PHCS Commercial |
$4,252.80
|
| Rate for Payer: United Healthcare All Payer |
$3,898.40
|
|
|
BILATERAL EXTREMITY S & I(T
|
Facility
|
IP
|
$4,430.00
|
|
|
Service Code
|
HCPCS 75716
|
| Hospital Charge Code |
320T0157
|
|
Hospital Revenue Code
|
323
|
| Min. Negotiated Rate |
$575.90 |
| Max. Negotiated Rate |
$4,252.80 |
| Rate for Payer: Aetna Commercial |
$3,411.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,455.40
|
| Rate for Payer: Cash Price |
$2,215.00
|
| Rate for Payer: Cigna Commercial |
$3,676.90
|
| Rate for Payer: First Health Commercial |
$4,208.50
|
| Rate for Payer: Humana Commercial |
$3,765.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,632.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,269.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,329.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,898.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,322.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$886.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$575.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,373.30
|
| Rate for Payer: PHCS Commercial |
$4,252.80
|
| Rate for Payer: United Healthcare All Payer |
$3,898.40
|
|
