|
BREAST AUGMENTATION W/IMPLANT
|
Facility
|
OP
|
$2,700.00
|
|
|
Service Code
|
HCPCS 19325
|
| Hospital Charge Code |
76100308
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$351.00 |
| Max. Negotiated Rate |
$11,412.41 |
| Rate for Payer: Aetna Commercial |
$2,079.00
|
| Rate for Payer: Anthem Medicaid |
$928.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8,151.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,106.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11,412.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$11,004.82
|
| Rate for Payer: Cash Price |
$1,350.00
|
| Rate for Payer: Cash Price |
$1,350.00
|
| Rate for Payer: Cigna Commercial |
$2,241.00
|
| Rate for Payer: First Health Commercial |
$2,565.00
|
| Rate for Payer: Humana Commercial |
$2,295.00
|
| Rate for Payer: Humana KY Medicaid |
$928.53
|
| Rate for Payer: Humana Medicare Advantage |
$8,151.72
|
| Rate for Payer: Kentucky WC Medicaid |
$937.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,214.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,992.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,782.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$947.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,376.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,025.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$351.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$837.00
|
| Rate for Payer: PHCS Commercial |
$2,592.00
|
| Rate for Payer: United Healthcare All Payer |
$2,376.00
|
|
|
BREAST AUGMENTATION W/IMPLANT
|
Facility
|
IP
|
$2,700.00
|
|
|
Service Code
|
HCPCS 19325
|
| Hospital Charge Code |
76100308
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$351.00 |
| Max. Negotiated Rate |
$2,592.00 |
| Rate for Payer: Aetna Commercial |
$2,079.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,106.00
|
| Rate for Payer: Cash Price |
$1,350.00
|
| Rate for Payer: Cigna Commercial |
$2,241.00
|
| Rate for Payer: First Health Commercial |
$2,565.00
|
| Rate for Payer: Humana Commercial |
$2,295.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,214.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,992.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$810.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,376.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,025.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$351.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$837.00
|
| Rate for Payer: PHCS Commercial |
$2,592.00
|
| Rate for Payer: United Healthcare All Payer |
$2,376.00
|
|
|
BREAST AUGMENTATION W/IMPLANT
|
Professional
|
Both
|
$2,700.00
|
|
|
Service Code
|
HCPCS 19325
|
| Hospital Charge Code |
76100308
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$421.12 |
| Max. Negotiated Rate |
$2,700.00 |
| Rate for Payer: Aetna Commercial |
$935.47
|
| Rate for Payer: Anthem Medicaid |
$421.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,700.00
|
| Rate for Payer: Cash Price |
$1,350.00
|
| Rate for Payer: Cash Price |
$1,350.00
|
| Rate for Payer: Cigna Commercial |
$888.81
|
| Rate for Payer: Healthspan PPO |
$747.99
|
| Rate for Payer: Humana Medicaid |
$421.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$827.77
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$429.54
|
| Rate for Payer: Molina Healthcare Passport |
$421.12
|
| Rate for Payer: Multiplan PHCS |
$1,620.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,890.00
|
| Rate for Payer: UHCCP Medicaid |
$945.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$425.33
|
|
|
BREAST AUGMENTATION WITH IMPLANT
|
Facility
|
OP
|
$11,412.41
|
|
|
Service Code
|
CPT 19325
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$8,151.72 |
| Max. Negotiated Rate |
$11,412.41 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8,151.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11,412.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$11,004.82
|
| Rate for Payer: Humana Medicare Advantage |
$8,151.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,782.06
|
|
|
BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$22,912.09
|
|
|
Service Code
|
MSDRG 584
|
| Min. Negotiated Rate |
$15,547.49 |
| Max. Negotiated Rate |
$22,912.09 |
| Rate for Payer: Anthem Medicaid |
$15,547.49
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$16,365.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$22,912.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$22,093.80
|
| Rate for Payer: Humana KY Medicaid |
$15,547.49
|
| Rate for Payer: Humana Medicare Advantage |
$16,365.78
|
| Rate for Payer: Kentucky WC Medicaid |
$15,702.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19,638.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$15,858.44
|
|
|
BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$19,699.78
|
|
|
Service Code
|
MSDRG 585
|
| Min. Negotiated Rate |
$13,367.71 |
| Max. Negotiated Rate |
$19,699.78 |
| Rate for Payer: Anthem Medicaid |
$13,367.71
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$14,071.27
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$19,699.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$18,996.21
|
| Rate for Payer: Humana KY Medicaid |
$13,367.71
|
| Rate for Payer: Humana Medicare Advantage |
$14,071.27
|
| Rate for Payer: Kentucky WC Medicaid |
$13,501.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16,885.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,635.06
|
|
|
BREAST CENTER LEVEL 1
|
Facility
|
IP
|
$1,100.00
|
|
| Hospital Charge Code |
76102546
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$341.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
BREAST CENTER LEVEL 1
|
Facility
|
OP
|
$1,100.00
|
|
| Hospital Charge Code |
76102546
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem Medicaid |
$378.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Humana KY Medicaid |
$378.29
|
| Rate for Payer: Kentucky WC Medicaid |
$382.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$385.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$341.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
BREAST CENTER LEVEL 2
|
Facility
|
OP
|
$2,510.00
|
|
| Hospital Charge Code |
76102547
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$326.30 |
| Max. Negotiated Rate |
$2,409.60 |
| Rate for Payer: Aetna Commercial |
$1,932.70
|
| Rate for Payer: Anthem Medicaid |
$863.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,957.80
|
| Rate for Payer: Cash Price |
$1,255.00
|
| Rate for Payer: Cigna Commercial |
$2,083.30
|
| Rate for Payer: First Health Commercial |
$2,384.50
|
| Rate for Payer: Humana Commercial |
$2,133.50
|
| Rate for Payer: Humana KY Medicaid |
$863.19
|
| Rate for Payer: Kentucky WC Medicaid |
$871.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,058.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,852.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$753.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$880.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,208.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,882.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$502.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$326.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$778.10
|
| Rate for Payer: PHCS Commercial |
$2,409.60
|
| Rate for Payer: United Healthcare All Payer |
$2,208.80
|
|
|
BREAST CENTER LEVEL 2
|
Facility
|
IP
|
$2,510.00
|
|
| Hospital Charge Code |
76102547
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$326.30 |
| Max. Negotiated Rate |
$2,409.60 |
| Rate for Payer: Aetna Commercial |
$1,932.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,957.80
|
| Rate for Payer: Cash Price |
$1,255.00
|
| Rate for Payer: Cigna Commercial |
$2,083.30
|
| Rate for Payer: First Health Commercial |
$2,384.50
|
| Rate for Payer: Humana Commercial |
$2,133.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,058.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,852.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$753.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,208.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,882.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$502.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$326.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$778.10
|
| Rate for Payer: PHCS Commercial |
$2,409.60
|
| Rate for Payer: United Healthcare All Payer |
$2,208.80
|
|
|
BREAST EXPANDER LOW HGHT 350CC
|
Facility
|
IP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
BREAST EXPANDER LOW HGHT 350CC
|
Facility
|
OP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem Medicaid |
$1,869.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Humana KY Medicaid |
$1,869.96
|
| Rate for Payer: Kentucky WC Medicaid |
$1,888.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,907.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
BREAST EXPANDER LOW HGHT 450CC
|
Facility
|
OP
|
$7,818.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,016.44 |
| Max. Negotiated Rate |
$7,506.00 |
| Rate for Payer: Aetna Commercial |
$6,020.44
|
| Rate for Payer: Anthem Medicaid |
$2,688.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,098.62
|
| Rate for Payer: Cash Price |
$3,909.38
|
| Rate for Payer: Cigna Commercial |
$6,489.56
|
| Rate for Payer: First Health Commercial |
$7,427.81
|
| Rate for Payer: Humana Commercial |
$6,645.94
|
| Rate for Payer: Humana KY Medicaid |
$2,688.87
|
| Rate for Payer: Kentucky WC Medicaid |
$2,716.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,411.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,770.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,345.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,742.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,880.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,864.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,563.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,016.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,423.81
|
| Rate for Payer: PHCS Commercial |
$7,506.00
|
| Rate for Payer: United Healthcare All Payer |
$6,880.50
|
|
|
BREAST EXPANDER LOW HGHT 450CC
|
Facility
|
IP
|
$7,818.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,016.44 |
| Max. Negotiated Rate |
$7,506.00 |
| Rate for Payer: Aetna Commercial |
$6,020.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,098.62
|
| Rate for Payer: Cash Price |
$3,909.38
|
| Rate for Payer: Cigna Commercial |
$6,489.56
|
| Rate for Payer: First Health Commercial |
$7,427.81
|
| Rate for Payer: Humana Commercial |
$6,645.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,411.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,770.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,345.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,880.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,864.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,563.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,016.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,423.81
|
| Rate for Payer: PHCS Commercial |
$7,506.00
|
| Rate for Payer: United Healthcare All Payer |
$6,880.50
|
|
|
BREAST EXPANDER LOW HGHT 550CC
|
Facility
|
OP
|
$7,818.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,016.44 |
| Max. Negotiated Rate |
$7,506.00 |
| Rate for Payer: Aetna Commercial |
$6,020.44
|
| Rate for Payer: Anthem Medicaid |
$2,688.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,098.62
|
| Rate for Payer: Cash Price |
$3,909.38
|
| Rate for Payer: Cigna Commercial |
$6,489.56
|
| Rate for Payer: First Health Commercial |
$7,427.81
|
| Rate for Payer: Humana Commercial |
$6,645.94
|
| Rate for Payer: Humana KY Medicaid |
$2,688.87
|
| Rate for Payer: Kentucky WC Medicaid |
$2,716.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,411.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,770.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,345.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,742.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,880.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,864.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,563.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,016.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,423.81
|
| Rate for Payer: PHCS Commercial |
$7,506.00
|
| Rate for Payer: United Healthcare All Payer |
$6,880.50
|
|
|
BREAST EXPANDER LOW HGHT 550CC
|
Facility
|
IP
|
$7,818.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,016.44 |
| Max. Negotiated Rate |
$7,506.00 |
| Rate for Payer: Aetna Commercial |
$6,020.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,098.62
|
| Rate for Payer: Cash Price |
$3,909.38
|
| Rate for Payer: Cigna Commercial |
$6,489.56
|
| Rate for Payer: First Health Commercial |
$7,427.81
|
| Rate for Payer: Humana Commercial |
$6,645.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,411.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,770.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,345.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,880.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,864.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,563.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,016.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,423.81
|
| Rate for Payer: PHCS Commercial |
$7,506.00
|
| Rate for Payer: United Healthcare All Payer |
$6,880.50
|
|
|
BREAST EXPANDER LOW HGHT 650CC
|
Facility
|
IP
|
$7,818.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,016.44 |
| Max. Negotiated Rate |
$7,506.00 |
| Rate for Payer: Aetna Commercial |
$6,020.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,098.62
|
| Rate for Payer: Cash Price |
$3,909.38
|
| Rate for Payer: Cigna Commercial |
$6,489.56
|
| Rate for Payer: First Health Commercial |
$7,427.81
|
| Rate for Payer: Humana Commercial |
$6,645.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,411.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,770.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,345.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,880.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,864.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,563.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,016.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,423.81
|
| Rate for Payer: PHCS Commercial |
$7,506.00
|
| Rate for Payer: United Healthcare All Payer |
$6,880.50
|
|
|
BREAST EXPANDER LOW HGHT 650CC
|
Facility
|
OP
|
$7,818.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,016.44 |
| Max. Negotiated Rate |
$7,506.00 |
| Rate for Payer: Aetna Commercial |
$6,020.44
|
| Rate for Payer: Anthem Medicaid |
$2,688.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,098.62
|
| Rate for Payer: Cash Price |
$3,909.38
|
| Rate for Payer: Cigna Commercial |
$6,489.56
|
| Rate for Payer: First Health Commercial |
$7,427.81
|
| Rate for Payer: Humana Commercial |
$6,645.94
|
| Rate for Payer: Humana KY Medicaid |
$2,688.87
|
| Rate for Payer: Kentucky WC Medicaid |
$2,716.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,411.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,770.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,345.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,742.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,880.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,864.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,563.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,016.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,423.81
|
| Rate for Payer: PHCS Commercial |
$7,506.00
|
| Rate for Payer: United Healthcare All Payer |
$6,880.50
|
|
|
BREAST EXPANDER MED HGHT 350CC
|
Facility
|
IP
|
$8,001.25
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,040.16 |
| Max. Negotiated Rate |
$7,681.20 |
| Rate for Payer: Aetna Commercial |
$6,160.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,240.98
|
| Rate for Payer: Cash Price |
$4,000.62
|
| Rate for Payer: Cigna Commercial |
$6,641.04
|
| Rate for Payer: First Health Commercial |
$7,601.19
|
| Rate for Payer: Humana Commercial |
$6,801.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,561.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,904.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,400.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,041.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,000.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,040.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,480.39
|
| Rate for Payer: PHCS Commercial |
$7,681.20
|
| Rate for Payer: United Healthcare All Payer |
$7,041.10
|
|
|
BREAST EXPANDER MED HGHT 350CC
|
Facility
|
OP
|
$8,001.25
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,040.16 |
| Max. Negotiated Rate |
$7,681.20 |
| Rate for Payer: Aetna Commercial |
$6,160.96
|
| Rate for Payer: Anthem Medicaid |
$2,751.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,240.98
|
| Rate for Payer: Cash Price |
$4,000.62
|
| Rate for Payer: Cigna Commercial |
$6,641.04
|
| Rate for Payer: First Health Commercial |
$7,601.19
|
| Rate for Payer: Humana Commercial |
$6,801.06
|
| Rate for Payer: Humana KY Medicaid |
$2,751.63
|
| Rate for Payer: Kentucky WC Medicaid |
$2,779.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,561.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,904.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,400.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,806.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,041.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,000.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,040.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,480.39
|
| Rate for Payer: PHCS Commercial |
$7,681.20
|
| Rate for Payer: United Healthcare All Payer |
$7,041.10
|
|
|
BREAST EXPANDER MED HGHT 450CC
|
Facility
|
IP
|
$7,818.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,016.44 |
| Max. Negotiated Rate |
$7,506.00 |
| Rate for Payer: Aetna Commercial |
$6,020.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,098.62
|
| Rate for Payer: Cash Price |
$3,909.38
|
| Rate for Payer: Cigna Commercial |
$6,489.56
|
| Rate for Payer: First Health Commercial |
$7,427.81
|
| Rate for Payer: Humana Commercial |
$6,645.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,411.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,770.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,345.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,880.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,864.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,563.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,016.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,423.81
|
| Rate for Payer: PHCS Commercial |
$7,506.00
|
| Rate for Payer: United Healthcare All Payer |
$6,880.50
|
|
|
BREAST EXPANDER MED HGHT 450CC
|
Facility
|
OP
|
$7,818.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,016.44 |
| Max. Negotiated Rate |
$7,506.00 |
| Rate for Payer: Aetna Commercial |
$6,020.44
|
| Rate for Payer: Anthem Medicaid |
$2,688.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,098.62
|
| Rate for Payer: Cash Price |
$3,909.38
|
| Rate for Payer: Cigna Commercial |
$6,489.56
|
| Rate for Payer: First Health Commercial |
$7,427.81
|
| Rate for Payer: Humana Commercial |
$6,645.94
|
| Rate for Payer: Humana KY Medicaid |
$2,688.87
|
| Rate for Payer: Kentucky WC Medicaid |
$2,716.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,411.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,770.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,345.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,742.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,880.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,864.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,563.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,016.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,423.81
|
| Rate for Payer: PHCS Commercial |
$7,506.00
|
| Rate for Payer: United Healthcare All Payer |
$6,880.50
|
|
|
BREAST EXPANDER MED HGHT 550CC
|
Facility
|
OP
|
$8,001.25
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,040.16 |
| Max. Negotiated Rate |
$7,681.20 |
| Rate for Payer: Aetna Commercial |
$6,160.96
|
| Rate for Payer: Anthem Medicaid |
$2,751.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,240.98
|
| Rate for Payer: Cash Price |
$4,000.62
|
| Rate for Payer: Cigna Commercial |
$6,641.04
|
| Rate for Payer: First Health Commercial |
$7,601.19
|
| Rate for Payer: Humana Commercial |
$6,801.06
|
| Rate for Payer: Humana KY Medicaid |
$2,751.63
|
| Rate for Payer: Kentucky WC Medicaid |
$2,779.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,561.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,904.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,400.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,806.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,041.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,000.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,040.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,480.39
|
| Rate for Payer: PHCS Commercial |
$7,681.20
|
| Rate for Payer: United Healthcare All Payer |
$7,041.10
|
|
|
BREAST EXPANDER MED HGHT 550CC
|
Facility
|
IP
|
$8,001.25
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,040.16 |
| Max. Negotiated Rate |
$7,681.20 |
| Rate for Payer: Aetna Commercial |
$6,160.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,240.98
|
| Rate for Payer: Cash Price |
$4,000.62
|
| Rate for Payer: Cigna Commercial |
$6,641.04
|
| Rate for Payer: First Health Commercial |
$7,601.19
|
| Rate for Payer: Humana Commercial |
$6,801.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,561.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,904.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,400.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,041.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,000.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,040.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,480.39
|
| Rate for Payer: PHCS Commercial |
$7,681.20
|
| Rate for Payer: United Healthcare All Payer |
$7,041.10
|
|
|
BREAST EXPANDER MED HGHT 650CC
|
Facility
|
IP
|
$7,818.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,016.44 |
| Max. Negotiated Rate |
$7,506.00 |
| Rate for Payer: Aetna Commercial |
$6,020.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,098.62
|
| Rate for Payer: Cash Price |
$3,909.38
|
| Rate for Payer: Cigna Commercial |
$6,489.56
|
| Rate for Payer: First Health Commercial |
$7,427.81
|
| Rate for Payer: Humana Commercial |
$6,645.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,411.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,770.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,345.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,880.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,864.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,563.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,016.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,423.81
|
| Rate for Payer: PHCS Commercial |
$7,506.00
|
| Rate for Payer: United Healthcare All Payer |
$6,880.50
|
|
