|
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: Ambetter Exchange |
$143.09
|
| Rate for Payer: Anthem Medicaid |
$127.99
|
| Rate for Payer: Buckeye Individual/Medicaid |
$143.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$143.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$171.71
|
| 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 |
$127.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$59.05
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$143.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$143.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$130.55
|
| Rate for Payer: Molina Healthcare Passport |
$127.99
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$186.02
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$129.27
|
| Rate for Payer: Wellcare Medicare Advantage |
$143.09
|
|
|
BILAT DIAGNOSITIC W/CAD(T
|
Facility
|
OP
|
$601.00
|
|
|
Service Code
|
HCPCS 77066
|
| Hospital Charge Code |
401T0010
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$180.30 |
| 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 |
$480.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$414.69
|
| Rate for Payer: PHCS Commercial |
$576.96
|
| Rate for Payer: United Healthcare All Payer |
$528.88
|
|
|
BILAT DIAGNOSITIC W/CAD(T
|
Facility
|
IP
|
$601.00
|
|
|
Service Code
|
HCPCS 77066
|
| Hospital Charge Code |
401T0010
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$180.30 |
| 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 |
$480.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$414.69
|
| 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 |
$1,400.00 |
| 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 |
$1,404.00 |
| Max. Negotiated Rate |
$4,492.80 |
| Rate for Payer: Aetna Commercial |
$3,603.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,650.40
|
| 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: 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 |
$3,744.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,071.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,229.20
|
| 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 |
$1,609.45 |
| 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 |
$2,908.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,650.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,071.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,926.11
|
| 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 |
$2,908.23
|
| 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 |
$3,489.88
|
| 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 |
$3,744.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,071.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,229.20
|
| 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 |
$2,808.00 |
| Rate for Payer: Aetna Commercial |
$495.07
|
| Rate for Payer: Ambetter Exchange |
$150.09
|
| Rate for Payer: Anthem Medicaid |
$396.54
|
| Rate for Payer: Buckeye Individual/Medicaid |
$150.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$150.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$180.11
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$150.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$150.09
|
| 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 |
$195.12
|
| Rate for Payer: UHCCP Medicaid |
$1,638.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$400.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$150.09
|
|
|
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: Ambetter Exchange |
$150.09
|
| Rate for Payer: Anthem Medicaid |
$396.54
|
| Rate for Payer: Buckeye Individual/Medicaid |
$150.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$150.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$180.11
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$150.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$150.09
|
| 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 |
$195.12
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$400.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$150.09
|
|
|
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 |
$1,523.48 |
| 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 |
$2,908.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,455.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,071.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,926.11
|
| 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 |
$2,908.23
|
| 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 |
$3,489.88
|
| 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 |
$3,544.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,854.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,056.70
|
| 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 |
$1,329.00 |
| 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 |
$3,544.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,854.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,056.70
|
| Rate for Payer: PHCS Commercial |
$4,252.80
|
| Rate for Payer: United Healthcare All Payer |
$3,898.40
|
|
|
BILATERAL ILIAC ANGIOGRAM
|
Facility
|
IP
|
$3,045.00
|
|
|
Service Code
|
HCPCS G0278
|
| Hospital Charge Code |
48100092
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$913.50 |
| Max. Negotiated Rate |
$2,923.20 |
| Rate for Payer: Aetna Commercial |
$2,344.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,375.10
|
| Rate for Payer: Cash Price |
$1,522.50
|
| Rate for Payer: Cigna Commercial |
$2,527.35
|
| Rate for Payer: First Health Commercial |
$2,892.75
|
| Rate for Payer: Humana Commercial |
$2,588.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,496.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,247.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$913.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,679.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,283.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,436.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,649.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,101.05
|
| Rate for Payer: PHCS Commercial |
$2,923.20
|
| Rate for Payer: United Healthcare All Payer |
$2,679.60
|
|
|
BILATERAL ILIAC ANGIOGRAM
|
Facility
|
OP
|
$3,045.00
|
|
|
Service Code
|
HCPCS G0278
|
| Hospital Charge Code |
48100092
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$913.50 |
| Max. Negotiated Rate |
$2,923.20 |
| Rate for Payer: Aetna Commercial |
$2,344.65
|
| Rate for Payer: Anthem Medicaid |
$1,047.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,375.10
|
| Rate for Payer: Cash Price |
$1,522.50
|
| Rate for Payer: Cigna Commercial |
$2,527.35
|
| Rate for Payer: First Health Commercial |
$2,892.75
|
| Rate for Payer: Humana Commercial |
$2,588.25
|
| Rate for Payer: Humana KY Medicaid |
$1,047.18
|
| Rate for Payer: Kentucky WC Medicaid |
$1,057.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,496.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,247.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$913.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,068.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,679.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,283.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,436.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,649.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,101.05
|
| Rate for Payer: PHCS Commercial |
$2,923.20
|
| Rate for Payer: United Healthcare All Payer |
$2,679.60
|
|
|
BILATERAL ILIAC ANGIOGRAM
|
Facility
|
OP
|
$800.00
|
|
|
Service Code
|
HCPCS G0278
|
| Hospital Charge Code |
76102536
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$240.00 |
| Max. Negotiated Rate |
$768.00 |
| Rate for Payer: Aetna Commercial |
$616.00
|
| Rate for Payer: Anthem Medicaid |
$275.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$664.00
|
| Rate for Payer: First Health Commercial |
$760.00
|
| Rate for Payer: Humana Commercial |
$680.00
|
| Rate for Payer: Humana KY Medicaid |
$275.12
|
| Rate for Payer: Kentucky WC Medicaid |
$277.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$590.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$280.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.00
|
| Rate for Payer: Ohio Health Group HMO |
$600.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$696.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$552.00
|
| Rate for Payer: PHCS Commercial |
$768.00
|
| Rate for Payer: United Healthcare All Payer |
$704.00
|
|
|
BILATERAL ILIAC ANGIOGRAM
|
Facility
|
IP
|
$800.00
|
|
|
Service Code
|
HCPCS G0278
|
| Hospital Charge Code |
76102536
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$240.00 |
| Max. Negotiated Rate |
$768.00 |
| Rate for Payer: Aetna Commercial |
$616.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$664.00
|
| Rate for Payer: First Health Commercial |
$760.00
|
| Rate for Payer: Humana Commercial |
$680.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$590.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.00
|
| Rate for Payer: Ohio Health Group HMO |
$600.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$696.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$552.00
|
| Rate for Payer: PHCS Commercial |
$768.00
|
| Rate for Payer: United Healthcare All Payer |
$704.00
|
|
|
BILATERAL MALE BRST REDCTN-80
|
Facility
|
IP
|
$937.50
|
|
| Hospital Charge Code |
22200382
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$281.25 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Aetna Commercial |
$721.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$731.25
|
| Rate for Payer: Cash Price |
$468.75
|
| Rate for Payer: Cigna Commercial |
$778.12
|
| Rate for Payer: First Health Commercial |
$890.62
|
| Rate for Payer: Humana Commercial |
$796.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$768.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$691.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$281.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$825.00
|
| Rate for Payer: Ohio Health Group HMO |
$703.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$750.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$815.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$646.88
|
| Rate for Payer: PHCS Commercial |
$900.00
|
| Rate for Payer: United Healthcare All Payer |
$825.00
|
|
|
BILATERAL MALE BRST REDCTN-80
|
Professional
|
Both
|
$937.50
|
|
| Hospital Charge Code |
22200382
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$328.12 |
| Max. Negotiated Rate |
$656.25 |
| Rate for Payer: Cash Price |
$468.75
|
| Rate for Payer: Multiplan PHCS |
$562.50
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$656.25
|
| Rate for Payer: UHCCP Medicaid |
$328.12
|
|
|
BILATERAL MALE BRST REDCTN-80
|
Facility
|
OP
|
$937.50
|
|
| Hospital Charge Code |
22200382
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$281.25 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Aetna Commercial |
$721.88
|
| Rate for Payer: Anthem Medicaid |
$322.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$731.25
|
| Rate for Payer: Cash Price |
$468.75
|
| Rate for Payer: Cigna Commercial |
$778.12
|
| Rate for Payer: First Health Commercial |
$890.62
|
| Rate for Payer: Humana Commercial |
$796.88
|
| Rate for Payer: Humana KY Medicaid |
$322.41
|
| Rate for Payer: Kentucky WC Medicaid |
$325.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$768.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$691.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$281.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$328.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$825.00
|
| Rate for Payer: Ohio Health Group HMO |
$703.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$750.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$815.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$646.88
|
| Rate for Payer: PHCS Commercial |
$900.00
|
| Rate for Payer: United Healthcare All Payer |
$825.00
|
|
|
BILATERAL MALE BRST REDUCTION
|
Facility
|
IP
|
$1,875.00
|
|
| Hospital Charge Code |
22200071
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$562.50 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,443.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,462.50
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cigna Commercial |
$1,556.25
|
| Rate for Payer: First Health Commercial |
$1,781.25
|
| Rate for Payer: Humana Commercial |
$1,593.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,537.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,383.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$562.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,650.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,406.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,631.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,293.75
|
| Rate for Payer: PHCS Commercial |
$1,800.00
|
| Rate for Payer: United Healthcare All Payer |
$1,650.00
|
|
|
BILATERAL MALE BRST REDUCTION
|
Professional
|
Both
|
$1,875.00
|
|
| Hospital Charge Code |
22200071
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$656.25 |
| Max. Negotiated Rate |
$1,312.50 |
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Multiplan PHCS |
$1,125.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,312.50
|
| Rate for Payer: UHCCP Medicaid |
$656.25
|
|
|
BILATERAL MALE BRST REDUCTION
|
Facility
|
OP
|
$1,875.00
|
|
| Hospital Charge Code |
22200071
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$562.50 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,443.75
|
| Rate for Payer: Anthem Medicaid |
$644.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,462.50
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cigna Commercial |
$1,556.25
|
| Rate for Payer: First Health Commercial |
$1,781.25
|
| Rate for Payer: Humana Commercial |
$1,593.75
|
| Rate for Payer: Humana KY Medicaid |
$644.81
|
| Rate for Payer: Kentucky WC Medicaid |
$651.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,537.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,383.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$562.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$657.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,650.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,406.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,631.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,293.75
|
| Rate for Payer: PHCS Commercial |
$1,800.00
|
| Rate for Payer: United Healthcare All Payer |
$1,650.00
|
|
|
BILATERAL SCREENING WITH CAD
|
Facility
|
IP
|
$671.00
|
|
|
Service Code
|
HCPCS 77067
|
| Hospital Charge Code |
40100013
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$201.30 |
| Max. Negotiated Rate |
$644.16 |
| Rate for Payer: Aetna Commercial |
$516.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$523.38
|
| Rate for Payer: Cash Price |
$335.50
|
| Rate for Payer: Cigna Commercial |
$556.93
|
| Rate for Payer: First Health Commercial |
$637.45
|
| Rate for Payer: Humana Commercial |
$570.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$550.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$495.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$201.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$590.48
|
| Rate for Payer: Ohio Health Group HMO |
$503.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$536.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$583.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$462.99
|
| Rate for Payer: PHCS Commercial |
$644.16
|
| Rate for Payer: United Healthcare All Payer |
$590.48
|
|
|
BILATERAL SCREENING WITH CAD
|
Facility
|
OP
|
$671.00
|
|
|
Service Code
|
HCPCS 77067
|
| Hospital Charge Code |
40100013
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$201.30 |
| Max. Negotiated Rate |
$644.16 |
| Rate for Payer: Aetna Commercial |
$516.67
|
| Rate for Payer: Anthem Medicaid |
$230.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$523.38
|
| Rate for Payer: Cash Price |
$335.50
|
| Rate for Payer: Cigna Commercial |
$556.93
|
| Rate for Payer: First Health Commercial |
$637.45
|
| Rate for Payer: Humana Commercial |
$570.35
|
| Rate for Payer: Humana KY Medicaid |
$230.76
|
| Rate for Payer: Kentucky WC Medicaid |
$233.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$550.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$495.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$201.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$235.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$590.48
|
| Rate for Payer: Ohio Health Group HMO |
$503.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$536.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$583.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$462.99
|
| Rate for Payer: PHCS Commercial |
$644.16
|
| Rate for Payer: United Healthcare All Payer |
$590.48
|
|
|
BILATERAL SCREENING WITH CAD
|
Professional
|
Both
|
$671.00
|
|
|
Service Code
|
HCPCS 77067
|
| Hospital Charge Code |
40100013
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$67.70 |
| Max. Negotiated Rate |
$402.60 |
| Rate for Payer: Ambetter Exchange |
$115.84
|
| Rate for Payer: Anthem Medicaid |
$103.33
|
| Rate for Payer: Buckeye Individual/Medicaid |
$115.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$115.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$139.01
|
| Rate for Payer: Cash Price |
$335.50
|
| Rate for Payer: Cash Price |
$335.50
|
| Rate for Payer: Cigna Commercial |
$214.76
|
| Rate for Payer: Humana Medicaid |
$103.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$67.70
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$115.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$115.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$105.40
|
| Rate for Payer: Molina Healthcare Passport |
$103.33
|
| Rate for Payer: Multiplan PHCS |
$402.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$150.59
|
| Rate for Payer: UHCCP Medicaid |
$234.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$104.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$115.84
|
|
|
BILATERAL SCREENING WITH CAD(P
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 77067
|
| Hospital Charge Code |
401P0013
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$67.70 |
| Max. Negotiated Rate |
$214.76 |
| Rate for Payer: Ambetter Exchange |
$115.84
|
| Rate for Payer: Anthem Medicaid |
$103.33
|
| Rate for Payer: Buckeye Individual/Medicaid |
$115.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$115.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$139.01
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$214.76
|
| Rate for Payer: Humana Medicaid |
$103.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$67.70
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$115.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$115.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$105.40
|
| Rate for Payer: Molina Healthcare Passport |
$103.33
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$150.59
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$104.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$115.84
|
|
|
BILATERAL SCREENING WITH CAD(T
|
Facility
|
OP
|
$446.00
|
|
|
Service Code
|
HCPCS 77067
|
| Hospital Charge Code |
401T0013
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$133.80 |
| Max. Negotiated Rate |
$428.16 |
| Rate for Payer: Aetna Commercial |
$343.42
|
| Rate for Payer: Anthem Medicaid |
$153.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$347.88
|
| Rate for Payer: Cash Price |
$223.00
|
| Rate for Payer: Cigna Commercial |
$370.18
|
| Rate for Payer: First Health Commercial |
$423.70
|
| Rate for Payer: Humana Commercial |
$379.10
|
| Rate for Payer: Humana KY Medicaid |
$153.38
|
| Rate for Payer: Kentucky WC Medicaid |
$154.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$365.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$329.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$133.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$156.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$392.48
|
| Rate for Payer: Ohio Health Group HMO |
$334.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$388.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$307.74
|
| Rate for Payer: PHCS Commercial |
$428.16
|
| Rate for Payer: United Healthcare All Payer |
$392.48
|
|
