|
BILATERAL SCREENING WITH CAD(T
|
Facility
|
IP
|
$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 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: 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: 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
|
|
|
BILAT FOLLOWUP PROC W/CAD
|
Professional
|
Both
|
$890.00
|
|
|
Service Code
|
HCPCS 77066
|
| Hospital Charge Code |
40100009
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$59.05 |
| Max. Negotiated Rate |
$534.00 |
| 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 |
$445.00
|
| Rate for Payer: Cash Price |
$445.00
|
| 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 |
$534.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$186.02
|
| Rate for Payer: UHCCP Medicaid |
$311.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$129.27
|
| Rate for Payer: Wellcare Medicare Advantage |
$143.09
|
|
|
BILAT FOLLOWUP PROC W/CAD
|
Facility
|
OP
|
$890.00
|
|
|
Service Code
|
HCPCS 77066
|
| Hospital Charge Code |
40100009
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$267.00 |
| Max. Negotiated Rate |
$854.40 |
| Rate for Payer: Aetna Commercial |
$685.30
|
| Rate for Payer: Anthem Medicaid |
$306.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$694.20
|
| Rate for Payer: Cash Price |
$445.00
|
| Rate for Payer: Cigna Commercial |
$738.70
|
| Rate for Payer: First Health Commercial |
$845.50
|
| Rate for Payer: Humana Commercial |
$756.50
|
| Rate for Payer: Humana KY Medicaid |
$306.07
|
| Rate for Payer: Kentucky WC Medicaid |
$309.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$729.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$656.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$267.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$312.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$783.20
|
| Rate for Payer: Ohio Health Group HMO |
$667.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$712.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$774.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$614.10
|
| Rate for Payer: PHCS Commercial |
$854.40
|
| Rate for Payer: United Healthcare All Payer |
$783.20
|
|
|
BILAT FOLLOWUP PROC W/CAD
|
Facility
|
IP
|
$890.00
|
|
|
Service Code
|
HCPCS 77066
|
| Hospital Charge Code |
40100009
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$267.00 |
| Max. Negotiated Rate |
$854.40 |
| Rate for Payer: Aetna Commercial |
$685.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$694.20
|
| Rate for Payer: Cash Price |
$445.00
|
| Rate for Payer: Cigna Commercial |
$738.70
|
| Rate for Payer: First Health Commercial |
$845.50
|
| Rate for Payer: Humana Commercial |
$756.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$729.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$656.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$267.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$783.20
|
| Rate for Payer: Ohio Health Group HMO |
$667.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$712.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$774.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$614.10
|
| Rate for Payer: PHCS Commercial |
$854.40
|
| Rate for Payer: United Healthcare All Payer |
$783.20
|
|
|
BILAT FOLLOWUP PROC W/CAD(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 77066
|
| Hospital Charge Code |
401P0009
|
|
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 FOLLOWUP PROC W/CAD(T
|
Facility
|
IP
|
$640.00
|
|
|
Service Code
|
HCPCS 77066
|
| Hospital Charge Code |
401T0009
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$192.00 |
| Max. Negotiated Rate |
$614.40 |
| Rate for Payer: Aetna Commercial |
$492.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$499.20
|
| Rate for Payer: Cash Price |
$320.00
|
| Rate for Payer: Cigna Commercial |
$531.20
|
| Rate for Payer: First Health Commercial |
$608.00
|
| Rate for Payer: Humana Commercial |
$544.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$524.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$472.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$192.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$563.20
|
| Rate for Payer: Ohio Health Group HMO |
$480.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$512.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$556.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$441.60
|
| Rate for Payer: PHCS Commercial |
$614.40
|
| Rate for Payer: United Healthcare All Payer |
$563.20
|
|
|
BILAT FOLLOWUP PROC W/CAD(T
|
Facility
|
OP
|
$640.00
|
|
|
Service Code
|
HCPCS 77066
|
| Hospital Charge Code |
401T0009
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$192.00 |
| Max. Negotiated Rate |
$614.40 |
| Rate for Payer: Aetna Commercial |
$492.80
|
| Rate for Payer: Anthem Medicaid |
$220.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$499.20
|
| Rate for Payer: Cash Price |
$320.00
|
| Rate for Payer: Cigna Commercial |
$531.20
|
| Rate for Payer: First Health Commercial |
$608.00
|
| Rate for Payer: Humana Commercial |
$544.00
|
| Rate for Payer: Humana KY Medicaid |
$220.10
|
| Rate for Payer: Kentucky WC Medicaid |
$222.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$524.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$472.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$192.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$224.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$563.20
|
| Rate for Payer: Ohio Health Group HMO |
$480.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$512.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$556.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$441.60
|
| Rate for Payer: PHCS Commercial |
$614.40
|
| Rate for Payer: United Healthcare All Payer |
$563.20
|
|
|
BILAT MAT VIEW W/CAD
|
Facility
|
OP
|
$851.00
|
|
|
Service Code
|
HCPCS 77066
|
| Hospital Charge Code |
40100011
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$255.30 |
| 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 |
$680.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$740.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$587.19
|
| Rate for Payer: PHCS Commercial |
$816.96
|
| Rate for Payer: United Healthcare All Payer |
$748.88
|
|
|
BILAT MAT VIEW W/CAD
|
Facility
|
IP
|
$851.00
|
|
|
Service Code
|
HCPCS 77066
|
| Hospital Charge Code |
40100011
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$255.30 |
| 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 |
$680.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$740.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$587.19
|
| Rate for Payer: PHCS Commercial |
$816.96
|
| Rate for Payer: United Healthcare All Payer |
$748.88
|
|
|
BILAT MAT VIEW W/CAD
|
Professional
|
Both
|
$851.00
|
|
|
Service Code
|
HCPCS 77066
|
| Hospital Charge Code |
40100011
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$59.05 |
| Max. Negotiated Rate |
$510.60 |
| 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 |
$425.50
|
| Rate for Payer: Cash Price |
$425.50
|
| 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 |
$510.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$186.02
|
| Rate for Payer: UHCCP Medicaid |
$297.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$129.27
|
| Rate for Payer: Wellcare Medicare Advantage |
$143.09
|
|
|
BILAT MAT VIEW W/CAD(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 77066
|
| Hospital Charge Code |
401P0011
|
|
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 MAT VIEW W/CAD(T
|
Facility
|
OP
|
$601.00
|
|
|
Service Code
|
HCPCS 77066
|
| Hospital Charge Code |
401T0011
|
|
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 MAT VIEW W/CAD(T
|
Facility
|
IP
|
$601.00
|
|
|
Service Code
|
HCPCS 77066
|
| Hospital Charge Code |
401T0011
|
|
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
|
|
|
BIL BEAST AUGMENTATION -80
|
Professional
|
Both
|
$375.00
|
|
| Hospital Charge Code |
22200370
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$131.25 |
| Max. Negotiated Rate |
$262.50 |
| 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
|
|
|
BIL BEAST AUGMENTATION -80
|
Facility
|
OP
|
$375.00
|
|
| Hospital Charge Code |
22200370
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$112.50 |
| Max. Negotiated Rate |
$360.00 |
| Rate for Payer: Aetna Commercial |
$288.75
|
| Rate for Payer: Anthem Medicaid |
$128.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$292.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cigna Commercial |
$311.25
|
| Rate for Payer: First Health Commercial |
$356.25
|
| Rate for Payer: Humana Commercial |
$318.75
|
| Rate for Payer: Humana KY Medicaid |
$128.96
|
| Rate for Payer: Kentucky WC Medicaid |
$130.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$307.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$276.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$112.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$131.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$330.00
|
| Rate for Payer: Ohio Health Group HMO |
$281.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$326.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$258.75
|
| Rate for Payer: PHCS Commercial |
$360.00
|
| Rate for Payer: United Healthcare All Payer |
$330.00
|
|
|
BIL BEAST AUGMENTATION -80
|
Facility
|
IP
|
$375.00
|
|
| Hospital Charge Code |
22200370
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$112.50 |
| Max. Negotiated Rate |
$360.00 |
| Rate for Payer: Aetna Commercial |
$288.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$292.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cigna Commercial |
$311.25
|
| Rate for Payer: First Health Commercial |
$356.25
|
| Rate for Payer: Humana Commercial |
$318.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$307.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$276.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$112.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$330.00
|
| Rate for Payer: Ohio Health Group HMO |
$281.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$326.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$258.75
|
| Rate for Payer: PHCS Commercial |
$360.00
|
| Rate for Payer: United Healthcare All Payer |
$330.00
|
|
|
BIL BREAST AUGMENTATION
|
Professional
|
Both
|
$750.00
|
|
| Hospital Charge Code |
22200034
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$262.50 |
| Max. Negotiated Rate |
$525.00 |
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Multiplan PHCS |
$450.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$525.00
|
| Rate for Payer: UHCCP Medicaid |
$262.50
|
|
|
BIL BREAST AUGMENTATION
|
Facility
|
OP
|
$750.00
|
|
| Hospital Charge Code |
22200034
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Aetna Commercial |
$577.50
|
| Rate for Payer: Anthem Medicaid |
$257.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$585.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$622.50
|
| Rate for Payer: First Health Commercial |
$712.50
|
| Rate for Payer: Humana Commercial |
$637.50
|
| Rate for Payer: Humana KY Medicaid |
$257.93
|
| Rate for Payer: Kentucky WC Medicaid |
$260.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$615.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$553.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$225.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$263.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$660.00
|
| Rate for Payer: Ohio Health Group HMO |
$562.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$652.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$517.50
|
| Rate for Payer: PHCS Commercial |
$720.00
|
| Rate for Payer: United Healthcare All Payer |
$660.00
|
|
|
BIL BREAST AUGMENTATION
|
Facility
|
IP
|
$750.00
|
|
| Hospital Charge Code |
22200034
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Aetna Commercial |
$577.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$585.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$622.50
|
| Rate for Payer: First Health Commercial |
$712.50
|
| Rate for Payer: Humana Commercial |
$637.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$615.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$553.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$225.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$660.00
|
| Rate for Payer: Ohio Health Group HMO |
$562.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$652.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$517.50
|
| Rate for Payer: PHCS Commercial |
$720.00
|
| Rate for Payer: United Healthcare All Payer |
$660.00
|
|
|
BILIARY BALLOON DILATOR 10MM*4
|
Facility
|
IP
|
$3,185.75
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$955.73 |
| Max. Negotiated Rate |
$3,058.32 |
| Rate for Payer: Aetna Commercial |
$2,453.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,484.89
|
| Rate for Payer: Cash Price |
$1,592.88
|
| Rate for Payer: Cigna Commercial |
$2,644.17
|
| Rate for Payer: First Health Commercial |
$3,026.46
|
| Rate for Payer: Humana Commercial |
$2,707.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,612.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,351.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$955.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,803.46
|
| Rate for Payer: Ohio Health Group HMO |
$2,389.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,548.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,771.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,198.17
|
| Rate for Payer: PHCS Commercial |
$3,058.32
|
| Rate for Payer: United Healthcare All Payer |
$2,803.46
|
|
|
BILIARY BALLOON DILATOR 10MM*4
|
Facility
|
OP
|
$3,185.75
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$955.73 |
| Max. Negotiated Rate |
$3,058.32 |
| Rate for Payer: Aetna Commercial |
$2,453.03
|
| Rate for Payer: Anthem Medicaid |
$1,095.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,484.89
|
| Rate for Payer: Cash Price |
$1,592.88
|
| Rate for Payer: Cigna Commercial |
$2,644.17
|
| Rate for Payer: First Health Commercial |
$3,026.46
|
| Rate for Payer: Humana Commercial |
$2,707.89
|
| Rate for Payer: Humana KY Medicaid |
$1,095.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1,106.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,612.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,351.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$955.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,117.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,803.46
|
| Rate for Payer: Ohio Health Group HMO |
$2,389.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,548.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,771.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,198.17
|
| Rate for Payer: PHCS Commercial |
$3,058.32
|
| Rate for Payer: United Healthcare All Payer |
$2,803.46
|
|
|
BILIARY BALLOON DILATOR 4MM*4C
|
Facility
|
IP
|
$2,960.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$888.00 |
| Max. Negotiated Rate |
$2,841.60 |
| Rate for Payer: Aetna Commercial |
$2,279.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,308.80
|
| Rate for Payer: Cash Price |
$1,480.00
|
| Rate for Payer: Cigna Commercial |
$2,456.80
|
| Rate for Payer: First Health Commercial |
$2,812.00
|
| Rate for Payer: Humana Commercial |
$2,516.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,427.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,184.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$888.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,604.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,220.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,368.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,575.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,042.40
|
| Rate for Payer: PHCS Commercial |
$2,841.60
|
| Rate for Payer: United Healthcare All Payer |
$2,604.80
|
|
|
BILIARY BALLOON DILATOR 4MM*4C
|
Facility
|
OP
|
$2,960.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$888.00 |
| Max. Negotiated Rate |
$2,841.60 |
| Rate for Payer: Aetna Commercial |
$2,279.20
|
| Rate for Payer: Anthem Medicaid |
$1,017.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,308.80
|
| Rate for Payer: Cash Price |
$1,480.00
|
| Rate for Payer: Cigna Commercial |
$2,456.80
|
| Rate for Payer: First Health Commercial |
$2,812.00
|
| Rate for Payer: Humana Commercial |
$2,516.00
|
| Rate for Payer: Humana KY Medicaid |
$1,017.94
|
| Rate for Payer: Kentucky WC Medicaid |
$1,028.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,427.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,184.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$888.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,038.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,604.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,220.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,368.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,575.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,042.40
|
| Rate for Payer: PHCS Commercial |
$2,841.60
|
| Rate for Payer: United Healthcare All Payer |
$2,604.80
|
|
|
BILIARY BALLOON DILATOR 6MM*4C
|
Facility
|
OP
|
$3,185.75
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$955.73 |
| Max. Negotiated Rate |
$3,058.32 |
| Rate for Payer: Aetna Commercial |
$2,453.03
|
| Rate for Payer: Anthem Medicaid |
$1,095.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,484.89
|
| Rate for Payer: Cash Price |
$1,592.88
|
| Rate for Payer: Cigna Commercial |
$2,644.17
|
| Rate for Payer: First Health Commercial |
$3,026.46
|
| Rate for Payer: Humana Commercial |
$2,707.89
|
| Rate for Payer: Humana KY Medicaid |
$1,095.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1,106.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,612.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,351.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$955.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,117.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,803.46
|
| Rate for Payer: Ohio Health Group HMO |
$2,389.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,548.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,771.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,198.17
|
| Rate for Payer: PHCS Commercial |
$3,058.32
|
| Rate for Payer: United Healthcare All Payer |
$2,803.46
|
|
|
BILIARY BALLOON DILATOR 6MM*4C
|
Facility
|
IP
|
$3,185.75
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$955.73 |
| Max. Negotiated Rate |
$3,058.32 |
| Rate for Payer: Aetna Commercial |
$2,453.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,484.89
|
| Rate for Payer: Cash Price |
$1,592.88
|
| Rate for Payer: Cigna Commercial |
$2,644.17
|
| Rate for Payer: First Health Commercial |
$3,026.46
|
| Rate for Payer: Humana Commercial |
$2,707.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,612.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,351.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$955.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,803.46
|
| Rate for Payer: Ohio Health Group HMO |
$2,389.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,548.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,771.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,198.17
|
| Rate for Payer: PHCS Commercial |
$3,058.32
|
| Rate for Payer: United Healthcare All Payer |
$2,803.46
|
|
