|
BREAST RECONSTRUCTION W FLAP
|
Facility
|
OP
|
$5,500.00
|
|
|
Service Code
|
HCPCS 19367
|
| Hospital Charge Code |
76100319
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$715.00 |
| Max. Negotiated Rate |
$5,280.00 |
| Rate for Payer: Aetna Commercial |
$4,235.00
|
| Rate for Payer: Anthem Medicaid |
$1,891.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,290.00
|
| Rate for Payer: Cash Price |
$2,750.00
|
| Rate for Payer: Cigna Commercial |
$4,565.00
|
| Rate for Payer: First Health Commercial |
$5,225.00
|
| Rate for Payer: Humana Commercial |
$4,675.00
|
| Rate for Payer: Humana KY Medicaid |
$1,891.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1,910.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,510.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,059.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,650.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,929.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,840.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$715.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,705.00
|
| Rate for Payer: PHCS Commercial |
$5,280.00
|
| Rate for Payer: United Healthcare All Payer |
$4,840.00
|
|
|
BREAST RECONSTRUCTION W FLAP
|
Facility
|
IP
|
$5,500.00
|
|
|
Service Code
|
HCPCS 19367
|
| Hospital Charge Code |
76100319
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$715.00 |
| Max. Negotiated Rate |
$5,280.00 |
| Rate for Payer: Aetna Commercial |
$4,235.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,290.00
|
| Rate for Payer: Cash Price |
$2,750.00
|
| Rate for Payer: Cigna Commercial |
$4,565.00
|
| Rate for Payer: First Health Commercial |
$5,225.00
|
| Rate for Payer: Humana Commercial |
$4,675.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,510.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,059.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,650.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,840.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$715.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,705.00
|
| Rate for Payer: PHCS Commercial |
$5,280.00
|
| Rate for Payer: United Healthcare All Payer |
$4,840.00
|
|
|
BREAST RECONSTRUCTION W FLAP
|
Professional
|
Both
|
$5,500.00
|
|
|
Service Code
|
HCPCS 19367
|
| Hospital Charge Code |
76100319
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,359.87 |
| Max. Negotiated Rate |
$5,500.00 |
| Rate for Payer: Aetna Commercial |
$2,676.78
|
| Rate for Payer: Anthem Medicaid |
$1,359.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,500.00
|
| Rate for Payer: Cash Price |
$2,750.00
|
| Rate for Payer: Cash Price |
$2,750.00
|
| Rate for Payer: Cigna Commercial |
$2,548.85
|
| Rate for Payer: Healthspan PPO |
$2,140.33
|
| Rate for Payer: Humana Medicaid |
$1,359.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,334.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,387.07
|
| Rate for Payer: Molina Healthcare Passport |
$1,359.87
|
| Rate for Payer: Multiplan PHCS |
$3,300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,850.00
|
| Rate for Payer: UHCCP Medicaid |
$1,925.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,373.47
|
|
|
BREAST RECONSTRUCTION W FLAP(P
|
Professional
|
Both
|
$5,500.00
|
|
|
Service Code
|
HCPCS 19367
|
| Hospital Charge Code |
761P0319
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,359.87 |
| Max. Negotiated Rate |
$5,500.00 |
| Rate for Payer: Aetna Commercial |
$2,676.78
|
| Rate for Payer: Anthem Medicaid |
$1,359.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,500.00
|
| Rate for Payer: Cash Price |
$2,750.00
|
| Rate for Payer: Cash Price |
$2,750.00
|
| Rate for Payer: Cigna Commercial |
$2,548.85
|
| Rate for Payer: Healthspan PPO |
$2,140.33
|
| Rate for Payer: Humana Medicaid |
$1,359.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,334.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,387.07
|
| Rate for Payer: Molina Healthcare Passport |
$1,359.87
|
| Rate for Payer: Multiplan PHCS |
$3,300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,850.00
|
| Rate for Payer: UHCCP Medicaid |
$1,925.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,373.47
|
|
|
BREAST RECONSTR W/FREE FLAP
|
Professional
|
Both
|
$5,750.00
|
|
|
Service Code
|
HCPCS 19364
|
| Hospital Charge Code |
76100317
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,344.26 |
| Max. Negotiated Rate |
$5,750.00 |
| Rate for Payer: Aetna Commercial |
$4,142.12
|
| Rate for Payer: Anthem Medicaid |
$1,344.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,750.00
|
| Rate for Payer: Cash Price |
$2,875.00
|
| Rate for Payer: Cash Price |
$2,875.00
|
| Rate for Payer: Cigna Commercial |
$3,903.46
|
| Rate for Payer: Healthspan PPO |
$3,312.00
|
| Rate for Payer: Humana Medicaid |
$1,344.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$3,601.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,371.15
|
| Rate for Payer: Molina Healthcare Passport |
$1,344.26
|
| Rate for Payer: Multiplan PHCS |
$3,450.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,025.00
|
| Rate for Payer: UHCCP Medicaid |
$2,012.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,357.70
|
|
|
BREAST RECONSTR W/FREE FLAP
|
Facility
|
IP
|
$5,750.00
|
|
|
Service Code
|
HCPCS 19364
|
| Hospital Charge Code |
76100317
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$747.50 |
| Max. Negotiated Rate |
$5,520.00 |
| Rate for Payer: Aetna Commercial |
$4,427.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,485.00
|
| Rate for Payer: Cash Price |
$2,875.00
|
| Rate for Payer: Cigna Commercial |
$4,772.50
|
| Rate for Payer: First Health Commercial |
$5,462.50
|
| Rate for Payer: Humana Commercial |
$4,887.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,715.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,243.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,725.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,060.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,150.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$747.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,782.50
|
| Rate for Payer: PHCS Commercial |
$5,520.00
|
| Rate for Payer: United Healthcare All Payer |
$5,060.00
|
|
|
BREAST RECONSTR W/FREE FLAP
|
Facility
|
OP
|
$5,750.00
|
|
|
Service Code
|
HCPCS 19364
|
| Hospital Charge Code |
76100317
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$747.50 |
| Max. Negotiated Rate |
$5,520.00 |
| Rate for Payer: Aetna Commercial |
$4,427.50
|
| Rate for Payer: Anthem Medicaid |
$1,977.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,485.00
|
| Rate for Payer: Cash Price |
$2,875.00
|
| Rate for Payer: Cigna Commercial |
$4,772.50
|
| Rate for Payer: First Health Commercial |
$5,462.50
|
| Rate for Payer: Humana Commercial |
$4,887.50
|
| Rate for Payer: Humana KY Medicaid |
$1,977.42
|
| Rate for Payer: Kentucky WC Medicaid |
$1,997.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,715.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,243.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,725.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,017.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,060.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,150.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$747.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,782.50
|
| Rate for Payer: PHCS Commercial |
$5,520.00
|
| Rate for Payer: United Healthcare All Payer |
$5,060.00
|
|
|
BREAST RECONSTR W/FREE FLAP(P
|
Professional
|
Both
|
$5,750.00
|
|
|
Service Code
|
HCPCS 19364
|
| Hospital Charge Code |
761P0317
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,344.26 |
| Max. Negotiated Rate |
$5,750.00 |
| Rate for Payer: Aetna Commercial |
$4,142.12
|
| Rate for Payer: Anthem Medicaid |
$1,344.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,750.00
|
| Rate for Payer: Cash Price |
$2,875.00
|
| Rate for Payer: Cash Price |
$2,875.00
|
| Rate for Payer: Cigna Commercial |
$3,903.46
|
| Rate for Payer: Healthspan PPO |
$3,312.00
|
| Rate for Payer: Humana Medicaid |
$1,344.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$3,601.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,371.15
|
| Rate for Payer: Molina Healthcare Passport |
$1,344.26
|
| Rate for Payer: Multiplan PHCS |
$3,450.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,025.00
|
| Rate for Payer: UHCCP Medicaid |
$2,012.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,357.70
|
|
|
BREAST RECONSTR W/LAT FLAP
|
Facility
|
IP
|
$11,388.75
|
|
|
Service Code
|
HCPCS 19361
|
| Hospital Charge Code |
76100316
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,480.54 |
| Max. Negotiated Rate |
$10,933.20 |
| Rate for Payer: Aetna Commercial |
$8,769.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,883.22
|
| Rate for Payer: Cash Price |
$5,694.38
|
| Rate for Payer: Cigna Commercial |
$9,452.66
|
| Rate for Payer: First Health Commercial |
$10,819.31
|
| Rate for Payer: Humana Commercial |
$9,680.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,338.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,404.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,416.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,022.10
|
| Rate for Payer: Ohio Health Group HMO |
$8,541.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,277.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,480.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,530.51
|
| Rate for Payer: PHCS Commercial |
$10,933.20
|
| Rate for Payer: United Healthcare All Payer |
$10,022.10
|
|
|
BREAST RECONSTR W/LAT FLAP
|
Professional
|
Both
|
$11,388.75
|
|
|
Service Code
|
HCPCS 19361
|
| Hospital Charge Code |
76100316
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,157.11 |
| Max. Negotiated Rate |
$11,388.75 |
| Rate for Payer: Aetna Commercial |
$2,395.00
|
| Rate for Payer: Anthem Medicaid |
$1,157.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$11,388.75
|
| Rate for Payer: Cash Price |
$5,694.38
|
| Rate for Payer: Cash Price |
$5,694.38
|
| Rate for Payer: Cigna Commercial |
$2,149.15
|
| Rate for Payer: Healthspan PPO |
$1,915.02
|
| Rate for Payer: Humana Medicaid |
$1,157.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,171.76
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,180.25
|
| Rate for Payer: Molina Healthcare Passport |
$1,157.11
|
| Rate for Payer: Multiplan PHCS |
$6,833.25
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$7,972.12
|
| Rate for Payer: UHCCP Medicaid |
$3,986.06
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,168.68
|
|
|
BREAST RECONSTR W/LAT FLAP
|
Facility
|
OP
|
$11,388.75
|
|
|
Service Code
|
HCPCS 19361
|
| Hospital Charge Code |
76100316
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,480.54 |
| Max. Negotiated Rate |
$10,933.20 |
| Rate for Payer: Aetna Commercial |
$8,769.34
|
| Rate for Payer: Anthem Medicaid |
$3,916.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,883.22
|
| Rate for Payer: Cash Price |
$5,694.38
|
| Rate for Payer: Cigna Commercial |
$9,452.66
|
| Rate for Payer: First Health Commercial |
$10,819.31
|
| Rate for Payer: Humana Commercial |
$9,680.44
|
| Rate for Payer: Humana KY Medicaid |
$3,916.59
|
| Rate for Payer: Kentucky WC Medicaid |
$3,956.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,338.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,404.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,416.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,995.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,022.10
|
| Rate for Payer: Ohio Health Group HMO |
$8,541.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,277.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,480.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,530.51
|
| Rate for Payer: PHCS Commercial |
$10,933.20
|
| Rate for Payer: United Healthcare All Payer |
$10,022.10
|
|
|
BREAST RECONSTR W/LAT FLAP(P
|
Professional
|
Both
|
$4,500.00
|
|
|
Service Code
|
HCPCS 19361
|
| Hospital Charge Code |
761P0316
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,157.11 |
| Max. Negotiated Rate |
$4,500.00 |
| Rate for Payer: Aetna Commercial |
$2,395.00
|
| Rate for Payer: Anthem Medicaid |
$1,157.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,500.00
|
| Rate for Payer: Cash Price |
$2,250.00
|
| Rate for Payer: Cash Price |
$2,250.00
|
| Rate for Payer: Cigna Commercial |
$2,149.15
|
| Rate for Payer: Healthspan PPO |
$1,915.02
|
| Rate for Payer: Humana Medicaid |
$1,157.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,171.76
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,180.25
|
| Rate for Payer: Molina Healthcare Passport |
$1,157.11
|
| Rate for Payer: Multiplan PHCS |
$2,700.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,150.00
|
| Rate for Payer: UHCCP Medicaid |
$1,575.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,168.68
|
|
|
BREAST RECONSTR W/LAT FLAP(T
|
Facility
|
OP
|
$6,888.75
|
|
|
Service Code
|
HCPCS 19361
|
| Hospital Charge Code |
761T0316
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$895.54 |
| Max. Negotiated Rate |
$6,613.20 |
| Rate for Payer: Aetna Commercial |
$5,304.34
|
| Rate for Payer: Anthem Medicaid |
$2,369.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,373.22
|
| Rate for Payer: Cash Price |
$3,444.38
|
| Rate for Payer: Cigna Commercial |
$5,717.66
|
| Rate for Payer: First Health Commercial |
$6,544.31
|
| Rate for Payer: Humana Commercial |
$5,855.44
|
| Rate for Payer: Humana KY Medicaid |
$2,369.04
|
| Rate for Payer: Kentucky WC Medicaid |
$2,393.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,648.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,083.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,066.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,416.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,062.10
|
| Rate for Payer: Ohio Health Group HMO |
$5,166.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,377.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$895.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,135.51
|
| Rate for Payer: PHCS Commercial |
$6,613.20
|
| Rate for Payer: United Healthcare All Payer |
$6,062.10
|
|
|
BREAST RECONSTR W/LAT FLAP(T
|
Facility
|
IP
|
$6,888.75
|
|
|
Service Code
|
HCPCS 19361
|
| Hospital Charge Code |
761T0316
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$895.54 |
| Max. Negotiated Rate |
$6,613.20 |
| Rate for Payer: Aetna Commercial |
$5,304.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,373.22
|
| Rate for Payer: Cash Price |
$3,444.38
|
| Rate for Payer: Cigna Commercial |
$5,717.66
|
| Rate for Payer: First Health Commercial |
$6,544.31
|
| Rate for Payer: Humana Commercial |
$5,855.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,648.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,083.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,066.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,062.10
|
| Rate for Payer: Ohio Health Group HMO |
$5,166.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,377.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$895.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,135.51
|
| Rate for Payer: PHCS Commercial |
$6,613.20
|
| Rate for Payer: United Healthcare All Payer |
$6,062.10
|
|
|
BREAST RECONS.WITH TRAM FLAP
|
Facility
|
IP
|
$6,500.00
|
|
|
Service Code
|
HCPCS 19369
|
| Hospital Charge Code |
76100320
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$845.00 |
| Max. Negotiated Rate |
$6,240.00 |
| Rate for Payer: Aetna Commercial |
$5,005.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,070.00
|
| Rate for Payer: Cash Price |
$3,250.00
|
| Rate for Payer: Cigna Commercial |
$5,395.00
|
| Rate for Payer: First Health Commercial |
$6,175.00
|
| Rate for Payer: Humana Commercial |
$5,525.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,330.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,797.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,950.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,720.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,875.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$845.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,015.00
|
| Rate for Payer: PHCS Commercial |
$6,240.00
|
| Rate for Payer: United Healthcare All Payer |
$5,720.00
|
|
|
BREAST RECONS.WITH TRAM FLAP
|
Professional
|
Both
|
$6,500.00
|
|
|
Service Code
|
HCPCS 19369
|
| Hospital Charge Code |
76100320
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,475.78 |
| Max. Negotiated Rate |
$6,500.00 |
| Rate for Payer: Aetna Commercial |
$3,025.39
|
| Rate for Payer: Anthem Medicaid |
$1,475.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,500.00
|
| Rate for Payer: Cash Price |
$3,250.00
|
| Rate for Payer: Cash Price |
$3,250.00
|
| Rate for Payer: Cigna Commercial |
$2,889.88
|
| Rate for Payer: Healthspan PPO |
$2,419.07
|
| Rate for Payer: Humana Medicaid |
$1,475.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,667.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,505.30
|
| Rate for Payer: Molina Healthcare Passport |
$1,475.78
|
| Rate for Payer: Multiplan PHCS |
$3,900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,550.00
|
| Rate for Payer: UHCCP Medicaid |
$2,275.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,490.54
|
|
|
BREAST RECONS.WITH TRAM FLAP
|
Facility
|
OP
|
$6,500.00
|
|
|
Service Code
|
HCPCS 19369
|
| Hospital Charge Code |
76100320
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$845.00 |
| Max. Negotiated Rate |
$6,240.00 |
| Rate for Payer: Aetna Commercial |
$5,005.00
|
| Rate for Payer: Anthem Medicaid |
$2,235.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,070.00
|
| Rate for Payer: Cash Price |
$3,250.00
|
| Rate for Payer: Cigna Commercial |
$5,395.00
|
| Rate for Payer: First Health Commercial |
$6,175.00
|
| Rate for Payer: Humana Commercial |
$5,525.00
|
| Rate for Payer: Humana KY Medicaid |
$2,235.35
|
| Rate for Payer: Kentucky WC Medicaid |
$2,258.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,330.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,797.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,950.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,280.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,720.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,875.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$845.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,015.00
|
| Rate for Payer: PHCS Commercial |
$6,240.00
|
| Rate for Payer: United Healthcare All Payer |
$5,720.00
|
|
|
BREAST RECONS.WITH TRAM FLAP(P
|
Professional
|
Both
|
$6,500.00
|
|
|
Service Code
|
HCPCS 19369
|
| Hospital Charge Code |
761P0320
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,475.78 |
| Max. Negotiated Rate |
$6,500.00 |
| Rate for Payer: Aetna Commercial |
$3,025.39
|
| Rate for Payer: Anthem Medicaid |
$1,475.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,500.00
|
| Rate for Payer: Cash Price |
$3,250.00
|
| Rate for Payer: Cash Price |
$3,250.00
|
| Rate for Payer: Cigna Commercial |
$2,889.88
|
| Rate for Payer: Healthspan PPO |
$2,419.07
|
| Rate for Payer: Humana Medicaid |
$1,475.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,667.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,505.30
|
| Rate for Payer: Molina Healthcare Passport |
$1,475.78
|
| Rate for Payer: Multiplan PHCS |
$3,900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,550.00
|
| Rate for Payer: UHCCP Medicaid |
$2,275.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,490.54
|
|
|
BREAST REDUCTION
|
Facility
|
OP
|
$7,894.80
|
|
|
Service Code
|
CPT 19318
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,639.14 |
| Max. Negotiated Rate |
$7,894.80 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,639.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,894.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,612.84
|
| Rate for Payer: Humana Medicare Advantage |
$5,639.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,766.97
|
|
|
BREAST SALINE SIZER HIGH 330CC
|
Facility
|
OP
|
$1,065.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$138.45 |
| Max. Negotiated Rate |
$1,022.40 |
| Rate for Payer: Aetna Commercial |
$820.05
|
| Rate for Payer: Anthem Medicaid |
$366.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$830.70
|
| Rate for Payer: Cash Price |
$532.50
|
| Rate for Payer: Cigna Commercial |
$883.95
|
| Rate for Payer: First Health Commercial |
$1,011.75
|
| Rate for Payer: Humana Commercial |
$905.25
|
| Rate for Payer: Humana KY Medicaid |
$366.25
|
| Rate for Payer: Kentucky WC Medicaid |
$369.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$873.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$785.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$319.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$373.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$937.20
|
| Rate for Payer: Ohio Health Group HMO |
$798.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$213.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$138.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$330.15
|
| Rate for Payer: PHCS Commercial |
$1,022.40
|
| Rate for Payer: United Healthcare All Payer |
$937.20
|
|
|
BREAST SALINE SIZER HIGH 330CC
|
Facility
|
IP
|
$1,065.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$138.45 |
| Max. Negotiated Rate |
$1,022.40 |
| Rate for Payer: Aetna Commercial |
$820.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$830.70
|
| Rate for Payer: Cash Price |
$532.50
|
| Rate for Payer: Cigna Commercial |
$883.95
|
| Rate for Payer: First Health Commercial |
$1,011.75
|
| Rate for Payer: Humana Commercial |
$905.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$873.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$785.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$319.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$937.20
|
| Rate for Payer: Ohio Health Group HMO |
$798.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$213.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$138.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$330.15
|
| Rate for Payer: PHCS Commercial |
$1,022.40
|
| Rate for Payer: United Healthcare All Payer |
$937.20
|
|
|
BREAST SALINE SIZER HIGH 380CC
|
Facility
|
OP
|
$1,065.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$138.45 |
| Max. Negotiated Rate |
$1,022.40 |
| Rate for Payer: Aetna Commercial |
$820.05
|
| Rate for Payer: Anthem Medicaid |
$366.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$830.70
|
| Rate for Payer: Cash Price |
$532.50
|
| Rate for Payer: Cigna Commercial |
$883.95
|
| Rate for Payer: First Health Commercial |
$1,011.75
|
| Rate for Payer: Humana Commercial |
$905.25
|
| Rate for Payer: Humana KY Medicaid |
$366.25
|
| Rate for Payer: Kentucky WC Medicaid |
$369.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$873.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$785.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$319.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$373.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$937.20
|
| Rate for Payer: Ohio Health Group HMO |
$798.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$213.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$138.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$330.15
|
| Rate for Payer: PHCS Commercial |
$1,022.40
|
| Rate for Payer: United Healthcare All Payer |
$937.20
|
|
|
BREAST SALINE SIZER HIGH 380CC
|
Facility
|
IP
|
$1,065.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$138.45 |
| Max. Negotiated Rate |
$1,022.40 |
| Rate for Payer: Aetna Commercial |
$820.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$830.70
|
| Rate for Payer: Cash Price |
$532.50
|
| Rate for Payer: Cigna Commercial |
$883.95
|
| Rate for Payer: First Health Commercial |
$1,011.75
|
| Rate for Payer: Humana Commercial |
$905.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$873.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$785.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$319.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$937.20
|
| Rate for Payer: Ohio Health Group HMO |
$798.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$213.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$138.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$330.15
|
| Rate for Payer: PHCS Commercial |
$1,022.40
|
| Rate for Payer: United Healthcare All Payer |
$937.20
|
|
|
BREAST SALINE SIZER HIGH 630CC
|
Facility
|
OP
|
$1,065.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$138.45 |
| Max. Negotiated Rate |
$1,022.40 |
| Rate for Payer: Aetna Commercial |
$820.05
|
| Rate for Payer: Anthem Medicaid |
$366.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$830.70
|
| Rate for Payer: Cash Price |
$532.50
|
| Rate for Payer: Cigna Commercial |
$883.95
|
| Rate for Payer: First Health Commercial |
$1,011.75
|
| Rate for Payer: Humana Commercial |
$905.25
|
| Rate for Payer: Humana KY Medicaid |
$366.25
|
| Rate for Payer: Kentucky WC Medicaid |
$369.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$873.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$785.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$319.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$373.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$937.20
|
| Rate for Payer: Ohio Health Group HMO |
$798.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$213.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$138.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$330.15
|
| Rate for Payer: PHCS Commercial |
$1,022.40
|
| Rate for Payer: United Healthcare All Payer |
$937.20
|
|
|
BREAST SALINE SIZER HIGH 630CC
|
Facility
|
IP
|
$1,065.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$138.45 |
| Max. Negotiated Rate |
$1,022.40 |
| Rate for Payer: Aetna Commercial |
$820.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$830.70
|
| Rate for Payer: Cash Price |
$532.50
|
| Rate for Payer: Cigna Commercial |
$883.95
|
| Rate for Payer: First Health Commercial |
$1,011.75
|
| Rate for Payer: Humana Commercial |
$905.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$873.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$785.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$319.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$937.20
|
| Rate for Payer: Ohio Health Group HMO |
$798.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$213.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$138.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$330.15
|
| Rate for Payer: PHCS Commercial |
$1,022.40
|
| Rate for Payer: United Healthcare All Payer |
$937.20
|
|
