|
BX BONE SUPRFCL OPEN
|
Professional
|
Both
|
$4,783.88
|
|
|
Service Code
|
HCPCS 20240
|
| Hospital Charge Code |
76100330
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$144.88 |
| Max. Negotiated Rate |
$4,783.88 |
| Rate for Payer: Aetna Commercial |
$336.16
|
| Rate for Payer: Anthem Medicaid |
$144.88
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,783.88
|
| Rate for Payer: Cash Price |
$2,391.94
|
| Rate for Payer: Cash Price |
$2,391.94
|
| Rate for Payer: Cigna Commercial |
$375.17
|
| Rate for Payer: Healthspan PPO |
$304.49
|
| Rate for Payer: Humana Medicaid |
$144.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$278.64
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$147.78
|
| Rate for Payer: Molina Healthcare Passport |
$144.88
|
| Rate for Payer: Multiplan PHCS |
$2,870.33
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,348.72
|
| Rate for Payer: UHCCP Medicaid |
$1,674.36
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$146.33
|
|
|
BX BONE SUPRFCL OPEN(P
|
Professional
|
Both
|
$550.00
|
|
|
Service Code
|
HCPCS 20240
|
| Hospital Charge Code |
761P0330
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$144.88 |
| Max. Negotiated Rate |
$550.00 |
| Rate for Payer: Aetna Commercial |
$336.16
|
| Rate for Payer: Anthem Medicaid |
$144.88
|
| Rate for Payer: Buckeye Medicare Advantage |
$550.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$375.17
|
| Rate for Payer: Healthspan PPO |
$304.49
|
| Rate for Payer: Humana Medicaid |
$144.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$278.64
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$147.78
|
| Rate for Payer: Molina Healthcare Passport |
$144.88
|
| Rate for Payer: Multiplan PHCS |
$330.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$385.00
|
| Rate for Payer: UHCCP Medicaid |
$192.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$146.33
|
|
|
BX BONE SUPRFCL OPEN(T
|
Facility
|
IP
|
$4,233.88
|
|
|
Service Code
|
HCPCS 20240
|
| Hospital Charge Code |
761T0330
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$550.40 |
| Max. Negotiated Rate |
$4,064.52 |
| Rate for Payer: Aetna Commercial |
$3,260.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,302.43
|
| Rate for Payer: Cash Price |
$2,116.94
|
| Rate for Payer: Cigna Commercial |
$3,514.12
|
| Rate for Payer: First Health Commercial |
$4,022.19
|
| Rate for Payer: Humana Commercial |
$3,598.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,471.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,124.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,270.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,725.81
|
| Rate for Payer: Ohio Health Group HMO |
$3,175.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$846.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$550.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,312.50
|
| Rate for Payer: PHCS Commercial |
$4,064.52
|
| Rate for Payer: United Healthcare All Payer |
$3,725.81
|
|
|
BX BONE SUPRFCL OPEN(T
|
Facility
|
OP
|
$4,233.88
|
|
|
Service Code
|
HCPCS 20240
|
| Hospital Charge Code |
761T0330
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$550.40 |
| Max. Negotiated Rate |
$4,064.52 |
| Rate for Payer: Aetna Commercial |
$3,260.09
|
| Rate for Payer: Anthem Medicaid |
$1,456.03
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,302.43
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,440.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,317.21
|
| Rate for Payer: Cash Price |
$2,116.94
|
| Rate for Payer: Cash Price |
$2,116.94
|
| Rate for Payer: Cigna Commercial |
$3,514.12
|
| Rate for Payer: First Health Commercial |
$4,022.19
|
| Rate for Payer: Humana Commercial |
$3,598.80
|
| Rate for Payer: Humana KY Medicaid |
$1,456.03
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$1,470.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,471.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,124.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,485.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,725.81
|
| Rate for Payer: Ohio Health Group HMO |
$3,175.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$846.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$550.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,312.50
|
| Rate for Payer: PHCS Commercial |
$4,064.52
|
| Rate for Payer: United Healthcare All Payer |
$3,725.81
|
|
|
BX BREAST 1ST LESION MR IMAG
|
Professional
|
Both
|
$2,547.00
|
|
|
Service Code
|
HCPCS 19085
|
| Hospital Charge Code |
76100282
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$155.19 |
| Max. Negotiated Rate |
$2,547.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$155.19
|
| Rate for Payer: Anthem Medicaid |
$159.63
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,547.00
|
| Rate for Payer: Cash Price |
$1,273.50
|
| Rate for Payer: Cash Price |
$1,273.50
|
| Rate for Payer: Cigna Commercial |
$1,589.20
|
| Rate for Payer: Healthspan PPO |
$1,230.80
|
| Rate for Payer: Humana Medicaid |
$159.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$260.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$162.82
|
| Rate for Payer: Molina Healthcare Passport |
$159.63
|
| Rate for Payer: Multiplan PHCS |
$1,528.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,782.90
|
| Rate for Payer: UHCCP Medicaid |
$162.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$161.23
|
|
|
BX BREAST 1ST LESION MR IMAG
|
Facility
|
IP
|
$2,547.00
|
|
|
Service Code
|
HCPCS 19085
|
| Hospital Charge Code |
76100282
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$331.11 |
| Max. Negotiated Rate |
$2,445.12 |
| Rate for Payer: Aetna Commercial |
$1,961.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,986.66
|
| Rate for Payer: Cash Price |
$1,273.50
|
| Rate for Payer: Cigna Commercial |
$2,114.01
|
| Rate for Payer: First Health Commercial |
$2,419.65
|
| Rate for Payer: Humana Commercial |
$2,164.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,088.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,879.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$764.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,241.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,910.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$509.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$331.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$789.57
|
| Rate for Payer: PHCS Commercial |
$2,445.12
|
| Rate for Payer: United Healthcare All Payer |
$2,241.36
|
|
|
BX BREAST 1ST LESION MR IMAG
|
Facility
|
OP
|
$2,547.00
|
|
|
Service Code
|
HCPCS 19085
|
| Hospital Charge Code |
76100282
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$331.11 |
| Max. Negotiated Rate |
$2,445.12 |
| Rate for Payer: Aetna Commercial |
$1,961.19
|
| Rate for Payer: Anthem Medicaid |
$875.91
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,986.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$1,273.50
|
| Rate for Payer: Cash Price |
$1,273.50
|
| Rate for Payer: Cigna Commercial |
$2,114.01
|
| Rate for Payer: First Health Commercial |
$2,419.65
|
| Rate for Payer: Humana Commercial |
$2,164.95
|
| Rate for Payer: Humana KY Medicaid |
$875.91
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$884.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,088.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,879.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$893.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,241.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,910.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$509.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$331.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$789.57
|
| Rate for Payer: PHCS Commercial |
$2,445.12
|
| Rate for Payer: United Healthcare All Payer |
$2,241.36
|
|
|
BX BREAST 1ST LESION MR IMA(P
|
Professional
|
Both
|
$425.00
|
|
|
Service Code
|
HCPCS 19085
|
| Hospital Charge Code |
761P0282
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$155.19 |
| Max. Negotiated Rate |
$1,589.20 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$155.19
|
| Rate for Payer: Anthem Medicaid |
$159.63
|
| Rate for Payer: Buckeye Medicare Advantage |
$425.00
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cigna Commercial |
$1,589.20
|
| Rate for Payer: Healthspan PPO |
$1,230.80
|
| Rate for Payer: Humana Medicaid |
$159.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$260.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$162.82
|
| Rate for Payer: Molina Healthcare Passport |
$159.63
|
| Rate for Payer: Multiplan PHCS |
$255.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$297.50
|
| Rate for Payer: UHCCP Medicaid |
$162.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$161.23
|
|
|
BX BREAST 1ST LESION MR IMA(T
|
Facility
|
IP
|
$2,122.00
|
|
|
Service Code
|
HCPCS 19085
|
| Hospital Charge Code |
761T0282
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$275.86 |
| Max. Negotiated Rate |
$2,037.12 |
| Rate for Payer: Aetna Commercial |
$1,633.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,655.16
|
| Rate for Payer: Cash Price |
$1,061.00
|
| Rate for Payer: Cigna Commercial |
$1,761.26
|
| Rate for Payer: First Health Commercial |
$2,015.90
|
| Rate for Payer: Humana Commercial |
$1,803.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,740.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,566.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$636.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,867.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,591.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$275.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$657.82
|
| Rate for Payer: PHCS Commercial |
$2,037.12
|
| Rate for Payer: United Healthcare All Payer |
$1,867.36
|
|
|
BX BREAST 1ST LESION MR IMA(T
|
Facility
|
OP
|
$2,122.00
|
|
|
Service Code
|
HCPCS 19085
|
| Hospital Charge Code |
761T0282
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$275.86 |
| Max. Negotiated Rate |
$2,037.12 |
| Rate for Payer: Aetna Commercial |
$1,633.94
|
| Rate for Payer: Anthem Medicaid |
$729.76
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,655.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$1,061.00
|
| Rate for Payer: Cash Price |
$1,061.00
|
| Rate for Payer: Cigna Commercial |
$1,761.26
|
| Rate for Payer: First Health Commercial |
$2,015.90
|
| Rate for Payer: Humana Commercial |
$1,803.70
|
| Rate for Payer: Humana KY Medicaid |
$729.76
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$737.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,740.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,566.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$744.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,867.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,591.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$275.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$657.82
|
| Rate for Payer: PHCS Commercial |
$2,037.12
|
| Rate for Payer: United Healthcare All Payer |
$1,867.36
|
|
|
BX BREAST 1ST LESION STRTCTC
|
Professional
|
Both
|
$5,085.00
|
|
|
Service Code
|
HCPCS 19081
|
| Hospital Charge Code |
76100278
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$142.05 |
| Max. Negotiated Rate |
$5,085.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$142.05
|
| Rate for Payer: Anthem Medicaid |
$145.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,085.00
|
| Rate for Payer: Cash Price |
$2,542.50
|
| Rate for Payer: Cash Price |
$2,542.50
|
| Rate for Payer: Cigna Commercial |
$1,060.97
|
| Rate for Payer: Healthspan PPO |
$823.94
|
| Rate for Payer: Humana Medicaid |
$145.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$238.76
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$148.59
|
| Rate for Payer: Molina Healthcare Passport |
$145.68
|
| Rate for Payer: Multiplan PHCS |
$3,051.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,559.50
|
| Rate for Payer: UHCCP Medicaid |
$149.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$147.14
|
|
|
BX BREAST 1ST LESION STRTCTC
|
Facility
|
IP
|
$5,085.00
|
|
|
Service Code
|
HCPCS 19081
|
| Hospital Charge Code |
76100278
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$661.05 |
| Max. Negotiated Rate |
$4,881.60 |
| Rate for Payer: Aetna Commercial |
$3,915.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,966.30
|
| Rate for Payer: Cash Price |
$2,542.50
|
| Rate for Payer: Cigna Commercial |
$4,220.55
|
| Rate for Payer: First Health Commercial |
$4,830.75
|
| Rate for Payer: Humana Commercial |
$4,322.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,169.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,752.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,525.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,474.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,813.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,017.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$661.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,576.35
|
| Rate for Payer: PHCS Commercial |
$4,881.60
|
| Rate for Payer: United Healthcare All Payer |
$4,474.80
|
|
|
BX BREAST 1ST LESION STRTCTC
|
Facility
|
OP
|
$5,085.00
|
|
|
Service Code
|
HCPCS 19081
|
| Hospital Charge Code |
76100278
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$661.05 |
| Max. Negotiated Rate |
$4,881.60 |
| Rate for Payer: Aetna Commercial |
$3,915.45
|
| Rate for Payer: Anthem Medicaid |
$1,748.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,966.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$2,542.50
|
| Rate for Payer: Cash Price |
$2,542.50
|
| Rate for Payer: Cigna Commercial |
$4,220.55
|
| Rate for Payer: First Health Commercial |
$4,830.75
|
| Rate for Payer: Humana Commercial |
$4,322.25
|
| Rate for Payer: Humana KY Medicaid |
$1,748.73
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,766.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,169.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,752.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,783.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,474.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,813.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,017.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$661.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,576.35
|
| Rate for Payer: PHCS Commercial |
$4,881.60
|
| Rate for Payer: United Healthcare All Payer |
$4,474.80
|
|
|
BX BREAST 1ST LESION STRTCT(P
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 19081
|
| Hospital Charge Code |
761P0278
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$142.05 |
| Max. Negotiated Rate |
$1,060.97 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$142.05
|
| Rate for Payer: Anthem Medicaid |
$145.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,000.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$1,060.97
|
| Rate for Payer: Healthspan PPO |
$823.94
|
| Rate for Payer: Humana Medicaid |
$145.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$238.76
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$148.59
|
| Rate for Payer: Molina Healthcare Passport |
$145.68
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$149.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$147.14
|
|
|
BX BREAST 1ST LESION STRTCT(T
|
Facility
|
IP
|
$4,085.00
|
|
|
Service Code
|
HCPCS 19081
|
| Hospital Charge Code |
761T0278
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$531.05 |
| Max. Negotiated Rate |
$3,921.60 |
| Rate for Payer: Aetna Commercial |
$3,145.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,186.30
|
| Rate for Payer: Cash Price |
$2,042.50
|
| Rate for Payer: Cigna Commercial |
$3,390.55
|
| Rate for Payer: First Health Commercial |
$3,880.75
|
| Rate for Payer: Humana Commercial |
$3,472.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,349.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,014.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,225.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,594.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,063.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$817.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$531.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,266.35
|
| Rate for Payer: PHCS Commercial |
$3,921.60
|
| Rate for Payer: United Healthcare All Payer |
$3,594.80
|
|
|
BX BREAST 1ST LESION STRTCT(T
|
Facility
|
OP
|
$4,085.00
|
|
|
Service Code
|
HCPCS 19081
|
| Hospital Charge Code |
761T0278
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$531.05 |
| Max. Negotiated Rate |
$3,921.60 |
| Rate for Payer: Aetna Commercial |
$3,145.45
|
| Rate for Payer: Anthem Medicaid |
$1,404.83
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,186.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$2,042.50
|
| Rate for Payer: Cash Price |
$2,042.50
|
| Rate for Payer: Cigna Commercial |
$3,390.55
|
| Rate for Payer: First Health Commercial |
$3,880.75
|
| Rate for Payer: Humana Commercial |
$3,472.25
|
| Rate for Payer: Humana KY Medicaid |
$1,404.83
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,419.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,349.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,014.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,433.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,594.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,063.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$817.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$531.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,266.35
|
| Rate for Payer: PHCS Commercial |
$3,921.60
|
| Rate for Payer: United Healthcare All Payer |
$3,594.80
|
|
|
BX BREAST 1ST LESION US IMAG
|
Facility
|
OP
|
$3,861.00
|
|
|
Service Code
|
HCPCS 19083
|
| Hospital Charge Code |
76100280
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$501.93 |
| Max. Negotiated Rate |
$3,706.56 |
| Rate for Payer: Aetna Commercial |
$2,972.97
|
| Rate for Payer: Anthem Medicaid |
$1,327.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,011.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$1,930.50
|
| Rate for Payer: Cash Price |
$1,930.50
|
| Rate for Payer: Cigna Commercial |
$3,204.63
|
| Rate for Payer: First Health Commercial |
$3,667.95
|
| Rate for Payer: Humana Commercial |
$3,281.85
|
| Rate for Payer: Humana KY Medicaid |
$1,327.80
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,341.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,166.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,849.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,354.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,397.68
|
| Rate for Payer: Ohio Health Group HMO |
$2,895.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$772.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$501.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,196.91
|
| Rate for Payer: PHCS Commercial |
$3,706.56
|
| Rate for Payer: United Healthcare All Payer |
$3,397.68
|
|
|
BX BREAST 1ST LESION US IMAG
|
Facility
|
IP
|
$3,861.00
|
|
|
Service Code
|
HCPCS 19083
|
| Hospital Charge Code |
76100280
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$501.93 |
| Max. Negotiated Rate |
$3,706.56 |
| Rate for Payer: Aetna Commercial |
$2,972.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,011.58
|
| Rate for Payer: Cash Price |
$1,930.50
|
| Rate for Payer: Cigna Commercial |
$3,204.63
|
| Rate for Payer: First Health Commercial |
$3,667.95
|
| Rate for Payer: Humana Commercial |
$3,281.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,166.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,849.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,158.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,397.68
|
| Rate for Payer: Ohio Health Group HMO |
$2,895.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$772.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$501.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,196.91
|
| Rate for Payer: PHCS Commercial |
$3,706.56
|
| Rate for Payer: United Healthcare All Payer |
$3,397.68
|
|
|
BX BREAST 1ST LESION US IMAG
|
Professional
|
Both
|
$3,861.00
|
|
|
Service Code
|
HCPCS 19083
|
| Hospital Charge Code |
76100280
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$133.00 |
| Max. Negotiated Rate |
$3,861.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$133.00
|
| Rate for Payer: Anthem Medicaid |
$136.63
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,861.00
|
| Rate for Payer: Cash Price |
$1,930.50
|
| Rate for Payer: Cash Price |
$1,930.50
|
| Rate for Payer: Cigna Commercial |
$1,052.98
|
| Rate for Payer: Healthspan PPO |
$817.14
|
| Rate for Payer: Humana Medicaid |
$136.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$223.55
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$139.36
|
| Rate for Payer: Molina Healthcare Passport |
$136.63
|
| Rate for Payer: Multiplan PHCS |
$2,316.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,702.70
|
| Rate for Payer: UHCCP Medicaid |
$139.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$138.00
|
|
|
BX BREAST 1ST LESION US IMA(P
|
Professional
|
Both
|
$1,275.00
|
|
|
Service Code
|
HCPCS 19083
|
| Hospital Charge Code |
761P0280
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$133.00 |
| Max. Negotiated Rate |
$1,275.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$133.00
|
| Rate for Payer: Anthem Medicaid |
$136.63
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,275.00
|
| Rate for Payer: Cash Price |
$637.50
|
| Rate for Payer: Cash Price |
$637.50
|
| Rate for Payer: Cigna Commercial |
$1,052.98
|
| Rate for Payer: Healthspan PPO |
$817.14
|
| Rate for Payer: Humana Medicaid |
$136.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$223.55
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$139.36
|
| Rate for Payer: Molina Healthcare Passport |
$136.63
|
| Rate for Payer: Multiplan PHCS |
$765.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$892.50
|
| Rate for Payer: UHCCP Medicaid |
$139.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$138.00
|
|
|
BX BREAST 1ST LESION US IMA(T
|
Facility
|
IP
|
$2,586.00
|
|
|
Service Code
|
HCPCS 19083
|
| Hospital Charge Code |
761T0280
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$336.18 |
| Max. Negotiated Rate |
$2,482.56 |
| Rate for Payer: Aetna Commercial |
$1,991.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,017.08
|
| Rate for Payer: Cash Price |
$1,293.00
|
| Rate for Payer: Cigna Commercial |
$2,146.38
|
| Rate for Payer: First Health Commercial |
$2,456.70
|
| Rate for Payer: Humana Commercial |
$2,198.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,120.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,908.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$775.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,275.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,939.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$517.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$336.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$801.66
|
| Rate for Payer: PHCS Commercial |
$2,482.56
|
| Rate for Payer: United Healthcare All Payer |
$2,275.68
|
|
|
BX BREAST 1ST LESION US IMA(T
|
Facility
|
OP
|
$2,586.00
|
|
|
Service Code
|
HCPCS 19083
|
| Hospital Charge Code |
761T0280
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$336.18 |
| Max. Negotiated Rate |
$2,482.56 |
| Rate for Payer: Aetna Commercial |
$1,991.22
|
| Rate for Payer: Anthem Medicaid |
$889.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,017.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$1,293.00
|
| Rate for Payer: Cash Price |
$1,293.00
|
| Rate for Payer: Cigna Commercial |
$2,146.38
|
| Rate for Payer: First Health Commercial |
$2,456.70
|
| Rate for Payer: Humana Commercial |
$2,198.10
|
| Rate for Payer: Humana KY Medicaid |
$889.33
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$898.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,120.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,908.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$907.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,275.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,939.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$517.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$336.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$801.66
|
| Rate for Payer: PHCS Commercial |
$2,482.56
|
| Rate for Payer: United Healthcare All Payer |
$2,275.68
|
|
|
BX BREAST ADD LESION MR IMAG
|
Facility
|
IP
|
$1,873.00
|
|
|
Service Code
|
HCPCS 19086
|
| Hospital Charge Code |
76100283
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$243.49 |
| Max. Negotiated Rate |
$1,798.08 |
| Rate for Payer: Aetna Commercial |
$1,442.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,460.94
|
| Rate for Payer: Cash Price |
$936.50
|
| Rate for Payer: Cigna Commercial |
$1,554.59
|
| Rate for Payer: First Health Commercial |
$1,779.35
|
| Rate for Payer: Humana Commercial |
$1,592.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,535.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,382.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,648.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,404.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$374.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.63
|
| Rate for Payer: PHCS Commercial |
$1,798.08
|
| Rate for Payer: United Healthcare All Payer |
$1,648.24
|
|
|
BX BREAST ADD LESION MR IMAG
|
Facility
|
OP
|
$1,873.00
|
|
|
Service Code
|
HCPCS 19086
|
| Hospital Charge Code |
76100283
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$243.49 |
| Max. Negotiated Rate |
$1,798.08 |
| Rate for Payer: Aetna Commercial |
$1,442.21
|
| Rate for Payer: Anthem Medicaid |
$644.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,460.94
|
| Rate for Payer: Cash Price |
$936.50
|
| Rate for Payer: Cigna Commercial |
$1,554.59
|
| Rate for Payer: First Health Commercial |
$1,779.35
|
| Rate for Payer: Humana Commercial |
$1,592.05
|
| Rate for Payer: Humana KY Medicaid |
$644.12
|
| Rate for Payer: Kentucky WC Medicaid |
$650.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,535.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,382.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$657.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,648.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,404.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$374.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.63
|
| Rate for Payer: PHCS Commercial |
$1,798.08
|
| Rate for Payer: United Healthcare All Payer |
$1,648.24
|
|
|
BX BREAST ADD LESION MR IMAG
|
Professional
|
Both
|
$1,873.00
|
|
|
Service Code
|
HCPCS 19086
|
| Hospital Charge Code |
76100283
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$68.15 |
| Max. Negotiated Rate |
$1,873.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$68.15
|
| Rate for Payer: Anthem Medicaid |
$72.71
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,873.00
|
| Rate for Payer: Cash Price |
$936.50
|
| Rate for Payer: Cash Price |
$936.50
|
| Rate for Payer: Cigna Commercial |
$1,261.56
|
| Rate for Payer: Healthspan PPO |
$972.34
|
| Rate for Payer: Humana Medicaid |
$72.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$114.55
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$74.16
|
| Rate for Payer: Molina Healthcare Passport |
$72.71
|
| Rate for Payer: Multiplan PHCS |
$1,123.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,311.10
|
| Rate for Payer: UHCCP Medicaid |
$71.56
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$73.44
|
|
