|
BREAK FREE
|
Professional
|
Both
|
$60.00
|
|
| Hospital Charge Code |
22200130
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$42.00 |
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Multiplan PHCS |
$36.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$42.00
|
| Rate for Payer: UHCCP Medicaid |
$21.00
|
|
|
BREAK FREE
|
Facility
|
OP
|
$60.00
|
|
| Hospital Charge Code |
22200130
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$18.00 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem Medicaid |
$20.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.80
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Humana KY Medicaid |
$20.63
|
| Rate for Payer: Kentucky WC Medicaid |
$20.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.40
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
BREAKUP FAT NECROS/AERATE (P
|
Professional
|
Both
|
$1,700.00
|
|
|
Service Code
|
HCPCS 44005
|
| Hospital Charge Code |
761P2699
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$595.00 |
| Max. Negotiated Rate |
$1,580.74 |
| Rate for Payer: Aetna Commercial |
$1,580.74
|
| Rate for Payer: Ambetter Exchange |
$1,039.78
|
| Rate for Payer: Anthem Medicaid |
$631.99
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,039.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,039.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,247.74
|
| Rate for Payer: Cash Price |
$850.00
|
| Rate for Payer: Cash Price |
$850.00
|
| Rate for Payer: Cigna Commercial |
$1,466.69
|
| Rate for Payer: Healthspan PPO |
$1,333.07
|
| Rate for Payer: Humana Medicaid |
$631.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,396.60
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,039.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,039.78
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$644.63
|
| Rate for Payer: Molina Healthcare Passport |
$631.99
|
| Rate for Payer: Multiplan PHCS |
$1,020.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,351.71
|
| Rate for Payer: UHCCP Medicaid |
$595.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$638.31
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,039.78
|
|
|
BREAKUP FAT NECROS/AERATE (T
|
Facility
|
IP
|
$3,797.33
|
|
|
Service Code
|
HCPCS 19499
|
| Hospital Charge Code |
761T2699
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,139.20 |
| Max. Negotiated Rate |
$3,645.44 |
| Rate for Payer: Aetna Commercial |
$2,923.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,961.92
|
| Rate for Payer: Cash Price |
$1,898.66
|
| Rate for Payer: Cigna Commercial |
$3,151.78
|
| Rate for Payer: First Health Commercial |
$3,607.46
|
| Rate for Payer: Humana Commercial |
$3,227.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,113.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,802.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,139.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,341.65
|
| Rate for Payer: Ohio Health Group HMO |
$2,848.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,037.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,303.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,620.16
|
| Rate for Payer: PHCS Commercial |
$3,645.44
|
| Rate for Payer: United Healthcare All Payer |
$3,341.65
|
|
|
BREAKUP FAT NECROS/AERATE (T
|
Facility
|
OP
|
$3,797.33
|
|
|
Service Code
|
HCPCS 19499
|
| Hospital Charge Code |
761T2699
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,305.90 |
| Max. Negotiated Rate |
$4,953.45 |
| Rate for Payer: Aetna Commercial |
$2,923.94
|
| Rate for Payer: Anthem Medicaid |
$1,305.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,538.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,961.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,953.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,776.54
|
| Rate for Payer: Cash Price |
$1,898.66
|
| Rate for Payer: Cash Price |
$1,898.66
|
| Rate for Payer: Cigna Commercial |
$3,151.78
|
| Rate for Payer: First Health Commercial |
$3,607.46
|
| Rate for Payer: Humana Commercial |
$3,227.73
|
| Rate for Payer: Humana KY Medicaid |
$1,305.90
|
| Rate for Payer: Humana Medicare Advantage |
$3,538.18
|
| Rate for Payer: Kentucky WC Medicaid |
$1,319.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,113.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,802.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,245.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,332.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,341.65
|
| Rate for Payer: Ohio Health Group HMO |
$2,848.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,037.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,303.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,620.16
|
| Rate for Payer: PHCS Commercial |
$3,645.44
|
| Rate for Payer: United Healthcare All Payer |
$3,341.65
|
|
|
BREAKUP FAT NECROS/AERATE TISS
|
Professional
|
Both
|
$5,497.33
|
|
|
Service Code
|
HCPCS 19499
|
| Hospital Charge Code |
76102699
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$3,848.13 |
| Rate for Payer: Anthem Medicaid |
$325.00
|
| Rate for Payer: Cash Price |
$2,748.66
|
| Rate for Payer: Cash Price |
$2,748.66
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$325.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$331.50
|
| Rate for Payer: Molina Healthcare Passport |
$325.00
|
| Rate for Payer: Multiplan PHCS |
$3,298.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,848.13
|
| Rate for Payer: UHCCP Medicaid |
$1,924.07
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$328.25
|
|
|
BREAST AUGMENTATION W/IMPLAN(P
|
Professional
|
Both
|
$2,700.00
|
|
|
Service Code
|
HCPCS 19325
|
| Hospital Charge Code |
761P0308
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$421.12 |
| Max. Negotiated Rate |
$1,620.00 |
| Rate for Payer: Aetna Commercial |
$935.47
|
| Rate for Payer: Ambetter Exchange |
$581.81
|
| Rate for Payer: Anthem Medicaid |
$421.12
|
| Rate for Payer: Buckeye Individual/Medicaid |
$581.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$581.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$698.17
|
| Rate for Payer: Cash Price |
$1,350.00
|
| Rate for Payer: Cash Price |
$1,350.00
|
| Rate for Payer: Cigna Commercial |
$888.81
|
| Rate for Payer: Healthspan PPO |
$747.99
|
| Rate for Payer: Humana Medicaid |
$421.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$827.77
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$581.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$581.81
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$429.54
|
| Rate for Payer: Molina Healthcare Passport |
$421.12
|
| Rate for Payer: Multiplan PHCS |
$1,620.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$756.35
|
| Rate for Payer: UHCCP Medicaid |
$945.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$425.33
|
| Rate for Payer: Wellcare Medicare Advantage |
$581.81
|
|
|
BREAST AUGMENTATION W/IMPLANT
|
Professional
|
Both
|
$2,700.00
|
|
|
Service Code
|
HCPCS 19325
|
| Hospital Charge Code |
76100308
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$421.12 |
| Max. Negotiated Rate |
$1,620.00 |
| Rate for Payer: Aetna Commercial |
$935.47
|
| Rate for Payer: Ambetter Exchange |
$581.81
|
| Rate for Payer: Anthem Medicaid |
$421.12
|
| Rate for Payer: Buckeye Individual/Medicaid |
$581.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$581.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$698.17
|
| Rate for Payer: Cash Price |
$1,350.00
|
| Rate for Payer: Cash Price |
$1,350.00
|
| Rate for Payer: Cigna Commercial |
$888.81
|
| Rate for Payer: Healthspan PPO |
$747.99
|
| Rate for Payer: Humana Medicaid |
$421.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$827.77
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$581.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$581.81
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$429.54
|
| Rate for Payer: Molina Healthcare Passport |
$421.12
|
| Rate for Payer: Multiplan PHCS |
$1,620.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$756.35
|
| Rate for Payer: UHCCP Medicaid |
$945.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$425.33
|
| Rate for Payer: Wellcare Medicare Advantage |
$581.81
|
|
|
BREAST AUGMENTATION W/IMPLANT
|
Facility
|
OP
|
$2,700.00
|
|
|
Service Code
|
HCPCS 19325
|
| Hospital Charge Code |
76100308
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$928.53 |
| Max. Negotiated Rate |
$12,378.25 |
| Rate for Payer: Aetna Commercial |
$2,079.00
|
| Rate for Payer: Anthem Medicaid |
$928.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8,841.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,106.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12,378.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$11,936.17
|
| Rate for Payer: Cash Price |
$1,350.00
|
| Rate for Payer: Cash Price |
$1,350.00
|
| Rate for Payer: Cigna Commercial |
$2,241.00
|
| Rate for Payer: First Health Commercial |
$2,565.00
|
| Rate for Payer: Humana Commercial |
$2,295.00
|
| Rate for Payer: Humana KY Medicaid |
$928.53
|
| Rate for Payer: Humana Medicare Advantage |
$8,841.61
|
| Rate for Payer: Kentucky WC Medicaid |
$937.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,214.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,992.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,609.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$947.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,376.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,025.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,160.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,349.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,863.00
|
| Rate for Payer: PHCS Commercial |
$2,592.00
|
| Rate for Payer: United Healthcare All Payer |
$2,376.00
|
|
|
BREAST AUGMENTATION W/IMPLANT
|
Facility
|
IP
|
$2,700.00
|
|
|
Service Code
|
HCPCS 19325
|
| Hospital Charge Code |
76100308
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$810.00 |
| Max. Negotiated Rate |
$2,592.00 |
| Rate for Payer: Aetna Commercial |
$2,079.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,106.00
|
| Rate for Payer: Cash Price |
$1,350.00
|
| Rate for Payer: Cigna Commercial |
$2,241.00
|
| Rate for Payer: First Health Commercial |
$2,565.00
|
| Rate for Payer: Humana Commercial |
$2,295.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,214.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,992.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$810.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,376.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,025.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,160.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,349.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,863.00
|
| Rate for Payer: PHCS Commercial |
$2,592.00
|
| Rate for Payer: United Healthcare All Payer |
$2,376.00
|
|
|
BREAST AUGMENTATION WITH IMPLANT
|
Facility
|
OP
|
$12,378.25
|
|
|
Service Code
|
CPT 19325
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$8,841.61 |
| Max. Negotiated Rate |
$12,378.25 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8,841.61
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12,378.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$11,936.17
|
| Rate for Payer: Humana Medicare Advantage |
$8,841.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,609.93
|
|
|
BREAST CENTER LEVEL 1
|
Facility
|
OP
|
$1,133.00
|
|
| Hospital Charge Code |
76102546
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$339.90 |
| Max. Negotiated Rate |
$1,087.68 |
| Rate for Payer: Aetna Commercial |
$872.41
|
| Rate for Payer: Anthem Medicaid |
$389.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$883.74
|
| Rate for Payer: Cash Price |
$566.50
|
| Rate for Payer: Cigna Commercial |
$940.39
|
| Rate for Payer: First Health Commercial |
$1,076.35
|
| Rate for Payer: Humana Commercial |
$963.05
|
| Rate for Payer: Humana KY Medicaid |
$389.64
|
| Rate for Payer: Kentucky WC Medicaid |
$393.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$929.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$836.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$339.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$397.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$997.04
|
| Rate for Payer: Ohio Health Group HMO |
$849.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$906.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$985.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$781.77
|
| Rate for Payer: PHCS Commercial |
$1,087.68
|
| Rate for Payer: United Healthcare All Payer |
$997.04
|
|
|
BREAST CENTER LEVEL 1
|
Facility
|
IP
|
$1,133.00
|
|
| Hospital Charge Code |
76102546
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$339.90 |
| Max. Negotiated Rate |
$1,087.68 |
| Rate for Payer: Aetna Commercial |
$872.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$883.74
|
| Rate for Payer: Cash Price |
$566.50
|
| Rate for Payer: Cigna Commercial |
$940.39
|
| Rate for Payer: First Health Commercial |
$1,076.35
|
| Rate for Payer: Humana Commercial |
$963.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$929.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$836.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$339.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$997.04
|
| Rate for Payer: Ohio Health Group HMO |
$849.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$906.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$985.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$781.77
|
| Rate for Payer: PHCS Commercial |
$1,087.68
|
| Rate for Payer: United Healthcare All Payer |
$997.04
|
|
|
BREAST CENTER LEVEL 2
|
Facility
|
OP
|
$2,585.00
|
|
| Hospital Charge Code |
76102547
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$775.50 |
| Max. Negotiated Rate |
$2,481.60 |
| Rate for Payer: Aetna Commercial |
$1,990.45
|
| Rate for Payer: Anthem Medicaid |
$888.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,016.30
|
| Rate for Payer: Cash Price |
$1,292.50
|
| Rate for Payer: Cigna Commercial |
$2,145.55
|
| Rate for Payer: First Health Commercial |
$2,455.75
|
| Rate for Payer: Humana Commercial |
$2,197.25
|
| Rate for Payer: Humana KY Medicaid |
$888.98
|
| Rate for Payer: Kentucky WC Medicaid |
$898.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,119.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,907.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$775.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$906.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,274.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,938.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,068.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,248.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,783.65
|
| Rate for Payer: PHCS Commercial |
$2,481.60
|
| Rate for Payer: United Healthcare All Payer |
$2,274.80
|
|
|
BREAST CENTER LEVEL 2
|
Facility
|
IP
|
$2,585.00
|
|
| Hospital Charge Code |
76102547
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$775.50 |
| Max. Negotiated Rate |
$2,481.60 |
| Rate for Payer: Aetna Commercial |
$1,990.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,016.30
|
| Rate for Payer: Cash Price |
$1,292.50
|
| Rate for Payer: Cigna Commercial |
$2,145.55
|
| Rate for Payer: First Health Commercial |
$2,455.75
|
| Rate for Payer: Humana Commercial |
$2,197.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,119.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,907.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$775.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,274.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,938.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,068.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,248.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,783.65
|
| Rate for Payer: PHCS Commercial |
$2,481.60
|
| Rate for Payer: United Healthcare All Payer |
$2,274.80
|
|
|
BREAST EXPANDER LOW HGHT 350CC
|
Facility
|
OP
|
$5,468.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,640.62 |
| Max. Negotiated Rate |
$5,250.00 |
| Rate for Payer: Aetna Commercial |
$4,210.94
|
| Rate for Payer: Anthem Medicaid |
$1,880.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,265.62
|
| Rate for Payer: Cash Price |
$2,734.38
|
| Rate for Payer: Cigna Commercial |
$4,539.06
|
| Rate for Payer: First Health Commercial |
$5,195.31
|
| Rate for Payer: Humana Commercial |
$4,648.44
|
| Rate for Payer: Humana KY Medicaid |
$1,880.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1,899.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,484.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,035.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,640.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,918.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,812.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,101.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,757.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,773.44
|
| Rate for Payer: PHCS Commercial |
$5,250.00
|
| Rate for Payer: United Healthcare All Payer |
$4,812.50
|
|
|
BREAST EXPANDER LOW HGHT 350CC
|
Facility
|
IP
|
$5,468.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,640.62 |
| Max. Negotiated Rate |
$5,250.00 |
| Rate for Payer: Aetna Commercial |
$4,210.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,265.62
|
| Rate for Payer: Cash Price |
$2,734.38
|
| Rate for Payer: Cigna Commercial |
$4,539.06
|
| Rate for Payer: First Health Commercial |
$5,195.31
|
| Rate for Payer: Humana Commercial |
$4,648.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,484.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,035.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,640.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,812.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,101.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,757.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,773.44
|
| Rate for Payer: PHCS Commercial |
$5,250.00
|
| Rate for Payer: United Healthcare All Payer |
$4,812.50
|
|
|
BREAST EXPANDER LOW HGHT 450CC
|
Facility
|
OP
|
$8,018.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,405.62 |
| Max. Negotiated Rate |
$7,698.00 |
| Rate for Payer: Aetna Commercial |
$6,174.44
|
| Rate for Payer: Anthem Medicaid |
$2,757.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,254.62
|
| Rate for Payer: Cash Price |
$4,009.38
|
| Rate for Payer: Cigna Commercial |
$6,655.56
|
| Rate for Payer: First Health Commercial |
$7,617.81
|
| Rate for Payer: Humana Commercial |
$6,815.94
|
| Rate for Payer: Humana KY Medicaid |
$2,757.65
|
| Rate for Payer: Kentucky WC Medicaid |
$2,785.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,575.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,917.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,405.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,812.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,056.50
|
| Rate for Payer: Ohio Health Group HMO |
$6,014.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,415.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,976.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,532.94
|
| Rate for Payer: PHCS Commercial |
$7,698.00
|
| Rate for Payer: United Healthcare All Payer |
$7,056.50
|
|
|
BREAST EXPANDER LOW HGHT 450CC
|
Facility
|
IP
|
$8,018.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,405.62 |
| Max. Negotiated Rate |
$7,698.00 |
| Rate for Payer: Aetna Commercial |
$6,174.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,254.62
|
| Rate for Payer: Cash Price |
$4,009.38
|
| Rate for Payer: Cigna Commercial |
$6,655.56
|
| Rate for Payer: First Health Commercial |
$7,617.81
|
| Rate for Payer: Humana Commercial |
$6,815.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,575.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,917.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,405.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,056.50
|
| Rate for Payer: Ohio Health Group HMO |
$6,014.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,415.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,976.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,532.94
|
| Rate for Payer: PHCS Commercial |
$7,698.00
|
| Rate for Payer: United Healthcare All Payer |
$7,056.50
|
|
|
BREAST EXPANDER LOW HGHT 550CC
|
Facility
|
IP
|
$8,018.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,405.62 |
| Max. Negotiated Rate |
$7,698.00 |
| Rate for Payer: Aetna Commercial |
$6,174.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,254.62
|
| Rate for Payer: Cash Price |
$4,009.38
|
| Rate for Payer: Cigna Commercial |
$6,655.56
|
| Rate for Payer: First Health Commercial |
$7,617.81
|
| Rate for Payer: Humana Commercial |
$6,815.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,575.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,917.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,405.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,056.50
|
| Rate for Payer: Ohio Health Group HMO |
$6,014.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,415.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,976.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,532.94
|
| Rate for Payer: PHCS Commercial |
$7,698.00
|
| Rate for Payer: United Healthcare All Payer |
$7,056.50
|
|
|
BREAST EXPANDER LOW HGHT 550CC
|
Facility
|
OP
|
$8,018.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,405.62 |
| Max. Negotiated Rate |
$7,698.00 |
| Rate for Payer: Aetna Commercial |
$6,174.44
|
| Rate for Payer: Anthem Medicaid |
$2,757.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,254.62
|
| Rate for Payer: Cash Price |
$4,009.38
|
| Rate for Payer: Cigna Commercial |
$6,655.56
|
| Rate for Payer: First Health Commercial |
$7,617.81
|
| Rate for Payer: Humana Commercial |
$6,815.94
|
| Rate for Payer: Humana KY Medicaid |
$2,757.65
|
| Rate for Payer: Kentucky WC Medicaid |
$2,785.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,575.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,917.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,405.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,812.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,056.50
|
| Rate for Payer: Ohio Health Group HMO |
$6,014.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,415.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,976.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,532.94
|
| Rate for Payer: PHCS Commercial |
$7,698.00
|
| Rate for Payer: United Healthcare All Payer |
$7,056.50
|
|
|
BREAST EXPANDER LOW HGHT 650CC
|
Facility
|
OP
|
$8,018.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,405.62 |
| Max. Negotiated Rate |
$7,698.00 |
| Rate for Payer: Aetna Commercial |
$6,174.44
|
| Rate for Payer: Anthem Medicaid |
$2,757.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,254.62
|
| Rate for Payer: Cash Price |
$4,009.38
|
| Rate for Payer: Cigna Commercial |
$6,655.56
|
| Rate for Payer: First Health Commercial |
$7,617.81
|
| Rate for Payer: Humana Commercial |
$6,815.94
|
| Rate for Payer: Humana KY Medicaid |
$2,757.65
|
| Rate for Payer: Kentucky WC Medicaid |
$2,785.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,575.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,917.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,405.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,812.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,056.50
|
| Rate for Payer: Ohio Health Group HMO |
$6,014.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,415.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,976.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,532.94
|
| Rate for Payer: PHCS Commercial |
$7,698.00
|
| Rate for Payer: United Healthcare All Payer |
$7,056.50
|
|
|
BREAST EXPANDER LOW HGHT 650CC
|
Facility
|
IP
|
$8,018.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,405.62 |
| Max. Negotiated Rate |
$7,698.00 |
| Rate for Payer: Aetna Commercial |
$6,174.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,254.62
|
| Rate for Payer: Cash Price |
$4,009.38
|
| Rate for Payer: Cigna Commercial |
$6,655.56
|
| Rate for Payer: First Health Commercial |
$7,617.81
|
| Rate for Payer: Humana Commercial |
$6,815.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,575.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,917.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,405.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,056.50
|
| Rate for Payer: Ohio Health Group HMO |
$6,014.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,415.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,976.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,532.94
|
| Rate for Payer: PHCS Commercial |
$7,698.00
|
| Rate for Payer: United Healthcare All Payer |
$7,056.50
|
|
|
BREAST EXPANDER MED HGHT 350CC
|
Facility
|
OP
|
$8,201.25
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,460.38 |
| Max. Negotiated Rate |
$7,873.20 |
| Rate for Payer: Aetna Commercial |
$6,314.96
|
| Rate for Payer: Anthem Medicaid |
$2,820.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,396.98
|
| Rate for Payer: Cash Price |
$4,100.62
|
| Rate for Payer: Cigna Commercial |
$6,807.04
|
| Rate for Payer: First Health Commercial |
$7,791.19
|
| Rate for Payer: Humana Commercial |
$6,971.06
|
| Rate for Payer: Humana KY Medicaid |
$2,820.41
|
| Rate for Payer: Kentucky WC Medicaid |
$2,849.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,725.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,052.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,460.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,877.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,217.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,150.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,561.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,135.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,658.86
|
| Rate for Payer: PHCS Commercial |
$7,873.20
|
| Rate for Payer: United Healthcare All Payer |
$7,217.10
|
|
|
BREAST EXPANDER MED HGHT 350CC
|
Facility
|
IP
|
$8,201.25
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,460.38 |
| Max. Negotiated Rate |
$7,873.20 |
| Rate for Payer: Aetna Commercial |
$6,314.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,396.98
|
| Rate for Payer: Cash Price |
$4,100.62
|
| Rate for Payer: Cigna Commercial |
$6,807.04
|
| Rate for Payer: First Health Commercial |
$7,791.19
|
| Rate for Payer: Humana Commercial |
$6,971.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,725.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,052.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,460.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,217.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,150.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,561.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,135.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,658.86
|
| Rate for Payer: PHCS Commercial |
$7,873.20
|
| Rate for Payer: United Healthcare All Payer |
$7,217.10
|
|
