|
BREAST SALINE SIZER MOD+ 700CC
|
Facility
|
IP
|
$1,100.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$330.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$759.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
BREAST SALINE SIZER MOD+ 700CC
|
Facility
|
OP
|
$1,100.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$330.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem Medicaid |
$378.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Humana KY Medicaid |
$378.29
|
| Rate for Payer: Kentucky WC Medicaid |
$382.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$385.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$759.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
BREAST TOMOSYNTHESIS BILAT
|
Professional
|
Both
|
$355.00
|
|
|
Service Code
|
HCPCS 77062
|
| Hospital Charge Code |
40100002
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$124.25 |
| Max. Negotiated Rate |
$248.50 |
| Rate for Payer: Cash Price |
$177.50
|
| Rate for Payer: Cash Price |
$177.50
|
| Rate for Payer: Cigna Commercial |
$201.87
|
| Rate for Payer: Multiplan PHCS |
$213.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$248.50
|
| Rate for Payer: UHCCP Medicaid |
$124.25
|
|
|
BREAST TOMOSYNTHESIS BILAT
|
Facility
|
IP
|
$355.00
|
|
|
Service Code
|
HCPCS 77062
|
| Hospital Charge Code |
40100002
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$106.50 |
| Max. Negotiated Rate |
$340.80 |
| Rate for Payer: Aetna Commercial |
$273.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$276.90
|
| Rate for Payer: Cash Price |
$177.50
|
| Rate for Payer: Cigna Commercial |
$294.65
|
| Rate for Payer: First Health Commercial |
$337.25
|
| Rate for Payer: Humana Commercial |
$301.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$291.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$261.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$106.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$312.40
|
| Rate for Payer: Ohio Health Group HMO |
$266.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$284.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$308.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$244.95
|
| Rate for Payer: PHCS Commercial |
$340.80
|
| Rate for Payer: United Healthcare All Payer |
$312.40
|
|
|
BREAST TOMOSYNTHESIS BILAT
|
Facility
|
OP
|
$355.00
|
|
|
Service Code
|
HCPCS 77062
|
| Hospital Charge Code |
40100002
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$106.50 |
| Max. Negotiated Rate |
$340.80 |
| Rate for Payer: Aetna Commercial |
$273.35
|
| Rate for Payer: Anthem Medicaid |
$122.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$276.90
|
| Rate for Payer: Cash Price |
$177.50
|
| Rate for Payer: Cigna Commercial |
$294.65
|
| Rate for Payer: First Health Commercial |
$337.25
|
| Rate for Payer: Humana Commercial |
$301.75
|
| Rate for Payer: Humana KY Medicaid |
$122.08
|
| Rate for Payer: Kentucky WC Medicaid |
$123.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$291.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$261.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$106.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$124.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$312.40
|
| Rate for Payer: Ohio Health Group HMO |
$266.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$284.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$308.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$244.95
|
| Rate for Payer: PHCS Commercial |
$340.80
|
| Rate for Payer: United Healthcare All Payer |
$312.40
|
|
|
BREAST TOMOSYNTHESIS BILAT(P
|
Professional
|
Both
|
$230.00
|
|
|
Service Code
|
HCPCS 77062
|
| Hospital Charge Code |
401P0002
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$80.50 |
| Max. Negotiated Rate |
$201.87 |
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cigna Commercial |
$201.87
|
| Rate for Payer: Multiplan PHCS |
$138.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$161.00
|
| Rate for Payer: UHCCP Medicaid |
$80.50
|
|
|
BREAST TOMOSYNTHESIS BILAT(T
|
Facility
|
OP
|
$125.00
|
|
|
Service Code
|
HCPCS G0279
|
| Hospital Charge Code |
401T0002
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$37.50 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial |
$96.25
|
| Rate for Payer: Anthem Medicaid |
$42.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$97.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$103.75
|
| Rate for Payer: First Health Commercial |
$118.75
|
| Rate for Payer: Humana Commercial |
$106.25
|
| Rate for Payer: Humana KY Medicaid |
$42.99
|
| Rate for Payer: Kentucky WC Medicaid |
$43.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$102.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$110.00
|
| Rate for Payer: Ohio Health Group HMO |
$93.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$108.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$86.25
|
| Rate for Payer: PHCS Commercial |
$120.00
|
| Rate for Payer: United Healthcare All Payer |
$110.00
|
|
|
BREAST TOMOSYNTHESIS BILAT(T
|
Facility
|
IP
|
$125.00
|
|
|
Service Code
|
HCPCS G0279
|
| Hospital Charge Code |
401T0002
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$37.50 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial |
$96.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$97.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$103.75
|
| Rate for Payer: First Health Commercial |
$118.75
|
| Rate for Payer: Humana Commercial |
$106.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$102.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$110.00
|
| Rate for Payer: Ohio Health Group HMO |
$93.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$108.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$86.25
|
| Rate for Payer: PHCS Commercial |
$120.00
|
| Rate for Payer: United Healthcare All Payer |
$110.00
|
|
|
BREAST TOMOSYNTHESIS BILAT(T
|
Facility
|
OP
|
$125.00
|
|
|
Service Code
|
HCPCS 77062
|
| Hospital Charge Code |
401T0002
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$37.50 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial |
$96.25
|
| Rate for Payer: Anthem Medicaid |
$42.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$97.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$103.75
|
| Rate for Payer: First Health Commercial |
$118.75
|
| Rate for Payer: Humana Commercial |
$106.25
|
| Rate for Payer: Humana KY Medicaid |
$42.99
|
| Rate for Payer: Kentucky WC Medicaid |
$43.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$102.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$110.00
|
| Rate for Payer: Ohio Health Group HMO |
$93.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$108.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$86.25
|
| Rate for Payer: PHCS Commercial |
$120.00
|
| Rate for Payer: United Healthcare All Payer |
$110.00
|
|
|
BREAST TOMOSYNTHESIS BILAT(T
|
Facility
|
IP
|
$125.00
|
|
|
Service Code
|
HCPCS 77062
|
| Hospital Charge Code |
401T0002
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$37.50 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial |
$96.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$97.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$103.75
|
| Rate for Payer: First Health Commercial |
$118.75
|
| Rate for Payer: Humana Commercial |
$106.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$102.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$110.00
|
| Rate for Payer: Ohio Health Group HMO |
$93.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$108.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$86.25
|
| Rate for Payer: PHCS Commercial |
$120.00
|
| Rate for Payer: United Healthcare All Payer |
$110.00
|
|
|
BREAST TOMOSYNTHESIS UNILAT
|
Facility
|
IP
|
$352.00
|
|
|
Service Code
|
HCPCS 77061
|
| Hospital Charge Code |
40100001
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$105.60 |
| Max. Negotiated Rate |
$337.92 |
| Rate for Payer: Aetna Commercial |
$271.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$274.56
|
| Rate for Payer: Cash Price |
$176.00
|
| Rate for Payer: Cigna Commercial |
$292.16
|
| Rate for Payer: First Health Commercial |
$334.40
|
| Rate for Payer: Humana Commercial |
$299.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$288.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$259.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$105.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$309.76
|
| Rate for Payer: Ohio Health Group HMO |
$264.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$281.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$306.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$242.88
|
| Rate for Payer: PHCS Commercial |
$337.92
|
| Rate for Payer: United Healthcare All Payer |
$309.76
|
|
|
BREAST TOMOSYNTHESIS UNILAT
|
Professional
|
Both
|
$352.00
|
|
|
Service Code
|
HCPCS 77061
|
| Hospital Charge Code |
40100001
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$123.20 |
| Max. Negotiated Rate |
$255.89 |
| Rate for Payer: Cash Price |
$176.00
|
| Rate for Payer: Cash Price |
$176.00
|
| Rate for Payer: Cigna Commercial |
$255.89
|
| Rate for Payer: Multiplan PHCS |
$211.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$246.40
|
| Rate for Payer: UHCCP Medicaid |
$123.20
|
|
|
BREAST TOMOSYNTHESIS UNILAT
|
Facility
|
OP
|
$352.00
|
|
|
Service Code
|
HCPCS 77061
|
| Hospital Charge Code |
40100001
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$105.60 |
| Max. Negotiated Rate |
$337.92 |
| Rate for Payer: Aetna Commercial |
$271.04
|
| Rate for Payer: Anthem Medicaid |
$121.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$274.56
|
| Rate for Payer: Cash Price |
$176.00
|
| Rate for Payer: Cigna Commercial |
$292.16
|
| Rate for Payer: First Health Commercial |
$334.40
|
| Rate for Payer: Humana Commercial |
$299.20
|
| Rate for Payer: Humana KY Medicaid |
$121.05
|
| Rate for Payer: Kentucky WC Medicaid |
$122.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$288.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$259.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$105.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$123.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$309.76
|
| Rate for Payer: Ohio Health Group HMO |
$264.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$281.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$306.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$242.88
|
| Rate for Payer: PHCS Commercial |
$337.92
|
| Rate for Payer: United Healthcare All Payer |
$309.76
|
|
|
BREAST TOMOSYNTHESIS UNILAT(P
|
Professional
|
Both
|
$230.00
|
|
|
Service Code
|
HCPCS 77061
|
| Hospital Charge Code |
401P0001
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$80.50 |
| Max. Negotiated Rate |
$255.89 |
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cigna Commercial |
$255.89
|
| Rate for Payer: Multiplan PHCS |
$138.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$161.00
|
| Rate for Payer: UHCCP Medicaid |
$80.50
|
|
|
BREAST TOMOSYNTHESIS UNILAT(T
|
Facility
|
OP
|
$122.00
|
|
|
Service Code
|
HCPCS G0279
|
| Hospital Charge Code |
401T0001
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$36.60 |
| Max. Negotiated Rate |
$117.12 |
| Rate for Payer: Aetna Commercial |
$93.94
|
| Rate for Payer: Anthem Medicaid |
$41.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.16
|
| Rate for Payer: Cash Price |
$61.00
|
| Rate for Payer: Cigna Commercial |
$101.26
|
| Rate for Payer: First Health Commercial |
$115.90
|
| Rate for Payer: Humana Commercial |
$103.70
|
| Rate for Payer: Humana KY Medicaid |
$41.96
|
| Rate for Payer: Kentucky WC Medicaid |
$42.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.36
|
| Rate for Payer: Ohio Health Group HMO |
$91.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$97.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.18
|
| Rate for Payer: PHCS Commercial |
$117.12
|
| Rate for Payer: United Healthcare All Payer |
$107.36
|
|
|
BREAST TOMOSYNTHESIS UNILAT(T
|
Facility
|
IP
|
$122.00
|
|
|
Service Code
|
HCPCS 77061
|
| Hospital Charge Code |
401T0001
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$36.60 |
| Max. Negotiated Rate |
$117.12 |
| Rate for Payer: Aetna Commercial |
$93.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.16
|
| Rate for Payer: Cash Price |
$61.00
|
| Rate for Payer: Cigna Commercial |
$101.26
|
| Rate for Payer: First Health Commercial |
$115.90
|
| Rate for Payer: Humana Commercial |
$103.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.36
|
| Rate for Payer: Ohio Health Group HMO |
$91.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$97.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.18
|
| Rate for Payer: PHCS Commercial |
$117.12
|
| Rate for Payer: United Healthcare All Payer |
$107.36
|
|
|
BREAST TOMOSYNTHESIS UNILAT(T
|
Facility
|
OP
|
$122.00
|
|
|
Service Code
|
HCPCS 77061
|
| Hospital Charge Code |
401T0001
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$36.60 |
| Max. Negotiated Rate |
$117.12 |
| Rate for Payer: Aetna Commercial |
$93.94
|
| Rate for Payer: Anthem Medicaid |
$41.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.16
|
| Rate for Payer: Cash Price |
$61.00
|
| Rate for Payer: Cigna Commercial |
$101.26
|
| Rate for Payer: First Health Commercial |
$115.90
|
| Rate for Payer: Humana Commercial |
$103.70
|
| Rate for Payer: Humana KY Medicaid |
$41.96
|
| Rate for Payer: Kentucky WC Medicaid |
$42.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.36
|
| Rate for Payer: Ohio Health Group HMO |
$91.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$97.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.18
|
| Rate for Payer: PHCS Commercial |
$117.12
|
| Rate for Payer: United Healthcare All Payer |
$107.36
|
|
|
BREAST TOMOSYNTHESIS UNILAT(T
|
Facility
|
IP
|
$122.00
|
|
|
Service Code
|
HCPCS G0279
|
| Hospital Charge Code |
401T0001
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$36.60 |
| Max. Negotiated Rate |
$117.12 |
| Rate for Payer: Aetna Commercial |
$93.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.16
|
| Rate for Payer: Cash Price |
$61.00
|
| Rate for Payer: Cigna Commercial |
$101.26
|
| Rate for Payer: First Health Commercial |
$115.90
|
| Rate for Payer: Humana Commercial |
$103.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.36
|
| Rate for Payer: Ohio Health Group HMO |
$91.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$97.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.18
|
| Rate for Payer: PHCS Commercial |
$117.12
|
| Rate for Payer: United Healthcare All Payer |
$107.36
|
|
|
BREATH HYDROGEN/METHANE TES(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 91065
|
| Hospital Charge Code |
761P2446
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$13.37 |
| Max. Negotiated Rate |
$96.10 |
| Rate for Payer: Aetna Commercial |
$96.10
|
| Rate for Payer: Ambetter Exchange |
$58.41
|
| Rate for Payer: Anthem Medicaid |
$36.68
|
| Rate for Payer: Buckeye Individual/Medicaid |
$58.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$58.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$70.09
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$78.82
|
| Rate for Payer: Healthspan PPO |
$78.64
|
| Rate for Payer: Humana Medicaid |
$36.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$13.37
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$58.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58.41
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$37.41
|
| Rate for Payer: Molina Healthcare Passport |
$36.68
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$75.93
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$37.05
|
| Rate for Payer: Wellcare Medicare Advantage |
$58.41
|
|
|
BREATH HYDROGEN/METHANE TES(T
|
Facility
|
OP
|
$518.00
|
|
|
Service Code
|
HCPCS 91065
|
| Hospital Charge Code |
761T2446
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$144.57 |
| Max. Negotiated Rate |
$497.28 |
| Rate for Payer: Aetna Commercial |
$398.86
|
| Rate for Payer: Anthem Medicaid |
$178.14
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$144.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$404.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$202.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$195.17
|
| Rate for Payer: Cash Price |
$259.00
|
| Rate for Payer: Cash Price |
$259.00
|
| Rate for Payer: Cigna Commercial |
$429.94
|
| Rate for Payer: First Health Commercial |
$492.10
|
| Rate for Payer: Humana Commercial |
$440.30
|
| Rate for Payer: Humana KY Medicaid |
$178.14
|
| Rate for Payer: Humana Medicare Advantage |
$144.57
|
| Rate for Payer: Kentucky WC Medicaid |
$179.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$424.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$382.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$181.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$455.84
|
| Rate for Payer: Ohio Health Group HMO |
$388.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$414.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$450.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$357.42
|
| Rate for Payer: PHCS Commercial |
$497.28
|
| Rate for Payer: United Healthcare All Payer |
$455.84
|
|
|
BREATH HYDROGEN/METHANE TES(T
|
Facility
|
IP
|
$518.00
|
|
|
Service Code
|
HCPCS 91065
|
| Hospital Charge Code |
761T2446
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$155.40 |
| Max. Negotiated Rate |
$497.28 |
| Rate for Payer: Aetna Commercial |
$398.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$404.04
|
| Rate for Payer: Cash Price |
$259.00
|
| Rate for Payer: Cigna Commercial |
$429.94
|
| Rate for Payer: First Health Commercial |
$492.10
|
| Rate for Payer: Humana Commercial |
$440.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$424.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$382.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$155.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$455.84
|
| Rate for Payer: Ohio Health Group HMO |
$388.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$414.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$450.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$357.42
|
| Rate for Payer: PHCS Commercial |
$497.28
|
| Rate for Payer: United Healthcare All Payer |
$455.84
|
|
|
BREATH HYDROGEN/METHANE TEST
|
Facility
|
OP
|
$668.00
|
|
|
Service Code
|
HCPCS 91065
|
| Hospital Charge Code |
76102446
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$144.57 |
| Max. Negotiated Rate |
$641.28 |
| Rate for Payer: Aetna Commercial |
$514.36
|
| Rate for Payer: Anthem Medicaid |
$229.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$144.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$521.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$202.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$195.17
|
| Rate for Payer: Cash Price |
$334.00
|
| Rate for Payer: Cash Price |
$334.00
|
| Rate for Payer: Cigna Commercial |
$554.44
|
| Rate for Payer: First Health Commercial |
$634.60
|
| Rate for Payer: Humana Commercial |
$567.80
|
| Rate for Payer: Humana KY Medicaid |
$229.73
|
| Rate for Payer: Humana Medicare Advantage |
$144.57
|
| Rate for Payer: Kentucky WC Medicaid |
$232.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$547.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$492.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$234.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$587.84
|
| Rate for Payer: Ohio Health Group HMO |
$501.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$534.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$581.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$460.92
|
| Rate for Payer: PHCS Commercial |
$641.28
|
| Rate for Payer: United Healthcare All Payer |
$587.84
|
|
|
BREATH HYDROGEN/METHANE TEST
|
Professional
|
Both
|
$668.00
|
|
|
Service Code
|
HCPCS 91065
|
| Hospital Charge Code |
76102446
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$13.37 |
| Max. Negotiated Rate |
$400.80 |
| Rate for Payer: Aetna Commercial |
$96.10
|
| Rate for Payer: Ambetter Exchange |
$58.41
|
| Rate for Payer: Anthem Medicaid |
$36.68
|
| Rate for Payer: Buckeye Individual/Medicaid |
$58.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$58.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$70.09
|
| Rate for Payer: Cash Price |
$334.00
|
| Rate for Payer: Cash Price |
$334.00
|
| Rate for Payer: Cigna Commercial |
$78.82
|
| Rate for Payer: Healthspan PPO |
$78.64
|
| Rate for Payer: Humana Medicaid |
$36.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$13.37
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$58.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58.41
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$37.41
|
| Rate for Payer: Molina Healthcare Passport |
$36.68
|
| Rate for Payer: Multiplan PHCS |
$400.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$75.93
|
| Rate for Payer: UHCCP Medicaid |
$233.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$37.05
|
| Rate for Payer: Wellcare Medicare Advantage |
$58.41
|
|
|
BREATH HYDROGEN/METHANE TEST
|
Facility
|
IP
|
$668.00
|
|
|
Service Code
|
HCPCS 91065
|
| Hospital Charge Code |
76102446
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$200.40 |
| Max. Negotiated Rate |
$641.28 |
| Rate for Payer: Aetna Commercial |
$514.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$521.04
|
| Rate for Payer: Cash Price |
$334.00
|
| Rate for Payer: Cigna Commercial |
$554.44
|
| Rate for Payer: First Health Commercial |
$634.60
|
| Rate for Payer: Humana Commercial |
$567.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$547.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$492.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$200.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$587.84
|
| Rate for Payer: Ohio Health Group HMO |
$501.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$534.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$581.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$460.92
|
| Rate for Payer: PHCS Commercial |
$641.28
|
| Rate for Payer: United Healthcare All Payer |
$587.84
|
|
|
BREEZA
|
Facility
|
IP
|
$11.81
|
|
|
Service Code
|
NDC 15137002126
|
| Hospital Charge Code |
25004547
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.54 |
| Max. Negotiated Rate |
$11.34 |
| Rate for Payer: Aetna Commercial |
$9.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.21
|
| Rate for Payer: Cash Price |
$5.90
|
| Rate for Payer: Cigna Commercial |
$9.80
|
| Rate for Payer: First Health Commercial |
$11.22
|
| Rate for Payer: Humana Commercial |
$10.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.39
|
| Rate for Payer: Ohio Health Group HMO |
$8.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.15
|
| Rate for Payer: PHCS Commercial |
$11.34
|
| Rate for Payer: United Healthcare All Payer |
$10.39
|
|
