|
DELAYED BREAST PROSTHESIS(P
|
Professional
|
Both
|
$2,000.00
|
|
|
Service Code
|
HCPCS 19342
|
| Hospital Charge Code |
761P0312
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$651.49 |
| Max. Negotiated Rate |
$2,000.00 |
| Rate for Payer: Aetna Commercial |
$1,333.32
|
| Rate for Payer: Anthem Medicaid |
$651.49
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,258.86
|
| Rate for Payer: Healthspan PPO |
$1,066.11
|
| Rate for Payer: Humana Medicaid |
$651.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,185.79
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$664.52
|
| Rate for Payer: Molina Healthcare Passport |
$651.49
|
| Rate for Payer: Multiplan PHCS |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,400.00
|
| Rate for Payer: UHCCP Medicaid |
$700.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$658.00
|
|
|
DELAY FLAP F/C/C/N/AX/G/H/F
|
Professional
|
Both
|
$7,236.83
|
|
|
Service Code
|
HCPCS 15620
|
| Hospital Charge Code |
76100202
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$166.11 |
| Max. Negotiated Rate |
$7,236.83 |
| Rate for Payer: Aetna Commercial |
$442.63
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$166.11
|
| Rate for Payer: Anthem Medicaid |
$192.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$7,236.83
|
| Rate for Payer: Cash Price |
$3,618.42
|
| Rate for Payer: Cash Price |
$3,618.42
|
| Rate for Payer: Cigna Commercial |
$426.26
|
| Rate for Payer: Healthspan PPO |
$475.89
|
| Rate for Payer: Humana Medicaid |
$192.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$398.20
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$195.94
|
| Rate for Payer: Molina Healthcare Passport |
$192.10
|
| Rate for Payer: Multiplan PHCS |
$4,342.10
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5,065.78
|
| Rate for Payer: UHCCP Medicaid |
$174.42
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$194.02
|
|
|
DELAY FLAP F/C/C/N/AX/G/H/F
|
Facility
|
OP
|
$7,236.83
|
|
|
Service Code
|
HCPCS 15620
|
| Hospital Charge Code |
76100202
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$940.79 |
| Max. Negotiated Rate |
$6,947.36 |
| Rate for Payer: Aetna Commercial |
$5,572.36
|
| Rate for Payer: Anthem Medicaid |
$2,488.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,644.73
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$3,618.42
|
| Rate for Payer: Cash Price |
$3,618.42
|
| Rate for Payer: Cigna Commercial |
$6,006.57
|
| Rate for Payer: First Health Commercial |
$6,874.99
|
| Rate for Payer: Humana Commercial |
$6,151.31
|
| Rate for Payer: Humana KY Medicaid |
$2,488.75
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,514.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,934.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,340.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,538.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,368.41
|
| Rate for Payer: Ohio Health Group HMO |
$5,427.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,447.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$940.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,243.42
|
| Rate for Payer: PHCS Commercial |
$6,947.36
|
| Rate for Payer: United Healthcare All Payer |
$6,368.41
|
|
|
DELAY FLAP F/C/C/N/AX/G/H/F
|
Facility
|
IP
|
$7,236.83
|
|
|
Service Code
|
HCPCS 15620
|
| Hospital Charge Code |
76100202
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$940.79 |
| Max. Negotiated Rate |
$6,947.36 |
| Rate for Payer: Aetna Commercial |
$5,572.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,644.73
|
| Rate for Payer: Cash Price |
$3,618.42
|
| Rate for Payer: Cigna Commercial |
$6,006.57
|
| Rate for Payer: First Health Commercial |
$6,874.99
|
| Rate for Payer: Humana Commercial |
$6,151.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,934.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,340.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,171.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,368.41
|
| Rate for Payer: Ohio Health Group HMO |
$5,427.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,447.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$940.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,243.42
|
| Rate for Payer: PHCS Commercial |
$6,947.36
|
| Rate for Payer: United Healthcare All Payer |
$6,368.41
|
|
|
DELAY FLAP F/C/C/N/AX/G/H/F(P
|
Professional
|
Both
|
$860.00
|
|
|
Service Code
|
HCPCS 15620
|
| Hospital Charge Code |
761P0202
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$166.11 |
| Max. Negotiated Rate |
$860.00 |
| Rate for Payer: Aetna Commercial |
$442.63
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$166.11
|
| Rate for Payer: Anthem Medicaid |
$192.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$860.00
|
| Rate for Payer: Cash Price |
$430.00
|
| Rate for Payer: Cash Price |
$430.00
|
| Rate for Payer: Cigna Commercial |
$426.26
|
| Rate for Payer: Healthspan PPO |
$475.89
|
| Rate for Payer: Humana Medicaid |
$192.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$398.20
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$195.94
|
| Rate for Payer: Molina Healthcare Passport |
$192.10
|
| Rate for Payer: Multiplan PHCS |
$516.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$602.00
|
| Rate for Payer: UHCCP Medicaid |
$174.42
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$194.02
|
|
|
DELAY FLAP F/C/C/N/AX/G/H/F(T
|
Facility
|
IP
|
$6,376.83
|
|
|
Service Code
|
HCPCS 15620
|
| Hospital Charge Code |
761T0202
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$828.99 |
| Max. Negotiated Rate |
$6,121.76 |
| Rate for Payer: Aetna Commercial |
$4,910.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,973.93
|
| Rate for Payer: Cash Price |
$3,188.42
|
| Rate for Payer: Cigna Commercial |
$5,292.77
|
| Rate for Payer: First Health Commercial |
$6,057.99
|
| Rate for Payer: Humana Commercial |
$5,420.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,229.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,706.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,913.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,611.61
|
| Rate for Payer: Ohio Health Group HMO |
$4,782.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,275.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$828.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,976.82
|
| Rate for Payer: PHCS Commercial |
$6,121.76
|
| Rate for Payer: United Healthcare All Payer |
$5,611.61
|
|
|
DELAY FLAP F/C/C/N/AX/G/H/F(T
|
Facility
|
OP
|
$6,376.83
|
|
|
Service Code
|
HCPCS 15620
|
| Hospital Charge Code |
761T0202
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$828.99 |
| Max. Negotiated Rate |
$6,121.76 |
| Rate for Payer: Aetna Commercial |
$4,910.16
|
| Rate for Payer: Anthem Medicaid |
$2,192.99
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,973.93
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$3,188.42
|
| Rate for Payer: Cash Price |
$3,188.42
|
| Rate for Payer: Cigna Commercial |
$5,292.77
|
| Rate for Payer: First Health Commercial |
$6,057.99
|
| Rate for Payer: Humana Commercial |
$5,420.31
|
| Rate for Payer: Humana KY Medicaid |
$2,192.99
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,215.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,229.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,706.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,236.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,611.61
|
| Rate for Payer: Ohio Health Group HMO |
$4,782.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,275.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$828.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,976.82
|
| Rate for Payer: PHCS Commercial |
$6,121.76
|
| Rate for Payer: United Healthcare All Payer |
$5,611.61
|
|
|
DELAY OF FLAP AT FACE
|
Professional
|
Both
|
$6,852.00
|
|
|
Service Code
|
HCPCS 15630
|
| Hospital Charge Code |
76100203
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$174.07 |
| Max. Negotiated Rate |
$6,852.00 |
| Rate for Payer: Aetna Commercial |
$482.39
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$174.07
|
| Rate for Payer: Anthem Medicaid |
$214.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,852.00
|
| Rate for Payer: Cash Price |
$3,426.00
|
| Rate for Payer: Cash Price |
$3,426.00
|
| Rate for Payer: Cigna Commercial |
$459.91
|
| Rate for Payer: Healthspan PPO |
$502.54
|
| Rate for Payer: Humana Medicaid |
$214.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$431.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$218.30
|
| Rate for Payer: Molina Healthcare Passport |
$214.02
|
| Rate for Payer: Multiplan PHCS |
$4,111.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,796.40
|
| Rate for Payer: UHCCP Medicaid |
$182.77
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$216.16
|
|
|
DELAY OF FLAP AT FACE
|
Facility
|
IP
|
$6,852.00
|
|
|
Service Code
|
HCPCS 15630
|
| Hospital Charge Code |
76100203
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$890.76 |
| Max. Negotiated Rate |
$6,577.92 |
| Rate for Payer: Aetna Commercial |
$5,276.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,344.56
|
| Rate for Payer: Cash Price |
$3,426.00
|
| Rate for Payer: Cigna Commercial |
$5,687.16
|
| Rate for Payer: First Health Commercial |
$6,509.40
|
| Rate for Payer: Humana Commercial |
$5,824.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,618.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,056.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,055.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,029.76
|
| Rate for Payer: Ohio Health Group HMO |
$5,139.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,370.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$890.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,124.12
|
| Rate for Payer: PHCS Commercial |
$6,577.92
|
| Rate for Payer: United Healthcare All Payer |
$6,029.76
|
|
|
DELAY OF FLAP AT FACE
|
Facility
|
OP
|
$6,852.00
|
|
|
Service Code
|
HCPCS 15630
|
| Hospital Charge Code |
76100203
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$890.76 |
| Max. Negotiated Rate |
$6,577.92 |
| Rate for Payer: Aetna Commercial |
$5,276.04
|
| Rate for Payer: Anthem Medicaid |
$2,356.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,344.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$3,426.00
|
| Rate for Payer: Cash Price |
$3,426.00
|
| Rate for Payer: Cigna Commercial |
$5,687.16
|
| Rate for Payer: First Health Commercial |
$6,509.40
|
| Rate for Payer: Humana Commercial |
$5,824.20
|
| Rate for Payer: Humana KY Medicaid |
$2,356.40
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,380.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,618.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,056.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,403.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,029.76
|
| Rate for Payer: Ohio Health Group HMO |
$5,139.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,370.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$890.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,124.12
|
| Rate for Payer: PHCS Commercial |
$6,577.92
|
| Rate for Payer: United Healthcare All Payer |
$6,029.76
|
|
|
DELAY OF FLAP AT FACE(P
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 15630
|
| Hospital Charge Code |
761P0203
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$174.07 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Aetna Commercial |
$482.39
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$174.07
|
| Rate for Payer: Anthem Medicaid |
$214.02
|
| 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 |
$459.91
|
| Rate for Payer: Healthspan PPO |
$502.54
|
| Rate for Payer: Humana Medicaid |
$214.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$431.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$218.30
|
| Rate for Payer: Molina Healthcare Passport |
$214.02
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$182.77
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$216.16
|
|
|
DELAY OF FLAP AT FACE(T
|
Facility
|
OP
|
$5,852.00
|
|
|
Service Code
|
HCPCS 15630
|
| Hospital Charge Code |
761T0203
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$760.76 |
| Max. Negotiated Rate |
$5,617.92 |
| Rate for Payer: Aetna Commercial |
$4,506.04
|
| Rate for Payer: Anthem Medicaid |
$2,012.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,564.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$2,926.00
|
| Rate for Payer: Cash Price |
$2,926.00
|
| Rate for Payer: Cigna Commercial |
$4,857.16
|
| Rate for Payer: First Health Commercial |
$5,559.40
|
| Rate for Payer: Humana Commercial |
$4,974.20
|
| Rate for Payer: Humana KY Medicaid |
$2,012.50
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,032.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,798.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,318.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,052.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,149.76
|
| Rate for Payer: Ohio Health Group HMO |
$4,389.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,170.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$760.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,814.12
|
| Rate for Payer: PHCS Commercial |
$5,617.92
|
| Rate for Payer: United Healthcare All Payer |
$5,149.76
|
|
|
DELAY OF FLAP AT FACE(T
|
Facility
|
IP
|
$5,852.00
|
|
|
Service Code
|
HCPCS 15630
|
| Hospital Charge Code |
761T0203
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$760.76 |
| Max. Negotiated Rate |
$5,617.92 |
| Rate for Payer: Aetna Commercial |
$4,506.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,564.56
|
| Rate for Payer: Cash Price |
$2,926.00
|
| Rate for Payer: Cigna Commercial |
$4,857.16
|
| Rate for Payer: First Health Commercial |
$5,559.40
|
| Rate for Payer: Humana Commercial |
$4,974.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,798.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,318.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,755.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,149.76
|
| Rate for Payer: Ohio Health Group HMO |
$4,389.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,170.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$760.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,814.12
|
| Rate for Payer: PHCS Commercial |
$5,617.92
|
| Rate for Payer: United Healthcare All Payer |
$5,149.76
|
|
|
DELAY OF TRAM FLAP
|
Professional
|
Both
|
$7,262.34
|
|
|
Service Code
|
HCPCS 15600
|
| Hospital Charge Code |
76100201
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$108.90 |
| Max. Negotiated Rate |
$7,262.34 |
| Rate for Payer: Aetna Commercial |
$282.72
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$108.90
|
| Rate for Payer: Anthem Medicaid |
$138.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$7,262.34
|
| Rate for Payer: Cash Price |
$3,631.17
|
| Rate for Payer: Cash Price |
$3,631.17
|
| Rate for Payer: Cigna Commercial |
$282.95
|
| Rate for Payer: Healthspan PPO |
$354.88
|
| Rate for Payer: Humana Medicaid |
$138.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$252.12
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$141.36
|
| Rate for Payer: Molina Healthcare Passport |
$138.59
|
| Rate for Payer: Multiplan PHCS |
$4,357.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5,083.64
|
| Rate for Payer: UHCCP Medicaid |
$114.34
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$139.98
|
|
|
DELAY OF TRAM FLAP
|
Facility
|
OP
|
$7,262.34
|
|
|
Service Code
|
HCPCS 15600
|
| Hospital Charge Code |
76100201
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$944.10 |
| Max. Negotiated Rate |
$6,971.85 |
| Rate for Payer: Aetna Commercial |
$5,592.00
|
| Rate for Payer: Anthem Medicaid |
$2,497.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,102.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,664.63
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,343.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,188.25
|
| Rate for Payer: Cash Price |
$3,631.17
|
| Rate for Payer: Cash Price |
$3,631.17
|
| Rate for Payer: Cigna Commercial |
$6,027.74
|
| Rate for Payer: First Health Commercial |
$6,899.22
|
| Rate for Payer: Humana Commercial |
$6,172.99
|
| Rate for Payer: Humana KY Medicaid |
$2,497.52
|
| Rate for Payer: Humana Medicare Advantage |
$3,102.41
|
| Rate for Payer: Kentucky WC Medicaid |
$2,522.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,955.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,359.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,547.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,390.86
|
| Rate for Payer: Ohio Health Group HMO |
$5,446.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,452.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$944.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,251.33
|
| Rate for Payer: PHCS Commercial |
$6,971.85
|
| Rate for Payer: United Healthcare All Payer |
$6,390.86
|
|
|
DELAY OF TRAM FLAP
|
Facility
|
IP
|
$7,262.34
|
|
|
Service Code
|
HCPCS 15600
|
| Hospital Charge Code |
76100201
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$944.10 |
| Max. Negotiated Rate |
$6,971.85 |
| Rate for Payer: Aetna Commercial |
$5,592.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,664.63
|
| Rate for Payer: Cash Price |
$3,631.17
|
| Rate for Payer: Cigna Commercial |
$6,027.74
|
| Rate for Payer: First Health Commercial |
$6,899.22
|
| Rate for Payer: Humana Commercial |
$6,172.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,955.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,359.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,178.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,390.86
|
| Rate for Payer: Ohio Health Group HMO |
$5,446.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,452.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$944.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,251.33
|
| Rate for Payer: PHCS Commercial |
$6,971.85
|
| Rate for Payer: United Healthcare All Payer |
$6,390.86
|
|
|
DELAY OF TRAM FLAP(P
|
Professional
|
Both
|
$650.00
|
|
|
Service Code
|
HCPCS 15600
|
| Hospital Charge Code |
761P0201
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$108.90 |
| Max. Negotiated Rate |
$650.00 |
| Rate for Payer: Aetna Commercial |
$282.72
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$108.90
|
| Rate for Payer: Anthem Medicaid |
$138.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$650.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$282.95
|
| Rate for Payer: Healthspan PPO |
$354.88
|
| Rate for Payer: Humana Medicaid |
$138.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$252.12
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$141.36
|
| Rate for Payer: Molina Healthcare Passport |
$138.59
|
| Rate for Payer: Multiplan PHCS |
$390.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$455.00
|
| Rate for Payer: UHCCP Medicaid |
$114.34
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$139.98
|
|
|
DELAY OF TRAM FLAP(T
|
Facility
|
OP
|
$6,612.34
|
|
|
Service Code
|
HCPCS 15600
|
| Hospital Charge Code |
761T0201
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$859.60 |
| Max. Negotiated Rate |
$6,347.85 |
| Rate for Payer: Aetna Commercial |
$5,091.50
|
| Rate for Payer: Anthem Medicaid |
$2,273.98
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,102.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,157.63
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,343.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,188.25
|
| Rate for Payer: Cash Price |
$3,306.17
|
| Rate for Payer: Cash Price |
$3,306.17
|
| Rate for Payer: Cigna Commercial |
$5,488.24
|
| Rate for Payer: First Health Commercial |
$6,281.72
|
| Rate for Payer: Humana Commercial |
$5,620.49
|
| Rate for Payer: Humana KY Medicaid |
$2,273.98
|
| Rate for Payer: Humana Medicare Advantage |
$3,102.41
|
| Rate for Payer: Kentucky WC Medicaid |
$2,297.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,422.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,879.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,319.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,818.86
|
| Rate for Payer: Ohio Health Group HMO |
$4,959.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,322.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$859.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,049.83
|
| Rate for Payer: PHCS Commercial |
$6,347.85
|
| Rate for Payer: United Healthcare All Payer |
$5,818.86
|
|
|
DELAY OF TRAM FLAP(T
|
Facility
|
IP
|
$6,612.34
|
|
|
Service Code
|
HCPCS 15600
|
| Hospital Charge Code |
761T0201
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$859.60 |
| Max. Negotiated Rate |
$6,347.85 |
| Rate for Payer: Aetna Commercial |
$5,091.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,157.63
|
| Rate for Payer: Cash Price |
$3,306.17
|
| Rate for Payer: Cigna Commercial |
$5,488.24
|
| Rate for Payer: First Health Commercial |
$6,281.72
|
| Rate for Payer: Humana Commercial |
$5,620.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,422.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,879.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,983.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,818.86
|
| Rate for Payer: Ohio Health Group HMO |
$4,959.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,322.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$859.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,049.83
|
| Rate for Payer: PHCS Commercial |
$6,347.85
|
| Rate for Payer: United Healthcare All Payer |
$5,818.86
|
|
|
DEL II R-T REC 9*34 LEFT
|
Facility
|
OP
|
$4,914.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$638.85 |
| Max. Negotiated Rate |
$4,717.68 |
| Rate for Payer: Aetna Commercial |
$3,783.97
|
| Rate for Payer: Anthem Medicaid |
$1,690.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,833.12
|
| Rate for Payer: Cash Price |
$2,457.12
|
| Rate for Payer: Cigna Commercial |
$4,078.83
|
| Rate for Payer: First Health Commercial |
$4,668.54
|
| Rate for Payer: Humana Commercial |
$4,177.11
|
| Rate for Payer: Humana KY Medicaid |
$1,690.01
|
| Rate for Payer: Kentucky WC Medicaid |
$1,707.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,029.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,626.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,474.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,723.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,324.54
|
| Rate for Payer: Ohio Health Group HMO |
$3,685.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$982.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$638.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,523.42
|
| Rate for Payer: PHCS Commercial |
$4,717.68
|
| Rate for Payer: United Healthcare All Payer |
$4,324.54
|
|
|
DEL II R-T REC 9*34 LEFT
|
Facility
|
IP
|
$4,914.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$638.85 |
| Max. Negotiated Rate |
$4,717.68 |
| Rate for Payer: Aetna Commercial |
$3,783.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,833.12
|
| Rate for Payer: Cash Price |
$2,457.12
|
| Rate for Payer: Cigna Commercial |
$4,078.83
|
| Rate for Payer: First Health Commercial |
$4,668.54
|
| Rate for Payer: Humana Commercial |
$4,177.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,029.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,626.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,474.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,324.54
|
| Rate for Payer: Ohio Health Group HMO |
$3,685.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$982.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$638.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,523.42
|
| Rate for Payer: PHCS Commercial |
$4,717.68
|
| Rate for Payer: United Healthcare All Payer |
$4,324.54
|
|
|
DELIVER PLACENTA
|
Facility
|
IP
|
$4,276.00
|
|
|
Service Code
|
HCPCS 59414
|
| Hospital Charge Code |
72000018
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$555.88 |
| Max. Negotiated Rate |
$4,104.96 |
| Rate for Payer: Aetna Commercial |
$3,292.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,335.28
|
| Rate for Payer: Cash Price |
$2,138.00
|
| Rate for Payer: Cigna Commercial |
$3,549.08
|
| Rate for Payer: First Health Commercial |
$4,062.20
|
| Rate for Payer: Humana Commercial |
$3,634.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,506.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,155.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,282.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,762.88
|
| Rate for Payer: Ohio Health Group HMO |
$3,207.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$855.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$555.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,325.56
|
| Rate for Payer: PHCS Commercial |
$4,104.96
|
| Rate for Payer: United Healthcare All Payer |
$3,762.88
|
|
|
DELIVER PLACENTA
|
Facility
|
OP
|
$4,276.00
|
|
|
Service Code
|
HCPCS 59414
|
| Hospital Charge Code |
72000018
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$555.88 |
| Max. Negotiated Rate |
$4,104.96 |
| Rate for Payer: Aetna Commercial |
$3,292.52
|
| Rate for Payer: Anthem Medicaid |
$1,470.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,703.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,335.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,784.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,649.77
|
| Rate for Payer: Cash Price |
$2,138.00
|
| Rate for Payer: Cash Price |
$2,138.00
|
| Rate for Payer: Cigna Commercial |
$3,549.08
|
| Rate for Payer: First Health Commercial |
$4,062.20
|
| Rate for Payer: Humana Commercial |
$3,634.60
|
| Rate for Payer: Humana KY Medicaid |
$1,470.52
|
| Rate for Payer: Humana Medicare Advantage |
$2,703.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1,485.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,506.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,155.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,244.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,500.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,762.88
|
| Rate for Payer: Ohio Health Group HMO |
$3,207.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$855.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$555.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,325.56
|
| Rate for Payer: PHCS Commercial |
$4,104.96
|
| Rate for Payer: United Healthcare All Payer |
$3,762.88
|
|
|
DELIVER PLACENTA
|
Professional
|
Both
|
$4,276.00
|
|
|
Service Code
|
HCPCS 59414
|
| Hospital Charge Code |
72000018
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$84.65 |
| Max. Negotiated Rate |
$4,276.00 |
| Rate for Payer: Aetna Commercial |
$154.64
|
| Rate for Payer: Anthem Medicaid |
$84.65
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,276.00
|
| Rate for Payer: Cash Price |
$2,138.00
|
| Rate for Payer: Cash Price |
$2,138.00
|
| Rate for Payer: Cigna Commercial |
$143.33
|
| Rate for Payer: Healthspan PPO |
$112.24
|
| Rate for Payer: Humana Medicaid |
$84.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$111.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$86.34
|
| Rate for Payer: Molina Healthcare Passport |
$84.65
|
| Rate for Payer: Multiplan PHCS |
$2,565.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,993.20
|
| Rate for Payer: UHCCP Medicaid |
$1,496.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$85.50
|
|
|
DELIVER PLACENTA(P
|
Professional
|
Both
|
$545.00
|
|
|
Service Code
|
HCPCS 59414
|
| Hospital Charge Code |
720P0018
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$84.65 |
| Max. Negotiated Rate |
$545.00 |
| Rate for Payer: Aetna Commercial |
$154.64
|
| Rate for Payer: Anthem Medicaid |
$84.65
|
| Rate for Payer: Buckeye Medicare Advantage |
$545.00
|
| Rate for Payer: Cash Price |
$272.50
|
| Rate for Payer: Cash Price |
$272.50
|
| Rate for Payer: Cigna Commercial |
$143.33
|
| Rate for Payer: Healthspan PPO |
$112.24
|
| Rate for Payer: Humana Medicaid |
$84.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$111.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$86.34
|
| Rate for Payer: Molina Healthcare Passport |
$84.65
|
| Rate for Payer: Multiplan PHCS |
$327.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$381.50
|
| Rate for Payer: UHCCP Medicaid |
$190.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$85.50
|
|
