|
DEST MAL LES > 4.0CM - TAL(T
|
Facility
|
OP
|
$467.00
|
|
|
Service Code
|
HCPCS 17266
|
| Hospital Charge Code |
761T0259
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$160.60 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Aetna Commercial |
$359.59
|
| Rate for Payer: Anthem Medicaid |
$160.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$364.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$233.50
|
| Rate for Payer: Cash Price |
$233.50
|
| Rate for Payer: Cigna Commercial |
$387.61
|
| Rate for Payer: First Health Commercial |
$443.65
|
| Rate for Payer: Humana Commercial |
$396.95
|
| Rate for Payer: Humana KY Medicaid |
$160.60
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$162.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$382.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$344.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$163.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$410.96
|
| Rate for Payer: Ohio Health Group HMO |
$350.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$373.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$406.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$322.23
|
| Rate for Payer: PHCS Commercial |
$448.32
|
| Rate for Payer: United Healthcare All Payer |
$410.96
|
|
|
DEST MAL LES .6-1.0CM - TAL
|
Facility
|
IP
|
$529.00
|
|
|
Service Code
|
HCPCS 17261
|
| Hospital Charge Code |
76100255
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$158.70 |
| Max. Negotiated Rate |
$507.84 |
| Rate for Payer: Aetna Commercial |
$407.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$412.62
|
| Rate for Payer: Cash Price |
$264.50
|
| Rate for Payer: Cigna Commercial |
$439.07
|
| Rate for Payer: First Health Commercial |
$502.55
|
| Rate for Payer: Humana Commercial |
$449.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$433.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$390.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$158.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$465.52
|
| Rate for Payer: Ohio Health Group HMO |
$396.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$423.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$460.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$365.01
|
| Rate for Payer: PHCS Commercial |
$507.84
|
| Rate for Payer: United Healthcare All Payer |
$465.52
|
|
|
DEST MAL LES .6-1.0CM - TAL
|
Facility
|
OP
|
$529.00
|
|
|
Service Code
|
HCPCS 17261
|
| Hospital Charge Code |
76100255
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$181.92 |
| Max. Negotiated Rate |
$507.84 |
| Rate for Payer: Aetna Commercial |
$407.33
|
| Rate for Payer: Anthem Medicaid |
$181.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$412.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$264.50
|
| Rate for Payer: Cash Price |
$264.50
|
| Rate for Payer: Cigna Commercial |
$439.07
|
| Rate for Payer: First Health Commercial |
$502.55
|
| Rate for Payer: Humana Commercial |
$449.65
|
| Rate for Payer: Humana KY Medicaid |
$181.92
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$183.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$433.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$390.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$185.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$465.52
|
| Rate for Payer: Ohio Health Group HMO |
$396.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$423.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$460.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$365.01
|
| Rate for Payer: PHCS Commercial |
$507.84
|
| Rate for Payer: United Healthcare All Payer |
$465.52
|
|
|
DEST MAL LES .6-1.0CM - TAL
|
Professional
|
Both
|
$529.00
|
|
|
Service Code
|
HCPCS 17261
|
| Hospital Charge Code |
76100255
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$43.43 |
| Max. Negotiated Rate |
$317.40 |
| Rate for Payer: Aetna Commercial |
$127.39
|
| Rate for Payer: Ambetter Exchange |
$82.41
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$43.43
|
| Rate for Payer: Anthem Medicaid |
$73.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$82.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$82.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$98.89
|
| Rate for Payer: Cash Price |
$264.50
|
| Rate for Payer: Cash Price |
$264.50
|
| Rate for Payer: Cigna Commercial |
$178.19
|
| Rate for Payer: Healthspan PPO |
$154.07
|
| Rate for Payer: Humana Medicaid |
$73.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$114.89
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$82.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$82.41
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$74.52
|
| Rate for Payer: Molina Healthcare Passport |
$73.06
|
| Rate for Payer: Multiplan PHCS |
$317.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$107.13
|
| Rate for Payer: UHCCP Medicaid |
$45.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$73.79
|
| Rate for Payer: Wellcare Medicare Advantage |
$82.41
|
|
|
DEST MAL LES .6-1.0CM - TAL(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 17261
|
| Hospital Charge Code |
761P0255
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$43.43 |
| Max. Negotiated Rate |
$178.19 |
| Rate for Payer: Aetna Commercial |
$127.39
|
| Rate for Payer: Ambetter Exchange |
$82.41
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$43.43
|
| Rate for Payer: Anthem Medicaid |
$73.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$82.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$82.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$98.89
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$178.19
|
| Rate for Payer: Healthspan PPO |
$154.07
|
| Rate for Payer: Humana Medicaid |
$73.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$114.89
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$82.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$82.41
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$74.52
|
| Rate for Payer: Molina Healthcare Passport |
$73.06
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$107.13
|
| Rate for Payer: UHCCP Medicaid |
$45.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$73.79
|
| Rate for Payer: Wellcare Medicare Advantage |
$82.41
|
|
|
DEST MAL LES .6-1.0CM - TAL(T
|
Facility
|
IP
|
$279.00
|
|
|
Service Code
|
HCPCS 17261
|
| Hospital Charge Code |
761T0255
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$83.70 |
| Max. Negotiated Rate |
$267.84 |
| Rate for Payer: Aetna Commercial |
$214.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$217.62
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cigna Commercial |
$231.57
|
| Rate for Payer: First Health Commercial |
$265.05
|
| Rate for Payer: Humana Commercial |
$237.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$228.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$205.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$83.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$245.52
|
| Rate for Payer: Ohio Health Group HMO |
$209.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$223.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$242.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$192.51
|
| Rate for Payer: PHCS Commercial |
$267.84
|
| Rate for Payer: United Healthcare All Payer |
$245.52
|
|
|
DEST MAL LES .6-1.0CM - TAL(T
|
Facility
|
OP
|
$279.00
|
|
|
Service Code
|
HCPCS 17261
|
| Hospital Charge Code |
761T0255
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$95.95 |
| Max. Negotiated Rate |
$267.84 |
| Rate for Payer: Aetna Commercial |
$214.83
|
| Rate for Payer: Anthem Medicaid |
$95.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$217.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cigna Commercial |
$231.57
|
| Rate for Payer: First Health Commercial |
$265.05
|
| Rate for Payer: Humana Commercial |
$237.15
|
| Rate for Payer: Humana KY Medicaid |
$95.95
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$96.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$228.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$205.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$97.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$245.52
|
| Rate for Payer: Ohio Health Group HMO |
$209.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$223.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$242.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$192.51
|
| Rate for Payer: PHCS Commercial |
$267.84
|
| Rate for Payer: United Healthcare All Payer |
$245.52
|
|
|
DEST MAL LESION < 0.5CM TAL
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 17260
|
| Hospital Charge Code |
76100254
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$50.18 |
| Max. Negotiated Rate |
$270.00 |
| Rate for Payer: Aetna Commercial |
$94.54
|
| Rate for Payer: Ambetter Exchange |
$66.22
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$50.18
|
| Rate for Payer: Anthem Medicaid |
$57.97
|
| Rate for Payer: Buckeye Individual/Medicaid |
$66.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$66.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$79.46
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$124.64
|
| Rate for Payer: Healthspan PPO |
$103.83
|
| Rate for Payer: Humana Medicaid |
$57.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$84.43
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$66.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$66.22
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$59.13
|
| Rate for Payer: Molina Healthcare Passport |
$57.97
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$86.09
|
| Rate for Payer: UHCCP Medicaid |
$52.69
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$58.55
|
| Rate for Payer: Wellcare Medicare Advantage |
$66.22
|
|
|
DEST MAL LESION < 0.5CM TAL
|
Facility
|
OP
|
$450.00
|
|
|
Service Code
|
HCPCS 17260
|
| Hospital Charge Code |
76100254
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$154.75 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna Commercial |
$346.50
|
| Rate for Payer: Anthem Medicaid |
$154.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$351.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$373.50
|
| Rate for Payer: First Health Commercial |
$427.50
|
| Rate for Payer: Humana Commercial |
$382.50
|
| Rate for Payer: Humana KY Medicaid |
$154.75
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$156.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$369.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$332.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$157.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$396.00
|
| Rate for Payer: Ohio Health Group HMO |
$337.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$360.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$391.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$310.50
|
| Rate for Payer: PHCS Commercial |
$432.00
|
| Rate for Payer: United Healthcare All Payer |
$396.00
|
|
|
DEST MAL LESION < 0.5CM TAL
|
Facility
|
IP
|
$450.00
|
|
|
Service Code
|
HCPCS 17260
|
| Hospital Charge Code |
76100254
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$135.00 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna Commercial |
$346.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$351.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$373.50
|
| Rate for Payer: First Health Commercial |
$427.50
|
| Rate for Payer: Humana Commercial |
$382.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$369.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$332.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$135.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$396.00
|
| Rate for Payer: Ohio Health Group HMO |
$337.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$360.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$391.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$310.50
|
| Rate for Payer: PHCS Commercial |
$432.00
|
| Rate for Payer: United Healthcare All Payer |
$396.00
|
|
|
DEST MAL LESION < 0.5CM TAL(P
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 17260
|
| Hospital Charge Code |
761P0254
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$50.18 |
| Max. Negotiated Rate |
$124.64 |
| Rate for Payer: Aetna Commercial |
$94.54
|
| Rate for Payer: Ambetter Exchange |
$66.22
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$50.18
|
| Rate for Payer: Anthem Medicaid |
$57.97
|
| Rate for Payer: Buckeye Individual/Medicaid |
$66.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$66.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$79.46
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$124.64
|
| Rate for Payer: Healthspan PPO |
$103.83
|
| Rate for Payer: Humana Medicaid |
$57.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$84.43
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$66.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$66.22
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$59.13
|
| Rate for Payer: Molina Healthcare Passport |
$57.97
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$86.09
|
| Rate for Payer: UHCCP Medicaid |
$52.69
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$58.55
|
| Rate for Payer: Wellcare Medicare Advantage |
$66.22
|
|
|
DEST MAL LESION < 0.5CM TAL(T
|
Facility
|
IP
|
$250.00
|
|
|
Service Code
|
HCPCS 17260
|
| Hospital Charge Code |
761T0254
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: Aetna Commercial |
$192.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$195.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$207.50
|
| Rate for Payer: First Health Commercial |
$237.50
|
| Rate for Payer: Humana Commercial |
$212.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$205.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$184.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$220.00
|
| Rate for Payer: Ohio Health Group HMO |
$187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$217.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$172.50
|
| Rate for Payer: PHCS Commercial |
$240.00
|
| Rate for Payer: United Healthcare All Payer |
$220.00
|
|
|
DEST MAL LESION < 0.5CM TAL(T
|
Facility
|
OP
|
$250.00
|
|
|
Service Code
|
HCPCS 17260
|
| Hospital Charge Code |
761T0254
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$85.97 |
| Max. Negotiated Rate |
$257.03 |
| Rate for Payer: Aetna Commercial |
$192.50
|
| Rate for Payer: Anthem Medicaid |
$85.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$195.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$207.50
|
| Rate for Payer: First Health Commercial |
$237.50
|
| Rate for Payer: Humana Commercial |
$212.50
|
| Rate for Payer: Humana KY Medicaid |
$85.97
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$86.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$205.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$184.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$87.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$220.00
|
| Rate for Payer: Ohio Health Group HMO |
$187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$217.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$172.50
|
| Rate for Payer: PHCS Commercial |
$240.00
|
| Rate for Payer: United Healthcare All Payer |
$220.00
|
|
|
DEST MOLL CONT TO 15
|
Professional
|
Both
|
$453.00
|
|
|
Service Code
|
HCPCS 17110
|
| Hospital Charge Code |
76100251
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$27.60 |
| Max. Negotiated Rate |
$271.80 |
| Rate for Payer: Aetna Commercial |
$94.16
|
| Rate for Payer: Ambetter Exchange |
$63.84
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$36.13
|
| Rate for Payer: Anthem Medicaid |
$27.60
|
| Rate for Payer: Buckeye Individual/Medicaid |
$63.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$63.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$76.61
|
| Rate for Payer: Cash Price |
$226.50
|
| Rate for Payer: Cash Price |
$226.50
|
| Rate for Payer: Cigna Commercial |
$135.24
|
| Rate for Payer: Healthspan PPO |
$118.52
|
| Rate for Payer: Humana Medicaid |
$27.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$83.96
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$63.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$63.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$28.15
|
| Rate for Payer: Molina Healthcare Passport |
$27.60
|
| Rate for Payer: Multiplan PHCS |
$271.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$82.99
|
| Rate for Payer: UHCCP Medicaid |
$37.94
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$27.88
|
| Rate for Payer: Wellcare Medicare Advantage |
$63.84
|
|
|
DEST MOLL CONT TO 15
|
Facility
|
OP
|
$453.00
|
|
|
Service Code
|
HCPCS 17110
|
| Hospital Charge Code |
76100251
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$155.79 |
| Max. Negotiated Rate |
$434.88 |
| Rate for Payer: Aetna Commercial |
$348.81
|
| Rate for Payer: Anthem Medicaid |
$155.79
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$353.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$226.50
|
| Rate for Payer: Cash Price |
$226.50
|
| Rate for Payer: Cigna Commercial |
$375.99
|
| Rate for Payer: First Health Commercial |
$430.35
|
| Rate for Payer: Humana Commercial |
$385.05
|
| Rate for Payer: Humana KY Medicaid |
$155.79
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$157.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$371.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$334.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$158.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$398.64
|
| Rate for Payer: Ohio Health Group HMO |
$339.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$394.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$312.57
|
| Rate for Payer: PHCS Commercial |
$434.88
|
| Rate for Payer: United Healthcare All Payer |
$398.64
|
|
|
DEST MOLL CONT TO 15
|
Facility
|
IP
|
$453.00
|
|
|
Service Code
|
HCPCS 17110
|
| Hospital Charge Code |
76100251
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$135.90 |
| Max. Negotiated Rate |
$434.88 |
| Rate for Payer: Aetna Commercial |
$348.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$353.34
|
| Rate for Payer: Cash Price |
$226.50
|
| Rate for Payer: Cigna Commercial |
$375.99
|
| Rate for Payer: First Health Commercial |
$430.35
|
| Rate for Payer: Humana Commercial |
$385.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$371.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$334.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$135.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$398.64
|
| Rate for Payer: Ohio Health Group HMO |
$339.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$394.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$312.57
|
| Rate for Payer: PHCS Commercial |
$434.88
|
| Rate for Payer: United Healthcare All Payer |
$398.64
|
|
|
DEST MOLL CONT TO 15(P
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
HCPCS 17110
|
| Hospital Charge Code |
761P0251
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$27.60 |
| Max. Negotiated Rate |
$135.24 |
| Rate for Payer: Aetna Commercial |
$94.16
|
| Rate for Payer: Ambetter Exchange |
$63.84
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$36.13
|
| Rate for Payer: Anthem Medicaid |
$27.60
|
| Rate for Payer: Buckeye Individual/Medicaid |
$63.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$63.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$76.61
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cigna Commercial |
$135.24
|
| Rate for Payer: Healthspan PPO |
$118.52
|
| Rate for Payer: Humana Medicaid |
$27.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$83.96
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$63.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$63.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$28.15
|
| Rate for Payer: Molina Healthcare Passport |
$27.60
|
| Rate for Payer: Multiplan PHCS |
$105.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$82.99
|
| Rate for Payer: UHCCP Medicaid |
$37.94
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$27.88
|
| Rate for Payer: Wellcare Medicare Advantage |
$63.84
|
|
|
DEST MOLL CONT TO 15(T
|
Facility
|
OP
|
$278.00
|
|
|
Service Code
|
HCPCS 17110
|
| Hospital Charge Code |
761T0251
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$95.60 |
| Max. Negotiated Rate |
$266.88 |
| Rate for Payer: Aetna Commercial |
$214.06
|
| Rate for Payer: Anthem Medicaid |
$95.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$216.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$139.00
|
| Rate for Payer: Cash Price |
$139.00
|
| Rate for Payer: Cigna Commercial |
$230.74
|
| Rate for Payer: First Health Commercial |
$264.10
|
| Rate for Payer: Humana Commercial |
$236.30
|
| Rate for Payer: Humana KY Medicaid |
$95.60
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$96.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$227.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$205.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$97.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$244.64
|
| Rate for Payer: Ohio Health Group HMO |
$208.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$222.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$241.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$191.82
|
| Rate for Payer: PHCS Commercial |
$266.88
|
| Rate for Payer: United Healthcare All Payer |
$244.64
|
|
|
DEST MOLL CONT TO 15(T
|
Facility
|
IP
|
$278.00
|
|
|
Service Code
|
HCPCS 17110
|
| Hospital Charge Code |
761T0251
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$83.40 |
| Max. Negotiated Rate |
$266.88 |
| Rate for Payer: Aetna Commercial |
$214.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$216.84
|
| Rate for Payer: Cash Price |
$139.00
|
| Rate for Payer: Cigna Commercial |
$230.74
|
| Rate for Payer: First Health Commercial |
$264.10
|
| Rate for Payer: Humana Commercial |
$236.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$227.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$205.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$83.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$244.64
|
| Rate for Payer: Ohio Health Group HMO |
$208.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$222.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$241.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$191.82
|
| Rate for Payer: PHCS Commercial |
$266.88
|
| Rate for Payer: United Healthcare All Payer |
$244.64
|
|
|
DESTR LESION(S) ANUS
|
Facility
|
OP
|
$335.00
|
|
|
Service Code
|
HCPCS 46900
|
| Hospital Charge Code |
76101935
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$115.21 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Aetna Commercial |
$257.95
|
| Rate for Payer: Anthem Medicaid |
$115.21
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$261.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cigna Commercial |
$278.05
|
| Rate for Payer: First Health Commercial |
$318.25
|
| Rate for Payer: Humana Commercial |
$284.75
|
| Rate for Payer: Humana KY Medicaid |
$115.21
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$116.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$274.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$247.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$117.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$294.80
|
| Rate for Payer: Ohio Health Group HMO |
$251.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$268.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$291.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$231.15
|
| Rate for Payer: PHCS Commercial |
$321.60
|
| Rate for Payer: United Healthcare All Payer |
$294.80
|
|
|
DESTR LESION(S) ANUS
|
Professional
|
Both
|
$335.00
|
|
|
Service Code
|
HCPCS 46900
|
| Hospital Charge Code |
76101935
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$65.03 |
| Max. Negotiated Rate |
$267.80 |
| Rate for Payer: Aetna Commercial |
$193.56
|
| Rate for Payer: Ambetter Exchange |
$130.33
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$139.14
|
| Rate for Payer: Anthem Medicaid |
$65.03
|
| Rate for Payer: Buckeye Individual/Medicaid |
$130.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$130.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$156.40
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cigna Commercial |
$267.80
|
| Rate for Payer: Healthspan PPO |
$256.66
|
| Rate for Payer: Humana Medicaid |
$65.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$172.17
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$130.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$130.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$66.33
|
| Rate for Payer: Molina Healthcare Passport |
$65.03
|
| Rate for Payer: Multiplan PHCS |
$201.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$169.43
|
| Rate for Payer: UHCCP Medicaid |
$146.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$65.68
|
| Rate for Payer: Wellcare Medicare Advantage |
$130.33
|
|
|
DESTR LESION(S) ANUS
|
Facility
|
IP
|
$335.00
|
|
|
Service Code
|
HCPCS 46900
|
| Hospital Charge Code |
76101935
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$100.50 |
| Max. Negotiated Rate |
$321.60 |
| Rate for Payer: Aetna Commercial |
$257.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$261.30
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cigna Commercial |
$278.05
|
| Rate for Payer: First Health Commercial |
$318.25
|
| Rate for Payer: Humana Commercial |
$284.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$274.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$247.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$100.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$294.80
|
| Rate for Payer: Ohio Health Group HMO |
$251.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$268.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$291.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$231.15
|
| Rate for Payer: PHCS Commercial |
$321.60
|
| Rate for Payer: United Healthcare All Payer |
$294.80
|
|
|
DESTR LESION(S) ANUS (P
|
Professional
|
Both
|
$335.00
|
|
|
Service Code
|
HCPCS 46900
|
| Hospital Charge Code |
761P1935
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$65.03 |
| Max. Negotiated Rate |
$267.80 |
| Rate for Payer: Aetna Commercial |
$193.56
|
| Rate for Payer: Ambetter Exchange |
$130.33
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$139.14
|
| Rate for Payer: Anthem Medicaid |
$65.03
|
| Rate for Payer: Buckeye Individual/Medicaid |
$130.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$130.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$156.40
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cigna Commercial |
$267.80
|
| Rate for Payer: Healthspan PPO |
$256.66
|
| Rate for Payer: Humana Medicaid |
$65.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$172.17
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$130.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$130.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$66.33
|
| Rate for Payer: Molina Healthcare Passport |
$65.03
|
| Rate for Payer: Multiplan PHCS |
$201.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$169.43
|
| Rate for Payer: UHCCP Medicaid |
$146.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$65.68
|
| Rate for Payer: Wellcare Medicare Advantage |
$130.33
|
|
|
DESTR MALIG LESION FACE
|
Facility
|
IP
|
$808.00
|
|
|
Service Code
|
HCPCS 17281
|
| Hospital Charge Code |
76100267
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$242.40 |
| Max. Negotiated Rate |
$775.68 |
| Rate for Payer: Aetna Commercial |
$622.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$630.24
|
| Rate for Payer: Cash Price |
$404.00
|
| Rate for Payer: Cigna Commercial |
$670.64
|
| Rate for Payer: First Health Commercial |
$767.60
|
| Rate for Payer: Humana Commercial |
$686.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$662.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$596.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$242.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$711.04
|
| Rate for Payer: Ohio Health Group HMO |
$606.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$646.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$702.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$557.52
|
| Rate for Payer: PHCS Commercial |
$775.68
|
| Rate for Payer: United Healthcare All Payer |
$711.04
|
|
|
DESTR MALIG LESION FACE
|
Professional
|
Both
|
$808.00
|
|
|
Service Code
|
HCPCS 17281
|
| Hospital Charge Code |
76100267
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$77.32 |
| Max. Negotiated Rate |
$484.80 |
| Rate for Payer: Aetna Commercial |
$175.02
|
| Rate for Payer: Ambetter Exchange |
$111.30
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$77.32
|
| Rate for Payer: Anthem Medicaid |
$109.44
|
| Rate for Payer: Buckeye Individual/Medicaid |
$111.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$111.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$133.56
|
| Rate for Payer: Cash Price |
$404.00
|
| Rate for Payer: Cash Price |
$404.00
|
| Rate for Payer: Cigna Commercial |
$212.97
|
| Rate for Payer: Healthspan PPO |
$192.58
|
| Rate for Payer: Humana Medicaid |
$109.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$157.45
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$111.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$111.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$111.63
|
| Rate for Payer: Molina Healthcare Passport |
$109.44
|
| Rate for Payer: Multiplan PHCS |
$484.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$144.69
|
| Rate for Payer: UHCCP Medicaid |
$81.19
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$110.53
|
| Rate for Payer: Wellcare Medicare Advantage |
$111.30
|
|
