|
DESTRUCTION RECTAL TUMOR
|
Facility
|
OP
|
$7,975.00
|
|
|
Service Code
|
HCPCS 45190
|
| Hospital Charge Code |
76102667
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,533.91 |
| Max. Negotiated Rate |
$7,656.00 |
| Rate for Payer: Aetna Commercial |
$6,140.75
|
| Rate for Payer: Anthem Medicaid |
$2,742.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,533.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,220.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,547.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,420.78
|
| Rate for Payer: Cash Price |
$3,987.50
|
| Rate for Payer: Cash Price |
$3,987.50
|
| Rate for Payer: Cigna Commercial |
$6,619.25
|
| Rate for Payer: First Health Commercial |
$7,576.25
|
| Rate for Payer: Humana Commercial |
$6,778.75
|
| Rate for Payer: Humana KY Medicaid |
$2,742.60
|
| Rate for Payer: Humana Medicare Advantage |
$2,533.91
|
| Rate for Payer: Kentucky WC Medicaid |
$2,770.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,539.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,885.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,040.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,797.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,018.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,981.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,380.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,938.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,502.75
|
| Rate for Payer: PHCS Commercial |
$7,656.00
|
| Rate for Payer: United Healthcare All Payer |
$7,018.00
|
|
|
DESTRUCTION RECTAL TUMOR
|
Facility
|
IP
|
$7,975.00
|
|
|
Service Code
|
HCPCS 45190
|
| Hospital Charge Code |
76102667
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,392.50 |
| Max. Negotiated Rate |
$7,656.00 |
| Rate for Payer: Aetna Commercial |
$6,140.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,220.50
|
| Rate for Payer: Cash Price |
$3,987.50
|
| Rate for Payer: Cigna Commercial |
$6,619.25
|
| Rate for Payer: First Health Commercial |
$7,576.25
|
| Rate for Payer: Humana Commercial |
$6,778.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,539.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,885.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,392.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,018.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,981.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,380.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,938.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,502.75
|
| Rate for Payer: PHCS Commercial |
$7,656.00
|
| Rate for Payer: United Healthcare All Payer |
$7,018.00
|
|
|
DESTRUCTION RECTAL TUMOR
|
Professional
|
Both
|
$7,975.00
|
|
|
Service Code
|
HCPCS 45190
|
| Hospital Charge Code |
76102667
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$394.39 |
| Max. Negotiated Rate |
$4,785.00 |
| Rate for Payer: Aetna Commercial |
$961.90
|
| Rate for Payer: Ambetter Exchange |
$656.84
|
| Rate for Payer: Anthem Medicaid |
$394.39
|
| Rate for Payer: Buckeye Individual/Medicaid |
$656.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$656.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$788.21
|
| Rate for Payer: Cash Price |
$3,987.50
|
| Rate for Payer: Cash Price |
$3,987.50
|
| Rate for Payer: Cigna Commercial |
$878.69
|
| Rate for Payer: Healthspan PPO |
$811.17
|
| Rate for Payer: Humana Medicaid |
$394.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$859.83
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$656.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$656.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$402.28
|
| Rate for Payer: Molina Healthcare Passport |
$394.39
|
| Rate for Payer: Multiplan PHCS |
$4,785.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$853.89
|
| Rate for Payer: UHCCP Medicaid |
$2,791.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$398.33
|
| Rate for Payer: Wellcare Medicare Advantage |
$656.84
|
|
|
DESTRUCTION RECTAL TUMOR (P
|
Professional
|
Both
|
$2,670.00
|
|
|
Service Code
|
HCPCS 45190
|
| Hospital Charge Code |
761P2667
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$394.39 |
| Max. Negotiated Rate |
$1,602.00 |
| Rate for Payer: Aetna Commercial |
$961.90
|
| Rate for Payer: Ambetter Exchange |
$656.84
|
| Rate for Payer: Anthem Medicaid |
$394.39
|
| Rate for Payer: Buckeye Individual/Medicaid |
$656.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$656.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$788.21
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cigna Commercial |
$878.69
|
| Rate for Payer: Healthspan PPO |
$811.17
|
| Rate for Payer: Humana Medicaid |
$394.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$859.83
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$656.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$656.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$402.28
|
| Rate for Payer: Molina Healthcare Passport |
$394.39
|
| Rate for Payer: Multiplan PHCS |
$1,602.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$853.89
|
| Rate for Payer: UHCCP Medicaid |
$934.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$398.33
|
| Rate for Payer: Wellcare Medicare Advantage |
$656.84
|
|
|
DESTRUCTION RECTAL TUMOR (T
|
Facility
|
IP
|
$5,305.00
|
|
|
Service Code
|
HCPCS 45190
|
| Hospital Charge Code |
761T2667
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,591.50 |
| Max. Negotiated Rate |
$5,092.80 |
| Rate for Payer: Aetna Commercial |
$4,084.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,137.90
|
| Rate for Payer: Cash Price |
$2,652.50
|
| Rate for Payer: Cigna Commercial |
$4,403.15
|
| Rate for Payer: First Health Commercial |
$5,039.75
|
| Rate for Payer: Humana Commercial |
$4,509.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,350.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,915.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,591.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,668.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,978.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,244.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,615.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,660.45
|
| Rate for Payer: PHCS Commercial |
$5,092.80
|
| Rate for Payer: United Healthcare All Payer |
$4,668.40
|
|
|
DESTRUCTION RECTAL TUMOR (T
|
Facility
|
OP
|
$5,305.00
|
|
|
Service Code
|
HCPCS 45190
|
| Hospital Charge Code |
761T2667
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,824.39 |
| Max. Negotiated Rate |
$5,092.80 |
| Rate for Payer: Aetna Commercial |
$4,084.85
|
| Rate for Payer: Anthem Medicaid |
$1,824.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,533.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,137.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,547.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,420.78
|
| Rate for Payer: Cash Price |
$2,652.50
|
| Rate for Payer: Cash Price |
$2,652.50
|
| Rate for Payer: Cigna Commercial |
$4,403.15
|
| Rate for Payer: First Health Commercial |
$5,039.75
|
| Rate for Payer: Humana Commercial |
$4,509.25
|
| Rate for Payer: Humana KY Medicaid |
$1,824.39
|
| Rate for Payer: Humana Medicare Advantage |
$2,533.91
|
| Rate for Payer: Kentucky WC Medicaid |
$1,842.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,350.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,915.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,040.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,860.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,668.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,978.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,244.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,615.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,660.45
|
| Rate for Payer: PHCS Commercial |
$5,092.80
|
| Rate for Payer: United Healthcare All Payer |
$4,668.40
|
|
|
DESTRUCT LESION 15 OR MORE
|
Facility
|
OP
|
$502.00
|
|
|
Service Code
|
HCPCS 17111
|
| Hospital Charge Code |
76100252
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$172.64 |
| Max. Negotiated Rate |
$481.92 |
| Rate for Payer: Aetna Commercial |
$386.54
|
| Rate for Payer: Anthem Medicaid |
$172.64
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$391.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$251.00
|
| Rate for Payer: Cash Price |
$251.00
|
| Rate for Payer: Cigna Commercial |
$416.66
|
| Rate for Payer: First Health Commercial |
$476.90
|
| Rate for Payer: Humana Commercial |
$426.70
|
| Rate for Payer: Humana KY Medicaid |
$172.64
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$174.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$411.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$370.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$176.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$441.76
|
| Rate for Payer: Ohio Health Group HMO |
$376.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$401.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$436.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$346.38
|
| Rate for Payer: PHCS Commercial |
$481.92
|
| Rate for Payer: United Healthcare All Payer |
$441.76
|
|
|
DESTRUCT LESION 15 OR MORE
|
Professional
|
Both
|
$502.00
|
|
|
Service Code
|
HCPCS 17111
|
| Hospital Charge Code |
76100252
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$43.22 |
| Max. Negotiated Rate |
$301.20 |
| Rate for Payer: Aetna Commercial |
$117.24
|
| Rate for Payer: Ambetter Exchange |
$78.33
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$44.49
|
| Rate for Payer: Anthem Medicaid |
$43.22
|
| Rate for Payer: Buckeye Individual/Medicaid |
$78.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$78.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$94.00
|
| Rate for Payer: Cash Price |
$251.00
|
| Rate for Payer: Cash Price |
$251.00
|
| Rate for Payer: Cigna Commercial |
$161.62
|
| Rate for Payer: Healthspan PPO |
$140.81
|
| Rate for Payer: Humana Medicaid |
$43.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$104.83
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$78.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$44.08
|
| Rate for Payer: Molina Healthcare Passport |
$43.22
|
| Rate for Payer: Multiplan PHCS |
$301.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$101.83
|
| Rate for Payer: UHCCP Medicaid |
$46.71
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$43.65
|
| Rate for Payer: Wellcare Medicare Advantage |
$78.33
|
|
|
DESTRUCT LESION 15 OR MORE
|
Facility
|
IP
|
$502.00
|
|
|
Service Code
|
HCPCS 17111
|
| Hospital Charge Code |
76100252
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$150.60 |
| Max. Negotiated Rate |
$481.92 |
| Rate for Payer: Aetna Commercial |
$386.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$391.56
|
| Rate for Payer: Cash Price |
$251.00
|
| Rate for Payer: Cigna Commercial |
$416.66
|
| Rate for Payer: First Health Commercial |
$476.90
|
| Rate for Payer: Humana Commercial |
$426.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$411.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$370.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$150.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$441.76
|
| Rate for Payer: Ohio Health Group HMO |
$376.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$401.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$436.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$346.38
|
| Rate for Payer: PHCS Commercial |
$481.92
|
| Rate for Payer: United Healthcare All Payer |
$441.76
|
|
|
DESTRUCT LESION 15 OR MORE(P
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 17111
|
| Hospital Charge Code |
761P0252
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$43.22 |
| Max. Negotiated Rate |
$161.62 |
| Rate for Payer: Aetna Commercial |
$117.24
|
| Rate for Payer: Ambetter Exchange |
$78.33
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$44.49
|
| Rate for Payer: Anthem Medicaid |
$43.22
|
| Rate for Payer: Buckeye Individual/Medicaid |
$78.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$78.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$94.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$161.62
|
| Rate for Payer: Healthspan PPO |
$140.81
|
| Rate for Payer: Humana Medicaid |
$43.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$104.83
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$78.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$44.08
|
| Rate for Payer: Molina Healthcare Passport |
$43.22
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$101.83
|
| Rate for Payer: UHCCP Medicaid |
$46.71
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$43.65
|
| Rate for Payer: Wellcare Medicare Advantage |
$78.33
|
|
|
DESTRUCT LESION 15 OR MORE(T
|
Facility
|
OP
|
$302.00
|
|
|
Service Code
|
HCPCS 17111
|
| Hospital Charge Code |
761T0252
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$103.86 |
| Max. Negotiated Rate |
$289.92 |
| Rate for Payer: Aetna Commercial |
$232.54
|
| Rate for Payer: Anthem Medicaid |
$103.86
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$235.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$151.00
|
| Rate for Payer: Cash Price |
$151.00
|
| Rate for Payer: Cigna Commercial |
$250.66
|
| Rate for Payer: First Health Commercial |
$286.90
|
| Rate for Payer: Humana Commercial |
$256.70
|
| Rate for Payer: Humana KY Medicaid |
$103.86
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$104.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$247.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$222.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$105.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$265.76
|
| Rate for Payer: Ohio Health Group HMO |
$226.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$241.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$262.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$208.38
|
| Rate for Payer: PHCS Commercial |
$289.92
|
| Rate for Payer: United Healthcare All Payer |
$265.76
|
|
|
DESTRUCT LESION 15 OR MORE(T
|
Facility
|
IP
|
$302.00
|
|
|
Service Code
|
HCPCS 17111
|
| Hospital Charge Code |
761T0252
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$90.60 |
| Max. Negotiated Rate |
$289.92 |
| Rate for Payer: Aetna Commercial |
$232.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$235.56
|
| Rate for Payer: Cash Price |
$151.00
|
| Rate for Payer: Cigna Commercial |
$250.66
|
| Rate for Payer: First Health Commercial |
$286.90
|
| Rate for Payer: Humana Commercial |
$256.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$247.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$222.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$90.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$265.76
|
| Rate for Payer: Ohio Health Group HMO |
$226.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$241.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$262.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$208.38
|
| Rate for Payer: PHCS Commercial |
$289.92
|
| Rate for Payer: United Healthcare All Payer |
$265.76
|
|
|
DESTRUCT PREMAL LESION 15+ (P
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
HCPCS 17004
|
| Hospital Charge Code |
761P0249
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$88.51 |
| Max. Negotiated Rate |
$231.55 |
| Rate for Payer: Aetna Commercial |
$191.59
|
| Rate for Payer: Ambetter Exchange |
$92.39
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$88.51
|
| Rate for Payer: Anthem Medicaid |
$143.35
|
| Rate for Payer: Buckeye Individual/Medicaid |
$92.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$92.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$110.87
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna Commercial |
$231.55
|
| Rate for Payer: Healthspan PPO |
$193.84
|
| Rate for Payer: Humana Medicaid |
$143.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$167.08
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$92.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$92.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$146.22
|
| Rate for Payer: Molina Healthcare Passport |
$143.35
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$120.11
|
| Rate for Payer: UHCCP Medicaid |
$92.94
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$144.78
|
| Rate for Payer: Wellcare Medicare Advantage |
$92.39
|
|
|
DESTRUCT PREMAL LESION 15+ (T
|
Facility
|
OP
|
$492.00
|
|
|
Service Code
|
HCPCS 17004
|
| Hospital Charge Code |
761T0249
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$169.20 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Aetna Commercial |
$378.84
|
| Rate for Payer: Anthem Medicaid |
$169.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$383.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Cigna Commercial |
$408.36
|
| Rate for Payer: First Health Commercial |
$467.40
|
| Rate for Payer: Humana Commercial |
$418.20
|
| Rate for Payer: Humana KY Medicaid |
$169.20
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$170.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$403.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$363.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$172.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$432.96
|
| Rate for Payer: Ohio Health Group HMO |
$369.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$393.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$428.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$339.48
|
| Rate for Payer: PHCS Commercial |
$472.32
|
| Rate for Payer: United Healthcare All Payer |
$432.96
|
|
|
DESTRUCT PREMAL LESION 15+ (T
|
Facility
|
IP
|
$492.00
|
|
|
Service Code
|
HCPCS 17004
|
| Hospital Charge Code |
761T0249
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$147.60 |
| Max. Negotiated Rate |
$472.32 |
| Rate for Payer: Aetna Commercial |
$378.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$383.76
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Cigna Commercial |
$408.36
|
| Rate for Payer: First Health Commercial |
$467.40
|
| Rate for Payer: Humana Commercial |
$418.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$403.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$363.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$432.96
|
| Rate for Payer: Ohio Health Group HMO |
$369.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$393.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$428.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$339.48
|
| Rate for Payer: PHCS Commercial |
$472.32
|
| Rate for Payer: United Healthcare All Payer |
$432.96
|
|
|
DESTRUCT PREMAL LESIONS 15+
|
Facility
|
IP
|
$842.00
|
|
|
Service Code
|
HCPCS 17004
|
| Hospital Charge Code |
76100249
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$252.60 |
| Max. Negotiated Rate |
$808.32 |
| Rate for Payer: Aetna Commercial |
$648.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$656.76
|
| Rate for Payer: Cash Price |
$421.00
|
| Rate for Payer: Cigna Commercial |
$698.86
|
| Rate for Payer: First Health Commercial |
$799.90
|
| Rate for Payer: Humana Commercial |
$715.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$690.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$621.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$252.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$740.96
|
| Rate for Payer: Ohio Health Group HMO |
$631.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$673.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$732.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.98
|
| Rate for Payer: PHCS Commercial |
$808.32
|
| Rate for Payer: United Healthcare All Payer |
$740.96
|
|
|
DESTRUCT PREMAL LESIONS 15+
|
Facility
|
OP
|
$842.00
|
|
|
Service Code
|
HCPCS 17004
|
| Hospital Charge Code |
76100249
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$289.56 |
| Max. Negotiated Rate |
$808.32 |
| Rate for Payer: Aetna Commercial |
$648.34
|
| Rate for Payer: Anthem Medicaid |
$289.56
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$656.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$421.00
|
| Rate for Payer: Cash Price |
$421.00
|
| Rate for Payer: Cigna Commercial |
$698.86
|
| Rate for Payer: First Health Commercial |
$799.90
|
| Rate for Payer: Humana Commercial |
$715.70
|
| Rate for Payer: Humana KY Medicaid |
$289.56
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$292.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$690.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$621.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$295.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$740.96
|
| Rate for Payer: Ohio Health Group HMO |
$631.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$673.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$732.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.98
|
| Rate for Payer: PHCS Commercial |
$808.32
|
| Rate for Payer: United Healthcare All Payer |
$740.96
|
|
|
DESTRUCT PREMAL LESIONS 15+
|
Professional
|
Both
|
$842.00
|
|
|
Service Code
|
HCPCS 17004
|
| Hospital Charge Code |
76100249
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$88.51 |
| Max. Negotiated Rate |
$505.20 |
| Rate for Payer: Aetna Commercial |
$191.59
|
| Rate for Payer: Ambetter Exchange |
$92.39
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$88.51
|
| Rate for Payer: Anthem Medicaid |
$143.35
|
| Rate for Payer: Buckeye Individual/Medicaid |
$92.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$92.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$110.87
|
| Rate for Payer: Cash Price |
$421.00
|
| Rate for Payer: Cash Price |
$421.00
|
| Rate for Payer: Cigna Commercial |
$231.55
|
| Rate for Payer: Healthspan PPO |
$193.84
|
| Rate for Payer: Humana Medicaid |
$143.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$167.08
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$92.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$92.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$146.22
|
| Rate for Payer: Molina Healthcare Passport |
$143.35
|
| Rate for Payer: Multiplan PHCS |
$505.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$120.11
|
| Rate for Payer: UHCCP Medicaid |
$92.94
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$144.78
|
| Rate for Payer: Wellcare Medicare Advantage |
$92.39
|
|
|
DESYREL (TRAZODONE) 50MG/1TAB
|
Facility
|
IP
|
$4.32
|
|
|
Service Code
|
NDC 904686861
|
| Hospital Charge Code |
25000544
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$4.15 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna Commercial |
$3.59
|
| Rate for Payer: First Health Commercial |
$4.10
|
| Rate for Payer: Humana Commercial |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.80
|
| Rate for Payer: Ohio Health Group HMO |
$3.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.98
|
| Rate for Payer: PHCS Commercial |
$4.15
|
| Rate for Payer: United Healthcare All Payer |
$3.80
|
|
|
DESYREL (TRAZODONE) 50MG/1TAB
|
Facility
|
OP
|
$4.32
|
|
|
Service Code
|
NDC 904686861
|
| Hospital Charge Code |
25000544
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$4.15 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna Commercial |
$3.59
|
| Rate for Payer: First Health Commercial |
$4.10
|
| Rate for Payer: Humana Commercial |
$3.67
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.80
|
| Rate for Payer: Ohio Health Group HMO |
$3.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.98
|
| Rate for Payer: PHCS Commercial |
$4.15
|
| Rate for Payer: United Healthcare All Payer |
$3.80
|
|
|
DETROL (TOLTERODINE TART)2MG
|
Facility
|
IP
|
$4.53
|
|
|
Service Code
|
NDC 31722080660
|
| Hospital Charge Code |
25000545
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.35 |
| Rate for Payer: Aetna Commercial |
$3.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna Commercial |
$3.76
|
| Rate for Payer: First Health Commercial |
$4.30
|
| Rate for Payer: Humana Commercial |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.99
|
| Rate for Payer: Ohio Health Group HMO |
$3.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.13
|
| Rate for Payer: PHCS Commercial |
$4.35
|
| Rate for Payer: United Healthcare All Payer |
$3.99
|
|
|
DETROL (TOLTERODINE TART)2MG
|
Facility
|
OP
|
$4.53
|
|
|
Service Code
|
NDC 31722080660
|
| Hospital Charge Code |
25000545
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.35 |
| Rate for Payer: Aetna Commercial |
$3.49
|
| Rate for Payer: Anthem Medicaid |
$1.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna Commercial |
$3.76
|
| Rate for Payer: First Health Commercial |
$4.30
|
| Rate for Payer: Humana Commercial |
$3.85
|
| Rate for Payer: Humana KY Medicaid |
$1.56
|
| Rate for Payer: Kentucky WC Medicaid |
$1.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.99
|
| Rate for Payer: Ohio Health Group HMO |
$3.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.13
|
| Rate for Payer: PHCS Commercial |
$4.35
|
| Rate for Payer: United Healthcare All Payer |
$3.99
|
|
|
DEUCE FEM SZ 3 LT
|
Facility
|
IP
|
$15,790.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,737.02 |
| Max. Negotiated Rate |
$15,158.48 |
| Rate for Payer: Aetna Commercial |
$12,158.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,316.26
|
| Rate for Payer: Cash Price |
$7,895.04
|
| Rate for Payer: Cigna Commercial |
$13,105.77
|
| Rate for Payer: First Health Commercial |
$15,000.58
|
| Rate for Payer: Humana Commercial |
$13,421.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,947.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,653.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,737.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,895.27
|
| Rate for Payer: Ohio Health Group HMO |
$11,842.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,632.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,737.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,895.16
|
| Rate for Payer: PHCS Commercial |
$15,158.48
|
| Rate for Payer: United Healthcare All Payer |
$13,895.27
|
|
|
DEUCE FEM SZ 3 LT
|
Facility
|
OP
|
$15,790.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,737.02 |
| Max. Negotiated Rate |
$15,158.48 |
| Rate for Payer: Aetna Commercial |
$12,158.36
|
| Rate for Payer: Anthem Medicaid |
$5,430.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,316.26
|
| Rate for Payer: Cash Price |
$7,895.04
|
| Rate for Payer: Cigna Commercial |
$13,105.77
|
| Rate for Payer: First Health Commercial |
$15,000.58
|
| Rate for Payer: Humana Commercial |
$13,421.57
|
| Rate for Payer: Humana KY Medicaid |
$5,430.21
|
| Rate for Payer: Kentucky WC Medicaid |
$5,485.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,947.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,653.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,737.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,539.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,895.27
|
| Rate for Payer: Ohio Health Group HMO |
$11,842.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,632.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,737.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,895.16
|
| Rate for Payer: PHCS Commercial |
$15,158.48
|
| Rate for Payer: United Healthcare All Payer |
$13,895.27
|
|
|
DEUCE FEM SZ 3 RT
|
Facility
|
OP
|
$23,694.69
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,108.41 |
| Max. Negotiated Rate |
$22,746.90 |
| Rate for Payer: Aetna Commercial |
$18,244.91
|
| Rate for Payer: Anthem Medicaid |
$8,148.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,481.86
|
| Rate for Payer: Cash Price |
$11,847.34
|
| Rate for Payer: Cigna Commercial |
$19,666.59
|
| Rate for Payer: First Health Commercial |
$22,509.96
|
| Rate for Payer: Humana Commercial |
$20,140.49
|
| Rate for Payer: Humana KY Medicaid |
$8,148.60
|
| Rate for Payer: Kentucky WC Medicaid |
$8,231.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,429.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,486.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,108.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,312.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,851.33
|
| Rate for Payer: Ohio Health Group HMO |
$17,771.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,955.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,614.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,349.34
|
| Rate for Payer: PHCS Commercial |
$22,746.90
|
| Rate for Payer: United Healthcare All Payer |
$20,851.33
|
|
