|
DILATION OF CERVICAL CANAL
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 57800
|
| Hospital Charge Code |
76102808
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$31.85 |
| Max. Negotiated Rate |
$89.49 |
| Rate for Payer: Aetna Commercial |
$73.88
|
| Rate for Payer: Ambetter Exchange |
$45.46
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$31.85
|
| Rate for Payer: Anthem Medicaid |
$37.90
|
| Rate for Payer: Buckeye Individual/Medicaid |
$45.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$45.46
|
| Rate for Payer: CareSource Just4Me Medicare |
$54.55
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$89.49
|
| Rate for Payer: Healthspan PPO |
$87.08
|
| Rate for Payer: Humana Medicaid |
$37.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$62.28
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$45.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$38.66
|
| Rate for Payer: Molina Healthcare Passport |
$37.90
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$59.10
|
| Rate for Payer: UHCCP Medicaid |
$33.44
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$38.28
|
| Rate for Payer: Wellcare Medicare Advantage |
$45.46
|
|
|
DILATION OF CERVICAL CANAL
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS 57800
|
| Hospital Charge Code |
76102808
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$34.39 |
| Max. Negotiated Rate |
$4,112.95 |
| Rate for Payer: Aetna Commercial |
$77.00
|
| Rate for Payer: Anthem Medicaid |
$34.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,937.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,112.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,966.06
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$83.00
|
| Rate for Payer: First Health Commercial |
$95.00
|
| Rate for Payer: Humana Commercial |
$85.00
|
| Rate for Payer: Humana KY Medicaid |
$34.39
|
| Rate for Payer: Humana Medicare Advantage |
$2,937.82
|
| Rate for Payer: Kentucky WC Medicaid |
$34.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,525.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.00
|
| Rate for Payer: Ohio Health Group HMO |
$75.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.00
|
| Rate for Payer: PHCS Commercial |
$96.00
|
| Rate for Payer: United Healthcare All Payer |
$88.00
|
|
|
DILATION OF CERVICAL CANAL
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS 57800
|
| Hospital Charge Code |
76102808
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.00 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna Commercial |
$77.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$83.00
|
| Rate for Payer: First Health Commercial |
$95.00
|
| Rate for Payer: Humana Commercial |
$85.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.00
|
| Rate for Payer: Ohio Health Group HMO |
$75.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.00
|
| Rate for Payer: PHCS Commercial |
$96.00
|
| Rate for Payer: United Healthcare All Payer |
$88.00
|
|
|
DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES
|
Facility
|
OP
|
$1,212.81
|
|
|
Service Code
|
CPT 43450
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$866.29 |
| Max. Negotiated Rate |
$1,212.81 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$866.29
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,212.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,169.49
|
| Rate for Payer: Humana Medicare Advantage |
$866.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,039.55
|
|
|
DILATION OF ESOPHAGUS, OVER GUIDE WIRE
|
Facility
|
OP
|
$2,453.89
|
|
|
Service Code
|
CPT 43453
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,752.78 |
| Max. Negotiated Rate |
$2,453.89 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,752.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,453.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,366.25
|
| Rate for Payer: Humana Medicare Advantage |
$1,752.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,103.34
|
|
|
DILATION OF RECTAL NARROWING
|
Facility
|
IP
|
$215.00
|
|
|
Service Code
|
HCPCS 45910
|
| Hospital Charge Code |
76102867
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$64.50 |
| Max. Negotiated Rate |
$206.40 |
| Rate for Payer: Aetna Commercial |
$165.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$167.70
|
| Rate for Payer: Cash Price |
$107.50
|
| Rate for Payer: Cigna Commercial |
$178.45
|
| Rate for Payer: First Health Commercial |
$204.25
|
| Rate for Payer: Humana Commercial |
$182.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$176.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$158.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$64.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$189.20
|
| Rate for Payer: Ohio Health Group HMO |
$161.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$172.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$187.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$148.35
|
| Rate for Payer: PHCS Commercial |
$206.40
|
| Rate for Payer: United Healthcare All Payer |
$189.20
|
|
|
DILATION OF RECTAL NARROWING
|
Facility
|
OP
|
$215.00
|
|
|
Service Code
|
HCPCS 45910
|
| Hospital Charge Code |
76102867
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$73.94 |
| Max. Negotiated Rate |
$1,525.23 |
| Rate for Payer: Aetna Commercial |
$165.55
|
| Rate for Payer: Anthem Medicaid |
$73.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,089.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$167.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,525.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,470.76
|
| Rate for Payer: Cash Price |
$107.50
|
| Rate for Payer: Cash Price |
$107.50
|
| Rate for Payer: Cigna Commercial |
$178.45
|
| Rate for Payer: First Health Commercial |
$204.25
|
| Rate for Payer: Humana Commercial |
$182.75
|
| Rate for Payer: Humana KY Medicaid |
$73.94
|
| Rate for Payer: Humana Medicare Advantage |
$1,089.45
|
| Rate for Payer: Kentucky WC Medicaid |
$74.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$176.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$158.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,307.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$75.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$189.20
|
| Rate for Payer: Ohio Health Group HMO |
$161.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$172.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$187.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$148.35
|
| Rate for Payer: PHCS Commercial |
$206.40
|
| Rate for Payer: United Healthcare All Payer |
$189.20
|
|
|
DILATION OF RECTAL NARROWING
|
Professional
|
Both
|
$215.00
|
|
|
Service Code
|
HCPCS 45910
|
| Hospital Charge Code |
76102867
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$75.25 |
| Max. Negotiated Rate |
$281.02 |
| Rate for Payer: Aetna Commercial |
$281.02
|
| Rate for Payer: Ambetter Exchange |
$183.15
|
| Rate for Payer: Anthem Medicaid |
$81.07
|
| Rate for Payer: Buckeye Individual/Medicaid |
$183.15
|
| Rate for Payer: Buckeye Medicare Advantage |
$183.15
|
| Rate for Payer: CareSource Just4Me Medicare |
$219.78
|
| Rate for Payer: Cash Price |
$107.50
|
| Rate for Payer: Cash Price |
$107.50
|
| Rate for Payer: Cigna Commercial |
$260.72
|
| Rate for Payer: Healthspan PPO |
$236.99
|
| Rate for Payer: Humana Medicaid |
$81.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$246.28
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$183.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$183.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$82.69
|
| Rate for Payer: Molina Healthcare Passport |
$81.07
|
| Rate for Payer: Multiplan PHCS |
$129.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$238.09
|
| Rate for Payer: UHCCP Medicaid |
$75.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$81.88
|
| Rate for Payer: Wellcare Medicare Advantage |
$183.15
|
|
|
DILATION OF VAGINA
|
Facility
|
IP
|
$6,308.00
|
|
|
Service Code
|
HCPCS 57400
|
| Hospital Charge Code |
76102936
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,892.40 |
| Max. Negotiated Rate |
$6,055.68 |
| Rate for Payer: Aetna Commercial |
$4,857.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,920.24
|
| Rate for Payer: Cash Price |
$3,154.00
|
| Rate for Payer: Cigna Commercial |
$5,235.64
|
| Rate for Payer: First Health Commercial |
$5,992.60
|
| Rate for Payer: Humana Commercial |
$5,361.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,172.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,655.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,551.04
|
| Rate for Payer: Ohio Health Group HMO |
$4,731.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,046.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,487.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,352.52
|
| Rate for Payer: PHCS Commercial |
$6,055.68
|
| Rate for Payer: United Healthcare All Payer |
$5,551.04
|
|
|
DILATION OF VAGINA
|
Facility
|
OP
|
$6,308.00
|
|
|
Service Code
|
HCPCS 57400
|
| Hospital Charge Code |
76102936
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,169.32 |
| Max. Negotiated Rate |
$6,055.68 |
| Rate for Payer: Aetna Commercial |
$4,857.16
|
| Rate for Payer: Anthem Medicaid |
$2,169.32
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,937.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,920.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,112.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,966.06
|
| Rate for Payer: Cash Price |
$3,154.00
|
| Rate for Payer: Cash Price |
$3,154.00
|
| Rate for Payer: Cigna Commercial |
$5,235.64
|
| Rate for Payer: First Health Commercial |
$5,992.60
|
| Rate for Payer: Humana Commercial |
$5,361.80
|
| Rate for Payer: Humana KY Medicaid |
$2,169.32
|
| Rate for Payer: Humana Medicare Advantage |
$2,937.82
|
| Rate for Payer: Kentucky WC Medicaid |
$2,191.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,172.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,655.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,525.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,212.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,551.04
|
| Rate for Payer: Ohio Health Group HMO |
$4,731.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,046.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,487.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,352.52
|
| Rate for Payer: PHCS Commercial |
$6,055.68
|
| Rate for Payer: United Healthcare All Payer |
$5,551.04
|
|
|
DILATION OF VAGINA
|
Professional
|
Both
|
$6,308.00
|
|
|
Service Code
|
HCPCS 57400
|
| Hospital Charge Code |
76102936
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$34.66 |
| Max. Negotiated Rate |
$3,784.80 |
| Rate for Payer: Aetna Commercial |
$206.83
|
| Rate for Payer: Ambetter Exchange |
$123.59
|
| Rate for Payer: Anthem Medicaid |
$34.66
|
| Rate for Payer: Buckeye Individual/Medicaid |
$123.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$123.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$148.31
|
| Rate for Payer: Cash Price |
$3,154.00
|
| Rate for Payer: Cash Price |
$3,154.00
|
| Rate for Payer: Cigna Commercial |
$199.81
|
| Rate for Payer: Healthspan PPO |
$200.26
|
| Rate for Payer: Humana Medicaid |
$34.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$174.54
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$123.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$123.59
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$35.35
|
| Rate for Payer: Molina Healthcare Passport |
$34.66
|
| Rate for Payer: Multiplan PHCS |
$3,784.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$160.67
|
| Rate for Payer: UHCCP Medicaid |
$2,207.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$35.01
|
| Rate for Payer: Wellcare Medicare Advantage |
$123.59
|
|
|
DILATION OF VAGINA (P
|
Professional
|
Both
|
$313.00
|
|
|
Service Code
|
HCPCS 57400
|
| Hospital Charge Code |
761P2936
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$34.66 |
| Max. Negotiated Rate |
$206.83 |
| Rate for Payer: Aetna Commercial |
$206.83
|
| Rate for Payer: Ambetter Exchange |
$123.59
|
| Rate for Payer: Anthem Medicaid |
$34.66
|
| Rate for Payer: Buckeye Individual/Medicaid |
$123.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$123.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$148.31
|
| Rate for Payer: Cash Price |
$156.50
|
| Rate for Payer: Cash Price |
$156.50
|
| Rate for Payer: Cigna Commercial |
$199.81
|
| Rate for Payer: Healthspan PPO |
$200.26
|
| Rate for Payer: Humana Medicaid |
$34.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$174.54
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$123.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$123.59
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$35.35
|
| Rate for Payer: Molina Healthcare Passport |
$34.66
|
| Rate for Payer: Multiplan PHCS |
$187.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$160.67
|
| Rate for Payer: UHCCP Medicaid |
$109.55
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$35.01
|
| Rate for Payer: Wellcare Medicare Advantage |
$123.59
|
|
|
DILATION OF VAGINA (T
|
Facility
|
IP
|
$5,995.00
|
|
|
Service Code
|
HCPCS 57400
|
| Hospital Charge Code |
761T2936
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,798.50 |
| Max. Negotiated Rate |
$5,755.20 |
| Rate for Payer: Aetna Commercial |
$4,616.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,676.10
|
| Rate for Payer: Cash Price |
$2,997.50
|
| Rate for Payer: Cigna Commercial |
$4,975.85
|
| Rate for Payer: First Health Commercial |
$5,695.25
|
| Rate for Payer: Humana Commercial |
$5,095.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,915.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,424.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,798.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,275.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,496.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,796.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,215.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,136.55
|
| Rate for Payer: PHCS Commercial |
$5,755.20
|
| Rate for Payer: United Healthcare All Payer |
$5,275.60
|
|
|
DILATION OF VAGINA (T
|
Facility
|
OP
|
$5,995.00
|
|
|
Service Code
|
HCPCS 57400
|
| Hospital Charge Code |
761T2936
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,061.68 |
| Max. Negotiated Rate |
$5,755.20 |
| Rate for Payer: Aetna Commercial |
$4,616.15
|
| Rate for Payer: Anthem Medicaid |
$2,061.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,937.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,676.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,112.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,966.06
|
| Rate for Payer: Cash Price |
$2,997.50
|
| Rate for Payer: Cash Price |
$2,997.50
|
| Rate for Payer: Cigna Commercial |
$4,975.85
|
| Rate for Payer: First Health Commercial |
$5,695.25
|
| Rate for Payer: Humana Commercial |
$5,095.75
|
| Rate for Payer: Humana KY Medicaid |
$2,061.68
|
| Rate for Payer: Humana Medicare Advantage |
$2,937.82
|
| Rate for Payer: Kentucky WC Medicaid |
$2,082.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,915.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,424.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,525.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,103.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,275.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,496.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,796.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,215.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,136.55
|
| Rate for Payer: PHCS Commercial |
$5,755.20
|
| Rate for Payer: United Healthcare All Payer |
$5,275.60
|
|
|
DILATION OF VAGINA UNDER ANESTHESIA (OTHER THAN LOCAL)
|
Facility
|
OP
|
$4,112.95
|
|
|
Service Code
|
CPT 57400
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,937.82 |
| Max. Negotiated Rate |
$4,112.95 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,937.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,112.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,966.06
|
| Rate for Payer: Humana Medicare Advantage |
$2,937.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,525.38
|
|
|
DILATION PAROTID DUCT
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
HCPCS 42660
|
| Hospital Charge Code |
76101695
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$51.59 |
| Max. Negotiated Rate |
$658.76 |
| Rate for Payer: Aetna Commercial |
$115.50
|
| Rate for Payer: Anthem Medicaid |
$51.59
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$470.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$658.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$635.23
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$124.50
|
| Rate for Payer: First Health Commercial |
$142.50
|
| Rate for Payer: Humana Commercial |
$127.50
|
| Rate for Payer: Humana KY Medicaid |
$51.59
|
| Rate for Payer: Humana Medicare Advantage |
$470.54
|
| Rate for Payer: Kentucky WC Medicaid |
$52.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$52.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.00
|
| Rate for Payer: Ohio Health Group HMO |
$112.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$103.50
|
| Rate for Payer: PHCS Commercial |
$144.00
|
| Rate for Payer: United Healthcare All Payer |
$132.00
|
|
|
DILATION PAROTID DUCT
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 42660
|
| Hospital Charge Code |
76101695
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$48.03 |
| Max. Negotiated Rate |
$144.54 |
| Rate for Payer: Aetna Commercial |
$114.46
|
| Rate for Payer: Ambetter Exchange |
$74.31
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$66.55
|
| Rate for Payer: Anthem Medicaid |
$48.03
|
| Rate for Payer: Buckeye Individual/Medicaid |
$74.31
|
| Rate for Payer: Buckeye Medicare Advantage |
$74.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$89.17
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$144.54
|
| Rate for Payer: Healthspan PPO |
$125.42
|
| Rate for Payer: Humana Medicaid |
$48.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$100.22
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$74.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$74.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$48.99
|
| Rate for Payer: Molina Healthcare Passport |
$48.03
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$96.60
|
| Rate for Payer: UHCCP Medicaid |
$69.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$48.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$74.31
|
|
|
DILATION PAROTID DUCT
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
HCPCS 42660
|
| Hospital Charge Code |
76101695
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$45.00 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$115.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$124.50
|
| Rate for Payer: First Health Commercial |
$142.50
|
| Rate for Payer: Humana Commercial |
$127.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.00
|
| Rate for Payer: Ohio Health Group HMO |
$112.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$103.50
|
| Rate for Payer: PHCS Commercial |
$144.00
|
| Rate for Payer: United Healthcare All Payer |
$132.00
|
|
|
DILATION PAROTID DUCT(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 42660
|
| Hospital Charge Code |
761P1695
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$48.03 |
| Max. Negotiated Rate |
$144.54 |
| Rate for Payer: Aetna Commercial |
$114.46
|
| Rate for Payer: Ambetter Exchange |
$74.31
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$66.55
|
| Rate for Payer: Anthem Medicaid |
$48.03
|
| Rate for Payer: Buckeye Individual/Medicaid |
$74.31
|
| Rate for Payer: Buckeye Medicare Advantage |
$74.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$89.17
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$144.54
|
| Rate for Payer: Healthspan PPO |
$125.42
|
| Rate for Payer: Humana Medicaid |
$48.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$100.22
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$74.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$74.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$48.99
|
| Rate for Payer: Molina Healthcare Passport |
$48.03
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$96.60
|
| Rate for Payer: UHCCP Medicaid |
$69.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$48.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$74.31
|
|
|
DILATION SALIVARY DUCT
|
Facility
|
OP
|
$300.00
|
|
|
Service Code
|
HCPCS 42650
|
| Hospital Charge Code |
76101694
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$103.17 |
| Max. Negotiated Rate |
$1,916.14 |
| Rate for Payer: Aetna Commercial |
$231.00
|
| Rate for Payer: Anthem Medicaid |
$103.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,368.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$234.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,916.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,847.70
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$249.00
|
| Rate for Payer: First Health Commercial |
$285.00
|
| Rate for Payer: Humana Commercial |
$255.00
|
| Rate for Payer: Humana KY Medicaid |
$103.17
|
| Rate for Payer: Humana Medicare Advantage |
$1,368.67
|
| Rate for Payer: Kentucky WC Medicaid |
$104.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$246.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$221.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,642.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$105.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$264.00
|
| Rate for Payer: Ohio Health Group HMO |
$225.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$207.00
|
| Rate for Payer: PHCS Commercial |
$288.00
|
| Rate for Payer: United Healthcare All Payer |
$264.00
|
|
|
DILATION SALIVARY DUCT
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 42650
|
| Hospital Charge Code |
76101694
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$34.03 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Aetna Commercial |
$85.84
|
| Rate for Payer: Ambetter Exchange |
$56.03
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$50.96
|
| Rate for Payer: Anthem Medicaid |
$34.03
|
| Rate for Payer: Buckeye Individual/Medicaid |
$56.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$56.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$67.24
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$109.80
|
| Rate for Payer: Healthspan PPO |
$97.21
|
| Rate for Payer: Humana Medicaid |
$34.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$75.81
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$56.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$34.71
|
| Rate for Payer: Molina Healthcare Passport |
$34.03
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$72.84
|
| Rate for Payer: UHCCP Medicaid |
$53.51
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$34.37
|
| Rate for Payer: Wellcare Medicare Advantage |
$56.03
|
|
|
DILATION SALIVARY DUCT
|
Facility
|
IP
|
$300.00
|
|
|
Service Code
|
HCPCS 42650
|
| Hospital Charge Code |
76101694
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$90.00 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: Aetna Commercial |
$231.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$234.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$249.00
|
| Rate for Payer: First Health Commercial |
$285.00
|
| Rate for Payer: Humana Commercial |
$255.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$246.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$221.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$90.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$264.00
|
| Rate for Payer: Ohio Health Group HMO |
$225.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$207.00
|
| Rate for Payer: PHCS Commercial |
$288.00
|
| Rate for Payer: United Healthcare All Payer |
$264.00
|
|
|
DILATION SALIVARY DUCT(P
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 42650
|
| Hospital Charge Code |
761P1694
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$34.03 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Aetna Commercial |
$85.84
|
| Rate for Payer: Ambetter Exchange |
$56.03
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$50.96
|
| Rate for Payer: Anthem Medicaid |
$34.03
|
| Rate for Payer: Buckeye Individual/Medicaid |
$56.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$56.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$67.24
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$109.80
|
| Rate for Payer: Healthspan PPO |
$97.21
|
| Rate for Payer: Humana Medicaid |
$34.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$75.81
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$56.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$34.71
|
| Rate for Payer: Molina Healthcare Passport |
$34.03
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$72.84
|
| Rate for Payer: UHCCP Medicaid |
$53.51
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$34.37
|
| Rate for Payer: Wellcare Medicare Advantage |
$56.03
|
|
|
DILATOR 14F 45CM CATH LAB
|
Facility
|
OP
|
$1,965.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$589.50 |
| Max. Negotiated Rate |
$1,886.40 |
| Rate for Payer: Aetna Commercial |
$1,513.05
|
| Rate for Payer: Anthem Medicaid |
$675.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,532.70
|
| Rate for Payer: Cash Price |
$982.50
|
| Rate for Payer: Cigna Commercial |
$1,630.95
|
| Rate for Payer: First Health Commercial |
$1,866.75
|
| Rate for Payer: Humana Commercial |
$1,670.25
|
| Rate for Payer: Humana KY Medicaid |
$675.76
|
| Rate for Payer: Kentucky WC Medicaid |
$682.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,611.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,450.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$589.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$689.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,729.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,473.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,572.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,709.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,355.85
|
| Rate for Payer: PHCS Commercial |
$1,886.40
|
| Rate for Payer: United Healthcare All Payer |
$1,729.20
|
|
|
DILATOR 14F 45CM CATH LAB
|
Facility
|
IP
|
$1,965.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$589.50 |
| Max. Negotiated Rate |
$1,886.40 |
| Rate for Payer: Aetna Commercial |
$1,513.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,532.70
|
| Rate for Payer: Cash Price |
$982.50
|
| Rate for Payer: Cigna Commercial |
$1,630.95
|
| Rate for Payer: First Health Commercial |
$1,866.75
|
| Rate for Payer: Humana Commercial |
$1,670.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,611.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,450.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$589.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,729.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,473.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,572.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,709.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,355.85
|
| Rate for Payer: PHCS Commercial |
$1,886.40
|
| Rate for Payer: United Healthcare All Payer |
$1,729.20
|
|
