|
EXC BACK TUM DEEP 5 CM/>(P
|
Professional
|
Both
|
$1,170.00
|
|
|
Service Code
|
HCPCS 21933
|
| Hospital Charge Code |
761P0415
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$409.50 |
| Max. Negotiated Rate |
$1,306.12 |
| Rate for Payer: Aetna Commercial |
$1,149.42
|
| Rate for Payer: Anthem Medicaid |
$539.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,170.00
|
| Rate for Payer: Cash Price |
$585.00
|
| Rate for Payer: Cash Price |
$585.00
|
| Rate for Payer: Cigna Commercial |
$1,306.12
|
| Rate for Payer: Healthspan PPO |
$820.63
|
| Rate for Payer: Humana Medicaid |
$539.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$940.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$549.79
|
| Rate for Payer: Molina Healthcare Passport |
$539.01
|
| Rate for Payer: Multiplan PHCS |
$702.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$819.00
|
| Rate for Payer: UHCCP Medicaid |
$409.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$544.40
|
|
|
EXC BACK TUM DEEP < 5 CM(T
|
Facility
|
IP
|
$5,846.00
|
|
|
Service Code
|
HCPCS 21932
|
| Hospital Charge Code |
761T0414
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$759.98 |
| Max. Negotiated Rate |
$5,612.16 |
| Rate for Payer: Aetna Commercial |
$4,501.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,559.88
|
| Rate for Payer: Cash Price |
$2,923.00
|
| Rate for Payer: Cigna Commercial |
$4,852.18
|
| Rate for Payer: First Health Commercial |
$5,553.70
|
| Rate for Payer: Humana Commercial |
$4,969.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,793.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,314.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,753.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,144.48
|
| Rate for Payer: Ohio Health Group HMO |
$4,384.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,169.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$759.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,812.26
|
| Rate for Payer: PHCS Commercial |
$5,612.16
|
| Rate for Payer: United Healthcare All Payer |
$5,144.48
|
|
|
EXC BACK TUM DEEP < 5 CM(T
|
Facility
|
OP
|
$5,846.00
|
|
|
Service Code
|
HCPCS 21932
|
| Hospital Charge Code |
761T0414
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$759.98 |
| Max. Negotiated Rate |
$5,612.16 |
| Rate for Payer: Aetna Commercial |
$4,501.42
|
| Rate for Payer: Anthem Medicaid |
$2,010.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,559.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,440.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,317.21
|
| Rate for Payer: Cash Price |
$2,923.00
|
| Rate for Payer: Cash Price |
$2,923.00
|
| Rate for Payer: Cigna Commercial |
$4,852.18
|
| Rate for Payer: First Health Commercial |
$5,553.70
|
| Rate for Payer: Humana Commercial |
$4,969.10
|
| Rate for Payer: Humana KY Medicaid |
$2,010.44
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$2,030.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,793.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,314.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,050.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,144.48
|
| Rate for Payer: Ohio Health Group HMO |
$4,384.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,169.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$759.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,812.26
|
| Rate for Payer: PHCS Commercial |
$5,612.16
|
| Rate for Payer: United Healthcare All Payer |
$5,144.48
|
|
|
EXC BACK TUM DEEP 5 CM/>(T
|
Facility
|
OP
|
$6,575.00
|
|
|
Service Code
|
HCPCS 21933
|
| Hospital Charge Code |
761T0415
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$854.75 |
| Max. Negotiated Rate |
$6,312.00 |
| Rate for Payer: Aetna Commercial |
$5,062.75
|
| Rate for Payer: Anthem Medicaid |
$2,261.14
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,128.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,440.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,317.21
|
| Rate for Payer: Cash Price |
$3,287.50
|
| Rate for Payer: Cash Price |
$3,287.50
|
| Rate for Payer: Cigna Commercial |
$5,457.25
|
| Rate for Payer: First Health Commercial |
$6,246.25
|
| Rate for Payer: Humana Commercial |
$5,588.75
|
| Rate for Payer: Humana KY Medicaid |
$2,261.14
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$2,284.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,391.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,852.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,306.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,786.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,931.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,315.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$854.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,038.25
|
| Rate for Payer: PHCS Commercial |
$6,312.00
|
| Rate for Payer: United Healthcare All Payer |
$5,786.00
|
|
|
EXC BACK TUM DEEP 5 CM/>(T
|
Facility
|
IP
|
$6,575.00
|
|
|
Service Code
|
HCPCS 21933
|
| Hospital Charge Code |
761T0415
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$854.75 |
| Max. Negotiated Rate |
$6,312.00 |
| Rate for Payer: Aetna Commercial |
$5,062.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,128.50
|
| Rate for Payer: Cash Price |
$3,287.50
|
| Rate for Payer: Cigna Commercial |
$5,457.25
|
| Rate for Payer: First Health Commercial |
$6,246.25
|
| Rate for Payer: Humana Commercial |
$5,588.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,391.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,852.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,972.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,786.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,931.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,315.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$854.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,038.25
|
| Rate for Payer: PHCS Commercial |
$6,312.00
|
| Rate for Payer: United Healthcare All Payer |
$5,786.00
|
|
|
EXC BENIGN 2.1 TO 3.0 CM
|
Facility
|
IP
|
$3,302.00
|
|
|
Service Code
|
HCPCS 11443
|
| Hospital Charge Code |
76100066
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$429.26 |
| Max. Negotiated Rate |
$3,169.92 |
| Rate for Payer: Aetna Commercial |
$2,542.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,575.56
|
| Rate for Payer: Cash Price |
$1,651.00
|
| Rate for Payer: Cigna Commercial |
$2,740.66
|
| Rate for Payer: First Health Commercial |
$3,136.90
|
| Rate for Payer: Humana Commercial |
$2,806.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,707.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,436.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$990.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,905.76
|
| Rate for Payer: Ohio Health Group HMO |
$2,476.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$660.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$429.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,023.62
|
| Rate for Payer: PHCS Commercial |
$3,169.92
|
| Rate for Payer: United Healthcare All Payer |
$2,905.76
|
|
|
EXC BENIGN 2.1 TO 3.0 CM
|
Facility
|
OP
|
$3,302.00
|
|
|
Service Code
|
HCPCS 11443
|
| Hospital Charge Code |
76100066
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$429.26 |
| Max. Negotiated Rate |
$3,169.92 |
| Rate for Payer: Aetna Commercial |
$2,542.54
|
| Rate for Payer: Anthem Medicaid |
$1,135.56
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,575.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$1,651.00
|
| Rate for Payer: Cash Price |
$1,651.00
|
| Rate for Payer: Cigna Commercial |
$2,740.66
|
| Rate for Payer: First Health Commercial |
$3,136.90
|
| Rate for Payer: Humana Commercial |
$2,806.70
|
| Rate for Payer: Humana KY Medicaid |
$1,135.56
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,147.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,707.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,436.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,158.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,905.76
|
| Rate for Payer: Ohio Health Group HMO |
$2,476.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$660.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$429.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,023.62
|
| Rate for Payer: PHCS Commercial |
$3,169.92
|
| Rate for Payer: United Healthcare All Payer |
$2,905.76
|
|
|
EXC BENIGN 2.1 TO 3.0 CM
|
Professional
|
Both
|
$3,302.00
|
|
|
Service Code
|
HCPCS 11443
|
| Hospital Charge Code |
76100066
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$91.56 |
| Max. Negotiated Rate |
$3,302.00 |
| Rate for Payer: Aetna Commercial |
$248.58
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$91.56
|
| Rate for Payer: Anthem Medicaid |
$94.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,302.00
|
| Rate for Payer: Cash Price |
$1,651.00
|
| Rate for Payer: Cash Price |
$1,651.00
|
| Rate for Payer: Cigna Commercial |
$295.17
|
| Rate for Payer: Healthspan PPO |
$242.83
|
| Rate for Payer: Humana Medicaid |
$94.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$218.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$96.58
|
| Rate for Payer: Molina Healthcare Passport |
$94.69
|
| Rate for Payer: Multiplan PHCS |
$1,981.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,311.40
|
| Rate for Payer: UHCCP Medicaid |
$96.14
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$95.64
|
|
|
EXC BENIGN 2.1 TO 3.0 CM(P
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 11443
|
| Hospital Charge Code |
761P0066
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$91.56 |
| Max. Negotiated Rate |
$500.00 |
| Rate for Payer: Aetna Commercial |
$248.58
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$91.56
|
| Rate for Payer: Anthem Medicaid |
$94.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$500.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$295.17
|
| Rate for Payer: Healthspan PPO |
$242.83
|
| Rate for Payer: Humana Medicaid |
$94.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$218.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$96.58
|
| Rate for Payer: Molina Healthcare Passport |
$94.69
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$350.00
|
| Rate for Payer: UHCCP Medicaid |
$96.14
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$95.64
|
|
|
EXC BENIGN 2.1 TO 3.0 CM(T
|
Facility
|
IP
|
$2,802.00
|
|
|
Service Code
|
HCPCS 11443
|
| Hospital Charge Code |
761T0066
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$364.26 |
| Max. Negotiated Rate |
$2,689.92 |
| Rate for Payer: Aetna Commercial |
$2,157.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,185.56
|
| Rate for Payer: Cash Price |
$1,401.00
|
| Rate for Payer: Cigna Commercial |
$2,325.66
|
| Rate for Payer: First Health Commercial |
$2,661.90
|
| Rate for Payer: Humana Commercial |
$2,381.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,297.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,067.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$840.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,465.76
|
| Rate for Payer: Ohio Health Group HMO |
$2,101.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$560.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$364.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$868.62
|
| Rate for Payer: PHCS Commercial |
$2,689.92
|
| Rate for Payer: United Healthcare All Payer |
$2,465.76
|
|
|
EXC BENIGN 2.1 TO 3.0 CM(T
|
Facility
|
OP
|
$2,802.00
|
|
|
Service Code
|
HCPCS 11443
|
| Hospital Charge Code |
761T0066
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$364.26 |
| Max. Negotiated Rate |
$2,689.92 |
| Rate for Payer: Aetna Commercial |
$2,157.54
|
| Rate for Payer: Anthem Medicaid |
$963.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,185.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$1,401.00
|
| Rate for Payer: Cash Price |
$1,401.00
|
| Rate for Payer: Cigna Commercial |
$2,325.66
|
| Rate for Payer: First Health Commercial |
$2,661.90
|
| Rate for Payer: Humana Commercial |
$2,381.70
|
| Rate for Payer: Humana KY Medicaid |
$963.61
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$973.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,297.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,067.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$982.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,465.76
|
| Rate for Payer: Ohio Health Group HMO |
$2,101.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$560.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$364.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$868.62
|
| Rate for Payer: PHCS Commercial |
$2,689.92
|
| Rate for Payer: United Healthcare All Payer |
$2,465.76
|
|
|
EXC BENIGN LESION 2.1-3.0 CM
|
Professional
|
Both
|
$3,786.00
|
|
|
Service Code
|
HCPCS 11423
|
| Hospital Charge Code |
76100060
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$78.90 |
| Max. Negotiated Rate |
$3,786.00 |
| Rate for Payer: Aetna Commercial |
$218.13
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$78.90
|
| Rate for Payer: Anthem Medicaid |
$83.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,786.00
|
| Rate for Payer: Cash Price |
$1,893.00
|
| Rate for Payer: Cash Price |
$1,893.00
|
| Rate for Payer: Cigna Commercial |
$262.75
|
| Rate for Payer: Healthspan PPO |
$218.07
|
| Rate for Payer: Humana Medicaid |
$83.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$191.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$85.09
|
| Rate for Payer: Molina Healthcare Passport |
$83.42
|
| Rate for Payer: Multiplan PHCS |
$2,271.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,650.20
|
| Rate for Payer: UHCCP Medicaid |
$82.84
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$84.25
|
|
|
EXC BENIGN LESION 2.1-3.0 CM
|
Facility
|
OP
|
$3,786.00
|
|
|
Service Code
|
HCPCS 11423
|
| Hospital Charge Code |
76100060
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$492.18 |
| Max. Negotiated Rate |
$3,634.56 |
| Rate for Payer: Aetna Commercial |
$2,915.22
|
| Rate for Payer: Anthem Medicaid |
$1,302.01
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,953.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$1,893.00
|
| Rate for Payer: Cash Price |
$1,893.00
|
| Rate for Payer: Cigna Commercial |
$3,142.38
|
| Rate for Payer: First Health Commercial |
$3,596.70
|
| Rate for Payer: Humana Commercial |
$3,218.10
|
| Rate for Payer: Humana KY Medicaid |
$1,302.01
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,315.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,104.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,794.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,328.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,331.68
|
| Rate for Payer: Ohio Health Group HMO |
$2,839.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$757.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$492.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,173.66
|
| Rate for Payer: PHCS Commercial |
$3,634.56
|
| Rate for Payer: United Healthcare All Payer |
$3,331.68
|
|
|
EXC BENIGN LESION 2.1-3.0 CM
|
Facility
|
IP
|
$3,786.00
|
|
|
Service Code
|
HCPCS 11423
|
| Hospital Charge Code |
76100060
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$492.18 |
| Max. Negotiated Rate |
$3,634.56 |
| Rate for Payer: Aetna Commercial |
$2,915.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,953.08
|
| Rate for Payer: Cash Price |
$1,893.00
|
| Rate for Payer: Cigna Commercial |
$3,142.38
|
| Rate for Payer: First Health Commercial |
$3,596.70
|
| Rate for Payer: Humana Commercial |
$3,218.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,104.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,794.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,135.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,331.68
|
| Rate for Payer: Ohio Health Group HMO |
$2,839.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$757.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$492.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,173.66
|
| Rate for Payer: PHCS Commercial |
$3,634.56
|
| Rate for Payer: United Healthcare All Payer |
$3,331.68
|
|
|
EXC BENIGN LESION 2.1-3.0 CM(P
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 11423
|
| Hospital Charge Code |
761P0060
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$78.90 |
| Max. Negotiated Rate |
$450.00 |
| Rate for Payer: Aetna Commercial |
$218.13
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$78.90
|
| Rate for Payer: Anthem Medicaid |
$83.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$450.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$262.75
|
| Rate for Payer: Healthspan PPO |
$218.07
|
| Rate for Payer: Humana Medicaid |
$83.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$191.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$85.09
|
| Rate for Payer: Molina Healthcare Passport |
$83.42
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$315.00
|
| Rate for Payer: UHCCP Medicaid |
$82.84
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$84.25
|
|
|
EXC BENIGN LESION 2.1-3.0 CM(T
|
Facility
|
OP
|
$3,336.00
|
|
|
Service Code
|
HCPCS 11423
|
| Hospital Charge Code |
761T0060
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$433.68 |
| Max. Negotiated Rate |
$3,202.56 |
| Rate for Payer: Aetna Commercial |
$2,568.72
|
| Rate for Payer: Anthem Medicaid |
$1,147.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,602.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$1,668.00
|
| Rate for Payer: Cash Price |
$1,668.00
|
| Rate for Payer: Cigna Commercial |
$2,768.88
|
| Rate for Payer: First Health Commercial |
$3,169.20
|
| Rate for Payer: Humana Commercial |
$2,835.60
|
| Rate for Payer: Humana KY Medicaid |
$1,147.25
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,158.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,735.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,461.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,170.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,935.68
|
| Rate for Payer: Ohio Health Group HMO |
$2,502.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$667.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$433.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,034.16
|
| Rate for Payer: PHCS Commercial |
$3,202.56
|
| Rate for Payer: United Healthcare All Payer |
$2,935.68
|
|
|
EXC BENIGN LESION 2.1-3.0 CM(T
|
Facility
|
IP
|
$3,336.00
|
|
|
Service Code
|
HCPCS 11423
|
| Hospital Charge Code |
761T0060
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$433.68 |
| Max. Negotiated Rate |
$3,202.56 |
| Rate for Payer: Aetna Commercial |
$2,568.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,602.08
|
| Rate for Payer: Cash Price |
$1,668.00
|
| Rate for Payer: Cigna Commercial |
$2,768.88
|
| Rate for Payer: First Health Commercial |
$3,169.20
|
| Rate for Payer: Humana Commercial |
$2,835.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,735.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,461.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,000.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,935.68
|
| Rate for Payer: Ohio Health Group HMO |
$2,502.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$667.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$433.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,034.16
|
| Rate for Payer: PHCS Commercial |
$3,202.56
|
| Rate for Payer: United Healthcare All Payer |
$2,935.68
|
|
|
EXC BENIGN MAXILLA TUM CYST
|
Facility
|
IP
|
$8,447.00
|
|
|
Service Code
|
HCPCS 21048
|
| Hospital Charge Code |
76100371
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,098.11 |
| Max. Negotiated Rate |
$8,109.12 |
| Rate for Payer: Aetna Commercial |
$6,504.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,588.66
|
| Rate for Payer: Cash Price |
$4,223.50
|
| Rate for Payer: Cigna Commercial |
$7,011.01
|
| Rate for Payer: First Health Commercial |
$8,024.65
|
| Rate for Payer: Humana Commercial |
$7,179.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,926.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,233.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,534.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,433.36
|
| Rate for Payer: Ohio Health Group HMO |
$6,335.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,689.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,098.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,618.57
|
| Rate for Payer: PHCS Commercial |
$8,109.12
|
| Rate for Payer: United Healthcare All Payer |
$7,433.36
|
|
|
EXC BENIGN MAXILLA TUM CYST
|
Professional
|
Both
|
$8,447.00
|
|
|
Service Code
|
HCPCS 21048
|
| Hospital Charge Code |
76100371
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$687.94 |
| Max. Negotiated Rate |
$8,447.00 |
| Rate for Payer: Aetna Commercial |
$1,592.37
|
| Rate for Payer: Anthem Medicaid |
$687.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$8,447.00
|
| Rate for Payer: Cash Price |
$4,223.50
|
| Rate for Payer: Cash Price |
$4,223.50
|
| Rate for Payer: Cigna Commercial |
$1,727.86
|
| Rate for Payer: Healthspan PPO |
$1,442.34
|
| Rate for Payer: Humana Medicaid |
$687.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,378.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$701.70
|
| Rate for Payer: Molina Healthcare Passport |
$687.94
|
| Rate for Payer: Multiplan PHCS |
$5,068.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5,912.90
|
| Rate for Payer: UHCCP Medicaid |
$2,956.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$694.82
|
|
|
EXC BENIGN MAXILLA TUM CYST
|
Facility
|
OP
|
$8,447.00
|
|
|
Service Code
|
HCPCS 21048
|
| Hospital Charge Code |
76100371
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,098.11 |
| Max. Negotiated Rate |
$8,109.12 |
| Rate for Payer: Aetna Commercial |
$6,504.19
|
| Rate for Payer: Anthem Medicaid |
$2,904.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,064.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,588.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,089.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,836.59
|
| Rate for Payer: Cash Price |
$4,223.50
|
| Rate for Payer: Cash Price |
$4,223.50
|
| Rate for Payer: Cigna Commercial |
$7,011.01
|
| Rate for Payer: First Health Commercial |
$8,024.65
|
| Rate for Payer: Humana Commercial |
$7,179.95
|
| Rate for Payer: Humana KY Medicaid |
$2,904.92
|
| Rate for Payer: Humana Medicare Advantage |
$5,064.14
|
| Rate for Payer: Kentucky WC Medicaid |
$2,934.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,926.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,233.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,076.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,963.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,433.36
|
| Rate for Payer: Ohio Health Group HMO |
$6,335.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,689.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,098.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,618.57
|
| Rate for Payer: PHCS Commercial |
$8,109.12
|
| Rate for Payer: United Healthcare All Payer |
$7,433.36
|
|
|
EXC BENIGN MAXILLA TUM CYST(P
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 21048
|
| Hospital Charge Code |
761P0371
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$525.00 |
| Max. Negotiated Rate |
$1,727.86 |
| Rate for Payer: Aetna Commercial |
$1,592.37
|
| Rate for Payer: Anthem Medicaid |
$687.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,500.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,727.86
|
| Rate for Payer: Healthspan PPO |
$1,442.34
|
| Rate for Payer: Humana Medicaid |
$687.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,378.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$701.70
|
| Rate for Payer: Molina Healthcare Passport |
$687.94
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,050.00
|
| Rate for Payer: UHCCP Medicaid |
$525.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$694.82
|
|
|
EXC BENIGN MAXILLA TUM CYST(T
|
Facility
|
OP
|
$6,947.00
|
|
|
Service Code
|
HCPCS 21048
|
| Hospital Charge Code |
761T0371
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$903.11 |
| Max. Negotiated Rate |
$7,089.80 |
| Rate for Payer: Aetna Commercial |
$5,349.19
|
| Rate for Payer: Anthem Medicaid |
$2,389.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,064.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,418.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,089.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,836.59
|
| Rate for Payer: Cash Price |
$3,473.50
|
| Rate for Payer: Cash Price |
$3,473.50
|
| Rate for Payer: Cigna Commercial |
$5,766.01
|
| Rate for Payer: First Health Commercial |
$6,599.65
|
| Rate for Payer: Humana Commercial |
$5,904.95
|
| Rate for Payer: Humana KY Medicaid |
$2,389.07
|
| Rate for Payer: Humana Medicare Advantage |
$5,064.14
|
| Rate for Payer: Kentucky WC Medicaid |
$2,413.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,696.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,126.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,076.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,437.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,113.36
|
| Rate for Payer: Ohio Health Group HMO |
$5,210.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,389.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$903.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,153.57
|
| Rate for Payer: PHCS Commercial |
$6,669.12
|
| Rate for Payer: United Healthcare All Payer |
$6,113.36
|
|
|
EXC BENIGN MAXILLA TUM CYST(T
|
Facility
|
IP
|
$6,947.00
|
|
|
Service Code
|
HCPCS 21048
|
| Hospital Charge Code |
761T0371
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$903.11 |
| Max. Negotiated Rate |
$6,669.12 |
| Rate for Payer: Aetna Commercial |
$5,349.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,418.66
|
| Rate for Payer: Cash Price |
$3,473.50
|
| Rate for Payer: Cigna Commercial |
$5,766.01
|
| Rate for Payer: First Health Commercial |
$6,599.65
|
| Rate for Payer: Humana Commercial |
$5,904.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,696.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,126.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,084.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,113.36
|
| Rate for Payer: Ohio Health Group HMO |
$5,210.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,389.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$903.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,153.57
|
| Rate for Payer: PHCS Commercial |
$6,669.12
|
| Rate for Payer: United Healthcare All Payer |
$6,113.36
|
|
|
EXC BEN LESION 1.1-2.0 CM
|
Facility
|
IP
|
$2,617.00
|
|
|
Service Code
|
HCPCS 11402
|
| Hospital Charge Code |
76100053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$340.21 |
| Max. Negotiated Rate |
$2,512.32 |
| Rate for Payer: Aetna Commercial |
$2,015.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,041.26
|
| Rate for Payer: Cash Price |
$1,308.50
|
| Rate for Payer: Cigna Commercial |
$2,172.11
|
| Rate for Payer: First Health Commercial |
$2,486.15
|
| Rate for Payer: Humana Commercial |
$2,224.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,145.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,931.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$785.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,302.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,962.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$523.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$340.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$811.27
|
| Rate for Payer: PHCS Commercial |
$2,512.32
|
| Rate for Payer: United Healthcare All Payer |
$2,302.96
|
|
|
EXC BEN LESION 1.1-2.0 CM
|
Professional
|
Both
|
$2,617.00
|
|
|
Service Code
|
HCPCS 11402
|
| Hospital Charge Code |
76100053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$59.70 |
| Max. Negotiated Rate |
$2,617.00 |
| Rate for Payer: Aetna Commercial |
$155.46
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$59.70
|
| Rate for Payer: Anthem Medicaid |
$59.90
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,617.00
|
| Rate for Payer: Cash Price |
$1,308.50
|
| Rate for Payer: Cash Price |
$1,308.50
|
| Rate for Payer: Cigna Commercial |
$207.57
|
| Rate for Payer: Healthspan PPO |
$173.94
|
| Rate for Payer: Humana Medicaid |
$59.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$138.77
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$61.10
|
| Rate for Payer: Molina Healthcare Passport |
$59.90
|
| Rate for Payer: Multiplan PHCS |
$1,570.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,831.90
|
| Rate for Payer: UHCCP Medicaid |
$62.68
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$60.50
|
|
