|
EXC BEN LESION 1.1-2.0 CM
|
Facility
|
OP
|
$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 Medicaid |
$899.99
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$608.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,041.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$851.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$821.37
|
| Rate for Payer: Cash Price |
$1,308.50
|
| 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: Humana KY Medicaid |
$899.99
|
| Rate for Payer: Humana Medicare Advantage |
$608.42
|
| Rate for Payer: Kentucky WC Medicaid |
$909.15
|
| 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 |
$730.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$918.04
|
| 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(P
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
HCPCS 11402
|
| Hospital Charge Code |
761P0053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$59.70 |
| Max. Negotiated Rate |
$350.00 |
| 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 |
$350.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| 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 |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$245.00
|
| Rate for Payer: UHCCP Medicaid |
$62.68
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$60.50
|
|
|
EXC BEN LESION 1.1-2.0 CM(T
|
Facility
|
OP
|
$2,267.00
|
|
|
Service Code
|
HCPCS 11402
|
| Hospital Charge Code |
761T0053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$294.71 |
| Max. Negotiated Rate |
$2,176.32 |
| Rate for Payer: Aetna Commercial |
$1,745.59
|
| Rate for Payer: Anthem Medicaid |
$779.62
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$608.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,768.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$851.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$821.37
|
| Rate for Payer: Cash Price |
$1,133.50
|
| Rate for Payer: Cash Price |
$1,133.50
|
| Rate for Payer: Cigna Commercial |
$1,881.61
|
| Rate for Payer: First Health Commercial |
$2,153.65
|
| Rate for Payer: Humana Commercial |
$1,926.95
|
| Rate for Payer: Humana KY Medicaid |
$779.62
|
| Rate for Payer: Humana Medicare Advantage |
$608.42
|
| Rate for Payer: Kentucky WC Medicaid |
$787.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,858.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,673.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$730.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$795.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,994.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,700.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$453.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$294.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$702.77
|
| Rate for Payer: PHCS Commercial |
$2,176.32
|
| Rate for Payer: United Healthcare All Payer |
$1,994.96
|
|
|
EXC BEN LESION 1.1-2.0 CM(T
|
Facility
|
IP
|
$2,267.00
|
|
|
Service Code
|
HCPCS 11402
|
| Hospital Charge Code |
761T0053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$294.71 |
| Max. Negotiated Rate |
$2,176.32 |
| Rate for Payer: Aetna Commercial |
$1,745.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,768.26
|
| Rate for Payer: Cash Price |
$1,133.50
|
| Rate for Payer: Cigna Commercial |
$1,881.61
|
| Rate for Payer: First Health Commercial |
$2,153.65
|
| Rate for Payer: Humana Commercial |
$1,926.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,858.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,673.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$680.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,994.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,700.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$453.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$294.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$702.77
|
| Rate for Payer: PHCS Commercial |
$2,176.32
|
| Rate for Payer: United Healthcare All Payer |
$1,994.96
|
|
|
EXC BEN LESION 2.1-3.0 CM
|
Facility
|
OP
|
$3,062.00
|
|
|
Service Code
|
HCPCS 11403
|
| Hospital Charge Code |
76100054
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$398.06 |
| Max. Negotiated Rate |
$2,939.52 |
| Rate for Payer: Aetna Commercial |
$2,357.74
|
| Rate for Payer: Anthem Medicaid |
$1,053.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$608.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,388.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$851.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$821.37
|
| Rate for Payer: Cash Price |
$1,531.00
|
| Rate for Payer: Cash Price |
$1,531.00
|
| Rate for Payer: Cigna Commercial |
$2,541.46
|
| Rate for Payer: First Health Commercial |
$2,908.90
|
| Rate for Payer: Humana Commercial |
$2,602.70
|
| Rate for Payer: Humana KY Medicaid |
$1,053.02
|
| Rate for Payer: Humana Medicare Advantage |
$608.42
|
| Rate for Payer: Kentucky WC Medicaid |
$1,063.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,510.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,259.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$730.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,074.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,694.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,296.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$612.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$398.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$949.22
|
| Rate for Payer: PHCS Commercial |
$2,939.52
|
| Rate for Payer: United Healthcare All Payer |
$2,694.56
|
|
|
EXC BEN LESION 2.1-3.0 CM
|
Facility
|
IP
|
$3,062.00
|
|
|
Service Code
|
HCPCS 11403
|
| Hospital Charge Code |
76100054
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$398.06 |
| Max. Negotiated Rate |
$2,939.52 |
| Rate for Payer: Aetna Commercial |
$2,357.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,388.36
|
| Rate for Payer: Cash Price |
$1,531.00
|
| Rate for Payer: Cigna Commercial |
$2,541.46
|
| Rate for Payer: First Health Commercial |
$2,908.90
|
| Rate for Payer: Humana Commercial |
$2,602.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,510.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,259.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$918.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,694.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,296.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$612.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$398.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$949.22
|
| Rate for Payer: PHCS Commercial |
$2,939.52
|
| Rate for Payer: United Healthcare All Payer |
$2,694.56
|
|
|
EXC BEN LESION 2.1-3.0 CM
|
Professional
|
Both
|
$3,062.00
|
|
|
Service Code
|
HCPCS 11403
|
| Hospital Charge Code |
76100054
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$73.72 |
| Max. Negotiated Rate |
$3,062.00 |
| Rate for Payer: Aetna Commercial |
$197.94
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$75.27
|
| Rate for Payer: Anthem Medicaid |
$73.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,062.00
|
| Rate for Payer: Cash Price |
$1,531.00
|
| Rate for Payer: Cash Price |
$1,531.00
|
| Rate for Payer: Cigna Commercial |
$239.86
|
| Rate for Payer: Healthspan PPO |
$201.08
|
| Rate for Payer: Humana Medicaid |
$73.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$176.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$75.19
|
| Rate for Payer: Molina Healthcare Passport |
$73.72
|
| Rate for Payer: Multiplan PHCS |
$1,837.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,143.40
|
| Rate for Payer: UHCCP Medicaid |
$79.03
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$74.46
|
|
|
EXC BEN LESION 2.1-3.0 CM(P
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 11403
|
| Hospital Charge Code |
761P0054
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$73.72 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna Commercial |
$197.94
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$75.27
|
| Rate for Payer: Anthem Medicaid |
$73.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$400.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$239.86
|
| Rate for Payer: Healthspan PPO |
$201.08
|
| Rate for Payer: Humana Medicaid |
$73.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$176.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$75.19
|
| Rate for Payer: Molina Healthcare Passport |
$73.72
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$79.03
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$74.46
|
|
|
EXC BEN LESION 2.1-3.0 CM(T
|
Facility
|
OP
|
$2,662.00
|
|
|
Service Code
|
HCPCS 11403
|
| Hospital Charge Code |
761T0054
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$346.06 |
| Max. Negotiated Rate |
$2,555.52 |
| Rate for Payer: Aetna Commercial |
$2,049.74
|
| Rate for Payer: Anthem Medicaid |
$915.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$608.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,076.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$851.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$821.37
|
| Rate for Payer: Cash Price |
$1,331.00
|
| Rate for Payer: Cash Price |
$1,331.00
|
| Rate for Payer: Cigna Commercial |
$2,209.46
|
| Rate for Payer: First Health Commercial |
$2,528.90
|
| Rate for Payer: Humana Commercial |
$2,262.70
|
| Rate for Payer: Humana KY Medicaid |
$915.46
|
| Rate for Payer: Humana Medicare Advantage |
$608.42
|
| Rate for Payer: Kentucky WC Medicaid |
$924.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,182.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,964.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$730.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$933.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,342.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,996.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$532.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$346.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$825.22
|
| Rate for Payer: PHCS Commercial |
$2,555.52
|
| Rate for Payer: United Healthcare All Payer |
$2,342.56
|
|
|
EXC BEN LESION 2.1-3.0 CM(T
|
Facility
|
IP
|
$2,662.00
|
|
|
Service Code
|
HCPCS 11403
|
| Hospital Charge Code |
761T0054
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$346.06 |
| Max. Negotiated Rate |
$2,555.52 |
| Rate for Payer: Aetna Commercial |
$2,049.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,076.36
|
| Rate for Payer: Cash Price |
$1,331.00
|
| Rate for Payer: Cigna Commercial |
$2,209.46
|
| Rate for Payer: First Health Commercial |
$2,528.90
|
| Rate for Payer: Humana Commercial |
$2,262.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,182.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,964.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$798.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,342.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,996.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$532.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$346.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$825.22
|
| Rate for Payer: PHCS Commercial |
$2,555.52
|
| Rate for Payer: United Healthcare All Payer |
$2,342.56
|
|
|
EXC BEN LESION 3.1-4.0 CM
|
Facility
|
IP
|
$3,741.00
|
|
|
Service Code
|
HCPCS 11404
|
| Hospital Charge Code |
76100055
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$486.33 |
| Max. Negotiated Rate |
$3,591.36 |
| Rate for Payer: Aetna Commercial |
$2,880.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,917.98
|
| Rate for Payer: Cash Price |
$1,870.50
|
| Rate for Payer: Cigna Commercial |
$3,105.03
|
| Rate for Payer: First Health Commercial |
$3,553.95
|
| Rate for Payer: Humana Commercial |
$3,179.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,067.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,760.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,122.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,292.08
|
| Rate for Payer: Ohio Health Group HMO |
$2,805.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$748.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$486.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,159.71
|
| Rate for Payer: PHCS Commercial |
$3,591.36
|
| Rate for Payer: United Healthcare All Payer |
$3,292.08
|
|
|
EXC BEN LESION 3.1-4.0 CM
|
Facility
|
OP
|
$4,103.00
|
|
|
Service Code
|
HCPCS 11424
|
| Hospital Charge Code |
76100061
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$533.39 |
| Max. Negotiated Rate |
$3,938.88 |
| Rate for Payer: Aetna Commercial |
$3,159.31
|
| Rate for Payer: Anthem Medicaid |
$1,411.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,200.34
|
| 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 |
$2,051.50
|
| Rate for Payer: Cash Price |
$2,051.50
|
| Rate for Payer: Cigna Commercial |
$3,405.49
|
| Rate for Payer: First Health Commercial |
$3,897.85
|
| Rate for Payer: Humana Commercial |
$3,487.55
|
| Rate for Payer: Humana KY Medicaid |
$1,411.02
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,425.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,364.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,028.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,439.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,610.64
|
| Rate for Payer: Ohio Health Group HMO |
$3,077.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$820.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$533.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,271.93
|
| Rate for Payer: PHCS Commercial |
$3,938.88
|
| Rate for Payer: United Healthcare All Payer |
$3,610.64
|
|
|
EXC BEN LESION 3.1-4.0 CM
|
Professional
|
Both
|
$3,741.00
|
|
|
Service Code
|
HCPCS 11404
|
| Hospital Charge Code |
76100055
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$83.40 |
| Max. Negotiated Rate |
$3,741.00 |
| Rate for Payer: Aetna Commercial |
$221.20
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$83.40
|
| Rate for Payer: Anthem Medicaid |
$85.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,741.00
|
| Rate for Payer: Cash Price |
$1,870.50
|
| Rate for Payer: Cash Price |
$1,870.50
|
| Rate for Payer: Cigna Commercial |
$273.40
|
| Rate for Payer: Healthspan PPO |
$229.50
|
| Rate for Payer: Humana Medicaid |
$85.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$196.35
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$87.44
|
| Rate for Payer: Molina Healthcare Passport |
$85.73
|
| Rate for Payer: Multiplan PHCS |
$2,244.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,618.70
|
| Rate for Payer: UHCCP Medicaid |
$87.57
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$86.59
|
|
|
EXC BEN LESION 3.1-4.0 CM
|
Facility
|
IP
|
$4,103.00
|
|
|
Service Code
|
HCPCS 11424
|
| Hospital Charge Code |
76100061
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$533.39 |
| Max. Negotiated Rate |
$3,938.88 |
| Rate for Payer: Aetna Commercial |
$3,159.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,200.34
|
| Rate for Payer: Cash Price |
$2,051.50
|
| Rate for Payer: Cigna Commercial |
$3,405.49
|
| Rate for Payer: First Health Commercial |
$3,897.85
|
| Rate for Payer: Humana Commercial |
$3,487.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,364.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,028.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,230.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,610.64
|
| Rate for Payer: Ohio Health Group HMO |
$3,077.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$820.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$533.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,271.93
|
| Rate for Payer: PHCS Commercial |
$3,938.88
|
| Rate for Payer: United Healthcare All Payer |
$3,610.64
|
|
|
EXC BEN LESION 3.1-4.0 CM
|
Professional
|
Both
|
$4,103.00
|
|
|
Service Code
|
HCPCS 11424
|
| Hospital Charge Code |
76100061
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$90.34 |
| Max. Negotiated Rate |
$4,103.00 |
| Rate for Payer: Aetna Commercial |
$252.37
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$90.34
|
| Rate for Payer: Anthem Medicaid |
$97.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,103.00
|
| Rate for Payer: Cash Price |
$2,051.50
|
| Rate for Payer: Cash Price |
$2,051.50
|
| Rate for Payer: Cigna Commercial |
$300.66
|
| Rate for Payer: Healthspan PPO |
$252.29
|
| Rate for Payer: Humana Medicaid |
$97.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$219.83
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$99.90
|
| Rate for Payer: Molina Healthcare Passport |
$97.94
|
| Rate for Payer: Multiplan PHCS |
$2,461.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,872.10
|
| Rate for Payer: UHCCP Medicaid |
$94.86
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$98.92
|
|
|
EXC BEN LESION 3.1-4.0 CM
|
Facility
|
OP
|
$3,741.00
|
|
|
Service Code
|
HCPCS 11404
|
| Hospital Charge Code |
76100055
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$486.33 |
| Max. Negotiated Rate |
$3,591.36 |
| Rate for Payer: Aetna Commercial |
$2,880.57
|
| Rate for Payer: Anthem Medicaid |
$1,286.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,917.98
|
| 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 |
$1,870.50
|
| Rate for Payer: Cash Price |
$1,870.50
|
| Rate for Payer: Cigna Commercial |
$3,105.03
|
| Rate for Payer: First Health Commercial |
$3,553.95
|
| Rate for Payer: Humana Commercial |
$3,179.85
|
| Rate for Payer: Humana KY Medicaid |
$1,286.53
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,299.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,067.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,760.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,312.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,292.08
|
| Rate for Payer: Ohio Health Group HMO |
$2,805.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$748.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$486.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,159.71
|
| Rate for Payer: PHCS Commercial |
$3,591.36
|
| Rate for Payer: United Healthcare All Payer |
$3,292.08
|
|
|
EXC BEN LESION 3.1-4.0 CM(P
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 11404
|
| Hospital Charge Code |
761P0055
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$83.40 |
| Max. Negotiated Rate |
$450.00 |
| Rate for Payer: Aetna Commercial |
$221.20
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$83.40
|
| Rate for Payer: Anthem Medicaid |
$85.73
|
| 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 |
$273.40
|
| Rate for Payer: Healthspan PPO |
$229.50
|
| Rate for Payer: Humana Medicaid |
$85.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$196.35
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$87.44
|
| Rate for Payer: Molina Healthcare Passport |
$85.73
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$315.00
|
| Rate for Payer: UHCCP Medicaid |
$87.57
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$86.59
|
|
|
EXC BEN LESION 3.1-4.0 CM(P
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 11424
|
| Hospital Charge Code |
761P0061
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$90.34 |
| Max. Negotiated Rate |
$500.00 |
| Rate for Payer: Aetna Commercial |
$252.37
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$90.34
|
| Rate for Payer: Anthem Medicaid |
$97.94
|
| 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 |
$300.66
|
| Rate for Payer: Healthspan PPO |
$252.29
|
| Rate for Payer: Humana Medicaid |
$97.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$219.83
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$99.90
|
| Rate for Payer: Molina Healthcare Passport |
$97.94
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$350.00
|
| Rate for Payer: UHCCP Medicaid |
$94.86
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$98.92
|
|
|
EXC BEN LESION 3.1-4.0 CM(T
|
Facility
|
OP
|
$3,603.00
|
|
|
Service Code
|
HCPCS 11424
|
| Hospital Charge Code |
761T0061
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$468.39 |
| Max. Negotiated Rate |
$3,458.88 |
| Rate for Payer: Aetna Commercial |
$2,774.31
|
| Rate for Payer: Anthem Medicaid |
$1,239.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,810.34
|
| 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 |
$1,801.50
|
| Rate for Payer: Cash Price |
$1,801.50
|
| Rate for Payer: Cigna Commercial |
$2,990.49
|
| Rate for Payer: First Health Commercial |
$3,422.85
|
| Rate for Payer: Humana Commercial |
$3,062.55
|
| Rate for Payer: Humana KY Medicaid |
$1,239.07
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,251.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,954.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,659.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,263.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,170.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,702.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$720.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$468.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,116.93
|
| Rate for Payer: PHCS Commercial |
$3,458.88
|
| Rate for Payer: United Healthcare All Payer |
$3,170.64
|
|
|
EXC BEN LESION 3.1-4.0 CM(T
|
Facility
|
IP
|
$3,603.00
|
|
|
Service Code
|
HCPCS 11424
|
| Hospital Charge Code |
761T0061
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$468.39 |
| Max. Negotiated Rate |
$3,458.88 |
| Rate for Payer: Aetna Commercial |
$2,774.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,810.34
|
| Rate for Payer: Cash Price |
$1,801.50
|
| Rate for Payer: Cigna Commercial |
$2,990.49
|
| Rate for Payer: First Health Commercial |
$3,422.85
|
| Rate for Payer: Humana Commercial |
$3,062.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,954.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,659.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,080.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,170.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,702.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$720.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$468.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,116.93
|
| Rate for Payer: PHCS Commercial |
$3,458.88
|
| Rate for Payer: United Healthcare All Payer |
$3,170.64
|
|
|
EXC BEN LESION 3.1-4.0 CM(T
|
Facility
|
IP
|
$3,291.00
|
|
|
Service Code
|
HCPCS 11404
|
| Hospital Charge Code |
761T0055
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$427.83 |
| Max. Negotiated Rate |
$3,159.36 |
| Rate for Payer: Aetna Commercial |
$2,534.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,566.98
|
| Rate for Payer: Cash Price |
$1,645.50
|
| Rate for Payer: Cigna Commercial |
$2,731.53
|
| Rate for Payer: First Health Commercial |
$3,126.45
|
| Rate for Payer: Humana Commercial |
$2,797.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,698.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,428.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$987.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,896.08
|
| Rate for Payer: Ohio Health Group HMO |
$2,468.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$658.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$427.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,020.21
|
| Rate for Payer: PHCS Commercial |
$3,159.36
|
| Rate for Payer: United Healthcare All Payer |
$2,896.08
|
|
|
EXC BEN LESION 3.1-4.0 CM(T
|
Facility
|
OP
|
$3,291.00
|
|
|
Service Code
|
HCPCS 11404
|
| Hospital Charge Code |
761T0055
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$427.83 |
| Max. Negotiated Rate |
$3,159.36 |
| Rate for Payer: Aetna Commercial |
$2,534.07
|
| Rate for Payer: Anthem Medicaid |
$1,131.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,566.98
|
| 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 |
$1,645.50
|
| Rate for Payer: Cash Price |
$1,645.50
|
| Rate for Payer: Cigna Commercial |
$2,731.53
|
| Rate for Payer: First Health Commercial |
$3,126.45
|
| Rate for Payer: Humana Commercial |
$2,797.35
|
| Rate for Payer: Humana KY Medicaid |
$1,131.77
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,143.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,698.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,428.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,154.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,896.08
|
| Rate for Payer: Ohio Health Group HMO |
$2,468.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$658.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$427.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,020.21
|
| Rate for Payer: PHCS Commercial |
$3,159.36
|
| Rate for Payer: United Healthcare All Payer |
$2,896.08
|
|
|
EXC BEN LESION .6-1.0 CM
|
Professional
|
Both
|
$1,904.00
|
|
|
Service Code
|
HCPCS 11401
|
| Hospital Charge Code |
76100052
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$47.71 |
| Max. Negotiated Rate |
$1,904.00 |
| Rate for Payer: Aetna Commercial |
$139.77
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$58.63
|
| Rate for Payer: Anthem Medicaid |
$47.71
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,904.00
|
| Rate for Payer: Cash Price |
$952.00
|
| Rate for Payer: Cash Price |
$952.00
|
| Rate for Payer: Cigna Commercial |
$186.50
|
| Rate for Payer: Healthspan PPO |
$155.40
|
| Rate for Payer: Humana Medicaid |
$47.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$125.42
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$48.66
|
| Rate for Payer: Molina Healthcare Passport |
$47.71
|
| Rate for Payer: Multiplan PHCS |
$1,142.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,332.80
|
| Rate for Payer: UHCCP Medicaid |
$61.56
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$48.19
|
|
|
EXC BEN LESION .6-1.0 CM
|
Facility
|
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS 11401
|
| Hospital Charge Code |
76100052
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$247.52 |
| Max. Negotiated Rate |
$1,827.84 |
| Rate for Payer: Aetna Commercial |
$1,466.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.12
|
| Rate for Payer: Cash Price |
$952.00
|
| Rate for Payer: Cigna Commercial |
$1,580.32
|
| Rate for Payer: First Health Commercial |
$1,808.80
|
| Rate for Payer: Humana Commercial |
$1,618.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,561.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,675.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$380.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$590.24
|
| Rate for Payer: PHCS Commercial |
$1,827.84
|
| Rate for Payer: United Healthcare All Payer |
$1,675.52
|
|
|
EXC BEN LESION .6-1.0 CM
|
Facility
|
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS 11401
|
| Hospital Charge Code |
76100052
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$247.52 |
| Max. Negotiated Rate |
$1,827.84 |
| Rate for Payer: Aetna Commercial |
$1,466.08
|
| Rate for Payer: Anthem Medicaid |
$654.79
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$952.00
|
| Rate for Payer: Cash Price |
$952.00
|
| Rate for Payer: Cigna Commercial |
$1,580.32
|
| Rate for Payer: First Health Commercial |
$1,808.80
|
| Rate for Payer: Humana Commercial |
$1,618.40
|
| Rate for Payer: Humana KY Medicaid |
$654.79
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$661.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,561.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$667.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,675.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$380.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$590.24
|
| Rate for Payer: PHCS Commercial |
$1,827.84
|
| Rate for Payer: United Healthcare All Payer |
$1,675.52
|
|
