|
EXC BRANCHIAL CLEFT CYST
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 42810
|
| Hospital Charge Code |
76101704
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$172.80 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial |
$407.04
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$172.80
|
| Rate for Payer: Anthem Medicaid |
$189.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$600.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$395.39
|
| Rate for Payer: Healthspan PPO |
$448.89
|
| Rate for Payer: Humana Medicaid |
$189.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$368.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$193.33
|
| Rate for Payer: Molina Healthcare Passport |
$189.54
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$181.44
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$191.44
|
|
|
EXC BRANCHIAL CLEFT CYST
|
Facility
|
IP
|
$600.00
|
|
|
Service Code
|
HCPCS 42810
|
| Hospital Charge Code |
76101704
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$78.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Aetna Commercial |
$462.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$498.00
|
| Rate for Payer: First Health Commercial |
$570.00
|
| Rate for Payer: Humana Commercial |
$510.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$442.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$186.00
|
| Rate for Payer: PHCS Commercial |
$576.00
|
| Rate for Payer: United Healthcare All Payer |
$528.00
|
|
|
EXC BRANCHIAL CLEFT CYST
|
Facility
|
OP
|
$600.00
|
|
|
Service Code
|
HCPCS 42810
|
| Hospital Charge Code |
76101704
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$78.00 |
| Max. Negotiated Rate |
$3,897.84 |
| Rate for Payer: Aetna Commercial |
$462.00
|
| Rate for Payer: Anthem Medicaid |
$206.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,784.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,897.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,758.63
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$498.00
|
| Rate for Payer: First Health Commercial |
$570.00
|
| Rate for Payer: Humana Commercial |
$510.00
|
| Rate for Payer: Humana KY Medicaid |
$206.34
|
| Rate for Payer: Humana Medicare Advantage |
$2,784.17
|
| Rate for Payer: Kentucky WC Medicaid |
$208.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$442.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,341.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$210.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$186.00
|
| Rate for Payer: PHCS Commercial |
$576.00
|
| Rate for Payer: United Healthcare All Payer |
$528.00
|
|
|
EXC BRANCHIAL CLEFT CYST(P
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 42810
|
| Hospital Charge Code |
761P1704
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$172.80 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial |
$407.04
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$172.80
|
| Rate for Payer: Anthem Medicaid |
$189.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$600.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$395.39
|
| Rate for Payer: Healthspan PPO |
$448.89
|
| Rate for Payer: Humana Medicaid |
$189.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$368.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$193.33
|
| Rate for Payer: Molina Healthcare Passport |
$189.54
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$181.44
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$191.44
|
|
|
EXC BREAST LES IDENT MARKER
|
Facility
|
OP
|
$4,028.75
|
|
|
Service Code
|
HCPCS 19126
|
| Hospital Charge Code |
76100290
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$523.74 |
| Max. Negotiated Rate |
$3,867.60 |
| Rate for Payer: Aetna Commercial |
$3,102.14
|
| Rate for Payer: Anthem Medicaid |
$1,385.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,142.42
|
| Rate for Payer: Cash Price |
$2,014.38
|
| Rate for Payer: Cigna Commercial |
$3,343.86
|
| Rate for Payer: First Health Commercial |
$3,827.31
|
| Rate for Payer: Humana Commercial |
$3,424.44
|
| Rate for Payer: Humana KY Medicaid |
$1,385.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1,399.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,303.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,973.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,208.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,413.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,545.30
|
| Rate for Payer: Ohio Health Group HMO |
$3,021.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$805.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$523.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,248.91
|
| Rate for Payer: PHCS Commercial |
$3,867.60
|
| Rate for Payer: United Healthcare All Payer |
$3,545.30
|
|
|
EXC BREAST LES IDENT MARKER
|
Professional
|
Both
|
$4,028.75
|
|
|
Service Code
|
HCPCS 19126
|
| Hospital Charge Code |
76100290
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$132.40 |
| Max. Negotiated Rate |
$4,028.75 |
| Rate for Payer: Aetna Commercial |
$241.69
|
| Rate for Payer: Anthem Medicaid |
$132.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,028.75
|
| Rate for Payer: Cash Price |
$2,014.38
|
| Rate for Payer: Cash Price |
$2,014.38
|
| Rate for Payer: Cigna Commercial |
$229.23
|
| Rate for Payer: Healthspan PPO |
$193.25
|
| Rate for Payer: Humana Medicaid |
$132.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$208.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$135.05
|
| Rate for Payer: Molina Healthcare Passport |
$132.40
|
| Rate for Payer: Multiplan PHCS |
$2,417.25
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,820.12
|
| Rate for Payer: UHCCP Medicaid |
$1,410.06
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$133.72
|
|
|
EXC BREAST LES IDENT MARKER
|
Facility
|
IP
|
$4,028.75
|
|
|
Service Code
|
HCPCS 19126
|
| Hospital Charge Code |
76100290
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$523.74 |
| Max. Negotiated Rate |
$3,867.60 |
| Rate for Payer: Aetna Commercial |
$3,102.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,142.42
|
| Rate for Payer: Cash Price |
$2,014.38
|
| Rate for Payer: Cigna Commercial |
$3,343.86
|
| Rate for Payer: First Health Commercial |
$3,827.31
|
| Rate for Payer: Humana Commercial |
$3,424.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,303.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,973.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,208.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,545.30
|
| Rate for Payer: Ohio Health Group HMO |
$3,021.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$805.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$523.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,248.91
|
| Rate for Payer: PHCS Commercial |
$3,867.60
|
| Rate for Payer: United Healthcare All Payer |
$3,545.30
|
|
|
EXC BREAST LES IDENT MARKER(P
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 19126
|
| Hospital Charge Code |
761P0290
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$132.40 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial |
$241.69
|
| Rate for Payer: Anthem Medicaid |
$132.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$600.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$229.23
|
| Rate for Payer: Healthspan PPO |
$193.25
|
| Rate for Payer: Humana Medicaid |
$132.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$208.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$135.05
|
| Rate for Payer: Molina Healthcare Passport |
$132.40
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$210.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$133.72
|
|
|
EXC BREAST LES IDENT MARKER(T
|
Facility
|
IP
|
$3,428.75
|
|
|
Service Code
|
HCPCS 19126
|
| Hospital Charge Code |
761T0290
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$445.74 |
| Max. Negotiated Rate |
$3,291.60 |
| Rate for Payer: Aetna Commercial |
$2,640.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,674.42
|
| Rate for Payer: Cash Price |
$1,714.38
|
| Rate for Payer: Cigna Commercial |
$2,845.86
|
| Rate for Payer: First Health Commercial |
$3,257.31
|
| Rate for Payer: Humana Commercial |
$2,914.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,811.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,530.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,028.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,017.30
|
| Rate for Payer: Ohio Health Group HMO |
$2,571.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$685.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$445.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,062.91
|
| Rate for Payer: PHCS Commercial |
$3,291.60
|
| Rate for Payer: United Healthcare All Payer |
$3,017.30
|
|
|
EXC BREAST LES IDENT MARKER(T
|
Facility
|
OP
|
$3,428.75
|
|
|
Service Code
|
HCPCS 19126
|
| Hospital Charge Code |
761T0290
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$445.74 |
| Max. Negotiated Rate |
$3,291.60 |
| Rate for Payer: Aetna Commercial |
$2,640.14
|
| Rate for Payer: Anthem Medicaid |
$1,179.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,674.42
|
| Rate for Payer: Cash Price |
$1,714.38
|
| Rate for Payer: Cigna Commercial |
$2,845.86
|
| Rate for Payer: First Health Commercial |
$3,257.31
|
| Rate for Payer: Humana Commercial |
$2,914.44
|
| Rate for Payer: Humana KY Medicaid |
$1,179.15
|
| Rate for Payer: Kentucky WC Medicaid |
$1,191.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,811.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,530.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,028.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,202.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,017.30
|
| Rate for Payer: Ohio Health Group HMO |
$2,571.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$685.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$445.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,062.91
|
| Rate for Payer: PHCS Commercial |
$3,291.60
|
| Rate for Payer: United Healthcare All Payer |
$3,017.30
|
|
|
EXC BRST MASS MAL/FEM
|
Facility
|
IP
|
$7,012.00
|
|
|
Service Code
|
HCPCS 19120
|
| Hospital Charge Code |
76100288
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$911.56 |
| Max. Negotiated Rate |
$6,731.52 |
| Rate for Payer: Aetna Commercial |
$5,399.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,469.36
|
| Rate for Payer: Cash Price |
$3,506.00
|
| Rate for Payer: Cigna Commercial |
$5,819.96
|
| Rate for Payer: First Health Commercial |
$6,661.40
|
| Rate for Payer: Humana Commercial |
$5,960.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,749.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,174.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,103.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,170.56
|
| Rate for Payer: Ohio Health Group HMO |
$5,259.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,402.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$911.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,173.72
|
| Rate for Payer: PHCS Commercial |
$6,731.52
|
| Rate for Payer: United Healthcare All Payer |
$6,170.56
|
|
|
EXC BRST MASS MAL/FEM
|
Facility
|
OP
|
$7,012.00
|
|
|
Service Code
|
HCPCS 19120
|
| Hospital Charge Code |
76100288
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$911.56 |
| Max. Negotiated Rate |
$6,731.52 |
| Rate for Payer: Aetna Commercial |
$5,399.24
|
| Rate for Payer: Anthem Medicaid |
$2,411.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,296.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,469.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,614.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,449.88
|
| Rate for Payer: Cash Price |
$3,506.00
|
| Rate for Payer: Cash Price |
$3,506.00
|
| Rate for Payer: Cigna Commercial |
$5,819.96
|
| Rate for Payer: First Health Commercial |
$6,661.40
|
| Rate for Payer: Humana Commercial |
$5,960.20
|
| Rate for Payer: Humana KY Medicaid |
$2,411.43
|
| Rate for Payer: Humana Medicare Advantage |
$3,296.21
|
| Rate for Payer: Kentucky WC Medicaid |
$2,435.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,749.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,174.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,955.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,459.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,170.56
|
| Rate for Payer: Ohio Health Group HMO |
$5,259.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,402.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$911.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,173.72
|
| Rate for Payer: PHCS Commercial |
$6,731.52
|
| Rate for Payer: United Healthcare All Payer |
$6,170.56
|
|
|
EXC BRST MASS MAL/FEM
|
Professional
|
Both
|
$7,012.00
|
|
|
Service Code
|
HCPCS 19120
|
| Hospital Charge Code |
76100288
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$215.08 |
| Max. Negotiated Rate |
$7,012.00 |
| Rate for Payer: Aetna Commercial |
$568.40
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$215.08
|
| Rate for Payer: Anthem Medicaid |
$263.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$7,012.00
|
| Rate for Payer: Cash Price |
$3,506.00
|
| Rate for Payer: Cash Price |
$3,506.00
|
| Rate for Payer: Cigna Commercial |
$524.47
|
| Rate for Payer: Healthspan PPO |
$523.81
|
| Rate for Payer: Humana Medicaid |
$263.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$512.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$269.00
|
| Rate for Payer: Molina Healthcare Passport |
$263.73
|
| Rate for Payer: Multiplan PHCS |
$4,207.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,908.40
|
| Rate for Payer: UHCCP Medicaid |
$225.83
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$266.37
|
|
|
EXC BRST MASS MAL/FEM(P
|
Professional
|
Both
|
$1,025.00
|
|
|
Service Code
|
HCPCS 19120
|
| Hospital Charge Code |
761P0288
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$215.08 |
| Max. Negotiated Rate |
$1,025.00 |
| Rate for Payer: Aetna Commercial |
$568.40
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$215.08
|
| Rate for Payer: Anthem Medicaid |
$263.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,025.00
|
| Rate for Payer: Cash Price |
$512.50
|
| Rate for Payer: Cash Price |
$512.50
|
| Rate for Payer: Cigna Commercial |
$524.47
|
| Rate for Payer: Healthspan PPO |
$523.81
|
| Rate for Payer: Humana Medicaid |
$263.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$512.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$269.00
|
| Rate for Payer: Molina Healthcare Passport |
$263.73
|
| Rate for Payer: Multiplan PHCS |
$615.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$717.50
|
| Rate for Payer: UHCCP Medicaid |
$225.83
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$266.37
|
|
|
EXC BRST MASS MAL/FEM(T
|
Facility
|
IP
|
$5,987.00
|
|
|
Service Code
|
HCPCS 19120
|
| Hospital Charge Code |
761T0288
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$778.31 |
| Max. Negotiated Rate |
$5,747.52 |
| Rate for Payer: Aetna Commercial |
$4,609.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,669.86
|
| Rate for Payer: Cash Price |
$2,993.50
|
| Rate for Payer: Cigna Commercial |
$4,969.21
|
| Rate for Payer: First Health Commercial |
$5,687.65
|
| Rate for Payer: Humana Commercial |
$5,088.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,909.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,418.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,268.56
|
| Rate for Payer: Ohio Health Group HMO |
$4,490.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,197.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$778.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,855.97
|
| Rate for Payer: PHCS Commercial |
$5,747.52
|
| Rate for Payer: United Healthcare All Payer |
$5,268.56
|
|
|
EXC BRST MASS MAL/FEM(T
|
Facility
|
OP
|
$5,987.00
|
|
|
Service Code
|
HCPCS 19120
|
| Hospital Charge Code |
761T0288
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$778.31 |
| Max. Negotiated Rate |
$5,747.52 |
| Rate for Payer: Aetna Commercial |
$4,609.99
|
| Rate for Payer: Anthem Medicaid |
$2,058.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,296.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,669.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,614.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,449.88
|
| Rate for Payer: Cash Price |
$2,993.50
|
| Rate for Payer: Cash Price |
$2,993.50
|
| Rate for Payer: Cigna Commercial |
$4,969.21
|
| Rate for Payer: First Health Commercial |
$5,687.65
|
| Rate for Payer: Humana Commercial |
$5,088.95
|
| Rate for Payer: Humana KY Medicaid |
$2,058.93
|
| Rate for Payer: Humana Medicare Advantage |
$3,296.21
|
| Rate for Payer: Kentucky WC Medicaid |
$2,079.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,909.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,418.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,955.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,100.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,268.56
|
| Rate for Payer: Ohio Health Group HMO |
$4,490.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,197.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$778.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,855.97
|
| Rate for Payer: PHCS Commercial |
$5,747.52
|
| Rate for Payer: United Healthcare All Payer |
$5,268.56
|
|
|
EX CEPH VERS W OR W/O TOCOLYSI
|
Professional
|
Both
|
$305.00
|
|
|
Service Code
|
HCPCS 59412
|
| Hospital Charge Code |
720P0006
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$106.75 |
| Max. Negotiated Rate |
$305.00 |
| Rate for Payer: Aetna Commercial |
$172.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$305.00
|
| Rate for Payer: Cash Price |
$152.50
|
| Rate for Payer: Cash Price |
$152.50
|
| Rate for Payer: Cigna Commercial |
$160.13
|
| Rate for Payer: Healthspan PPO |
$125.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$126.07
|
| Rate for Payer: Multiplan PHCS |
$183.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$213.50
|
| Rate for Payer: UHCCP Medicaid |
$106.75
|
|
|
EX CEPH VERS W OR W/O TOCOLYSI
|
Facility
|
IP
|
$3,731.00
|
|
|
Service Code
|
HCPCS 59412
|
| Hospital Charge Code |
720T0006
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$485.03 |
| Max. Negotiated Rate |
$3,581.76 |
| Rate for Payer: Aetna Commercial |
$2,872.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,910.18
|
| Rate for Payer: Cash Price |
$1,865.50
|
| Rate for Payer: Cigna Commercial |
$3,096.73
|
| Rate for Payer: First Health Commercial |
$3,544.45
|
| Rate for Payer: Humana Commercial |
$3,171.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,059.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,753.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,119.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,283.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,798.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$746.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$485.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,156.61
|
| Rate for Payer: PHCS Commercial |
$3,581.76
|
| Rate for Payer: United Healthcare All Payer |
$3,283.28
|
|
|
EX CEPH VERS W OR W/O TOCOLYSI
|
Professional
|
Both
|
$4,036.00
|
|
|
Service Code
|
HCPCS 59412
|
| Hospital Charge Code |
72000006
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$125.48 |
| Max. Negotiated Rate |
$4,036.00 |
| Rate for Payer: Aetna Commercial |
$172.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,036.00
|
| Rate for Payer: Cash Price |
$2,018.00
|
| Rate for Payer: Cash Price |
$2,018.00
|
| Rate for Payer: Cigna Commercial |
$160.13
|
| Rate for Payer: Healthspan PPO |
$125.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$126.07
|
| Rate for Payer: Multiplan PHCS |
$2,421.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,825.20
|
| Rate for Payer: UHCCP Medicaid |
$1,412.60
|
|
|
EX CEPH VERS W OR W/O TOCOLYSI
|
Facility
|
IP
|
$4,036.00
|
|
|
Service Code
|
HCPCS 59412
|
| Hospital Charge Code |
72000006
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$524.68 |
| Max. Negotiated Rate |
$3,874.56 |
| Rate for Payer: Aetna Commercial |
$3,107.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,148.08
|
| Rate for Payer: Cash Price |
$2,018.00
|
| Rate for Payer: Cigna Commercial |
$3,349.88
|
| Rate for Payer: First Health Commercial |
$3,834.20
|
| Rate for Payer: Humana Commercial |
$3,430.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,309.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,978.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,210.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,551.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,027.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$807.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$524.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,251.16
|
| Rate for Payer: PHCS Commercial |
$3,874.56
|
| Rate for Payer: United Healthcare All Payer |
$3,551.68
|
|
|
EX CEPH VERS W OR W/O TOCOLYSI
|
Facility
|
OP
|
$4,036.00
|
|
|
Service Code
|
HCPCS 59412
|
| Hospital Charge Code |
72000006
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$524.68 |
| Max. Negotiated Rate |
$3,874.56 |
| Rate for Payer: Aetna Commercial |
$3,107.72
|
| Rate for Payer: Anthem Medicaid |
$1,387.98
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,703.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,148.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,784.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,649.77
|
| Rate for Payer: Cash Price |
$2,018.00
|
| Rate for Payer: Cash Price |
$2,018.00
|
| Rate for Payer: Cigna Commercial |
$3,349.88
|
| Rate for Payer: First Health Commercial |
$3,834.20
|
| Rate for Payer: Humana Commercial |
$3,430.60
|
| Rate for Payer: Humana KY Medicaid |
$1,387.98
|
| Rate for Payer: Humana Medicare Advantage |
$2,703.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1,402.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,309.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,978.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,244.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,415.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,551.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,027.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$807.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$524.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,251.16
|
| Rate for Payer: PHCS Commercial |
$3,874.56
|
| Rate for Payer: United Healthcare All Payer |
$3,551.68
|
|
|
EX CEPH VERS W OR W/O TOCOLYSI
|
Facility
|
OP
|
$3,731.00
|
|
|
Service Code
|
HCPCS 59412
|
| Hospital Charge Code |
720T0006
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$485.03 |
| Max. Negotiated Rate |
$3,784.94 |
| Rate for Payer: Aetna Commercial |
$2,872.87
|
| Rate for Payer: Anthem Medicaid |
$1,283.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,703.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,910.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,784.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,649.77
|
| Rate for Payer: Cash Price |
$1,865.50
|
| Rate for Payer: Cash Price |
$1,865.50
|
| Rate for Payer: Cigna Commercial |
$3,096.73
|
| Rate for Payer: First Health Commercial |
$3,544.45
|
| Rate for Payer: Humana Commercial |
$3,171.35
|
| Rate for Payer: Humana KY Medicaid |
$1,283.09
|
| Rate for Payer: Humana Medicare Advantage |
$2,703.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1,296.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,059.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,753.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,244.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,308.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,283.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,798.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$746.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$485.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,156.61
|
| Rate for Payer: PHCS Commercial |
$3,581.76
|
| Rate for Payer: United Healthcare All Payer |
$3,283.28
|
|
|
EXC. EXCESSIVE SKIN ABD.
|
Facility
|
OP
|
$15,796.96
|
|
|
Service Code
|
HCPCS 15830
|
| Hospital Charge Code |
76100219
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,053.60 |
| Max. Negotiated Rate |
$15,165.08 |
| Rate for Payer: Aetna Commercial |
$12,163.66
|
| Rate for Payer: Anthem Medicaid |
$5,432.57
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,639.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,321.63
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,894.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,612.84
|
| Rate for Payer: Cash Price |
$7,898.48
|
| Rate for Payer: Cash Price |
$7,898.48
|
| Rate for Payer: Cigna Commercial |
$13,111.48
|
| Rate for Payer: First Health Commercial |
$15,007.11
|
| Rate for Payer: Humana Commercial |
$13,427.42
|
| Rate for Payer: Humana KY Medicaid |
$5,432.57
|
| Rate for Payer: Humana Medicare Advantage |
$5,639.14
|
| Rate for Payer: Kentucky WC Medicaid |
$5,487.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,953.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,658.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,766.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,541.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,901.32
|
| Rate for Payer: Ohio Health Group HMO |
$11,847.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,159.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,053.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,897.06
|
| Rate for Payer: PHCS Commercial |
$15,165.08
|
| Rate for Payer: United Healthcare All Payer |
$13,901.32
|
|
|
EXC. EXCESSIVE SKIN ABD.
|
Professional
|
Both
|
$15,796.96
|
|
|
Service Code
|
HCPCS 15830
|
| Hospital Charge Code |
76100219
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$818.54 |
| Max. Negotiated Rate |
$15,796.96 |
| Rate for Payer: Aetna Commercial |
$1,726.32
|
| Rate for Payer: Anthem Medicaid |
$818.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$15,796.96
|
| Rate for Payer: Cash Price |
$7,898.48
|
| Rate for Payer: Cash Price |
$7,898.48
|
| Rate for Payer: Cigna Commercial |
$1,623.16
|
| Rate for Payer: Healthspan PPO |
$1,380.35
|
| Rate for Payer: Humana Medicaid |
$818.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,462.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$834.91
|
| Rate for Payer: Molina Healthcare Passport |
$818.54
|
| Rate for Payer: Multiplan PHCS |
$9,478.18
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$11,057.87
|
| Rate for Payer: UHCCP Medicaid |
$5,528.94
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$826.73
|
|
|
EXC. EXCESSIVE SKIN ABD.
|
Facility
|
IP
|
$15,796.96
|
|
|
Service Code
|
HCPCS 15830
|
| Hospital Charge Code |
76100219
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,053.60 |
| Max. Negotiated Rate |
$15,165.08 |
| Rate for Payer: Aetna Commercial |
$12,163.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,321.63
|
| Rate for Payer: Cash Price |
$7,898.48
|
| Rate for Payer: Cigna Commercial |
$13,111.48
|
| Rate for Payer: First Health Commercial |
$15,007.11
|
| Rate for Payer: Humana Commercial |
$13,427.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,953.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,658.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,739.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,901.32
|
| Rate for Payer: Ohio Health Group HMO |
$11,847.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,159.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,053.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,897.06
|
| Rate for Payer: PHCS Commercial |
$15,165.08
|
| Rate for Payer: United Healthcare All Payer |
$13,901.32
|
|
