|
EXC HIDRADENITIS INGU COMP RPR
|
Facility
|
OP
|
$6,031.08
|
|
|
Service Code
|
HCPCS 11463
|
| Hospital Charge Code |
761T0072
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$784.04 |
| Max. Negotiated Rate |
$5,789.84 |
| Rate for Payer: Aetna Commercial |
$4,643.93
|
| Rate for Payer: Anthem Medicaid |
$2,074.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,704.24
|
| 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 |
$3,015.54
|
| Rate for Payer: Cash Price |
$3,015.54
|
| Rate for Payer: Cigna Commercial |
$5,005.80
|
| Rate for Payer: First Health Commercial |
$5,729.53
|
| Rate for Payer: Humana Commercial |
$5,126.42
|
| Rate for Payer: Humana KY Medicaid |
$2,074.09
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$2,095.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,945.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,450.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,115.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,307.35
|
| Rate for Payer: Ohio Health Group HMO |
$4,523.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,206.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$784.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,869.63
|
| Rate for Payer: PHCS Commercial |
$5,789.84
|
| Rate for Payer: United Healthcare All Payer |
$5,307.35
|
|
|
EXC HIP PELVIS LES SC 3 CM/>
|
Facility
|
OP
|
$1,150.00
|
|
|
Service Code
|
HCPCS 27043
|
| Hospital Charge Code |
76100766
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$149.50 |
| Max. Negotiated Rate |
$3,440.07 |
| Rate for Payer: Aetna Commercial |
$885.50
|
| Rate for Payer: Anthem Medicaid |
$395.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$897.00
|
| 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 |
$575.00
|
| Rate for Payer: Cash Price |
$575.00
|
| Rate for Payer: Cigna Commercial |
$954.50
|
| Rate for Payer: First Health Commercial |
$1,092.50
|
| Rate for Payer: Humana Commercial |
$977.50
|
| Rate for Payer: Humana KY Medicaid |
$395.48
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$399.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$943.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$848.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$403.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,012.00
|
| Rate for Payer: Ohio Health Group HMO |
$862.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$230.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$149.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$356.50
|
| Rate for Payer: PHCS Commercial |
$1,104.00
|
| Rate for Payer: United Healthcare All Payer |
$1,012.00
|
|
|
EXC HIP PELVIS LES SC 3 CM/>
|
Professional
|
Both
|
$1,150.00
|
|
|
Service Code
|
HCPCS 27043
|
| Hospital Charge Code |
76100766
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$339.82 |
| Max. Negotiated Rate |
$1,150.00 |
| Rate for Payer: Aetna Commercial |
$723.55
|
| Rate for Payer: Anthem Medicaid |
$339.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,150.00
|
| Rate for Payer: Cash Price |
$575.00
|
| Rate for Payer: Cash Price |
$575.00
|
| Rate for Payer: Cigna Commercial |
$823.10
|
| Rate for Payer: Healthspan PPO |
$515.62
|
| Rate for Payer: Humana Medicaid |
$339.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$597.20
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$346.62
|
| Rate for Payer: Molina Healthcare Passport |
$339.82
|
| Rate for Payer: Multiplan PHCS |
$690.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$805.00
|
| Rate for Payer: UHCCP Medicaid |
$402.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$343.22
|
|
|
EXC HIP PELVIS LES SC 3 CM/>
|
Facility
|
IP
|
$1,150.00
|
|
|
Service Code
|
HCPCS 27043
|
| Hospital Charge Code |
76100766
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$149.50 |
| Max. Negotiated Rate |
$1,104.00 |
| Rate for Payer: Aetna Commercial |
$885.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$897.00
|
| Rate for Payer: Cash Price |
$575.00
|
| Rate for Payer: Cigna Commercial |
$954.50
|
| Rate for Payer: First Health Commercial |
$1,092.50
|
| Rate for Payer: Humana Commercial |
$977.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$943.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$848.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,012.00
|
| Rate for Payer: Ohio Health Group HMO |
$862.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$230.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$149.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$356.50
|
| Rate for Payer: PHCS Commercial |
$1,104.00
|
| Rate for Payer: United Healthcare All Payer |
$1,012.00
|
|
|
EXC HIP PELVIS LES SC 3 CM/(P
|
Professional
|
Both
|
$1,150.00
|
|
|
Service Code
|
HCPCS 27043
|
| Hospital Charge Code |
761P0766
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$339.82 |
| Max. Negotiated Rate |
$1,150.00 |
| Rate for Payer: Aetna Commercial |
$723.55
|
| Rate for Payer: Anthem Medicaid |
$339.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,150.00
|
| Rate for Payer: Cash Price |
$575.00
|
| Rate for Payer: Cash Price |
$575.00
|
| Rate for Payer: Cigna Commercial |
$823.10
|
| Rate for Payer: Healthspan PPO |
$515.62
|
| Rate for Payer: Humana Medicaid |
$339.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$597.20
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$346.62
|
| Rate for Payer: Molina Healthcare Passport |
$339.82
|
| Rate for Payer: Multiplan PHCS |
$690.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$805.00
|
| Rate for Payer: UHCCP Medicaid |
$402.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$343.22
|
|
|
EXC HIP/PELV TUM DEEP 5 CM/>
|
Facility
|
OP
|
$1,170.00
|
|
|
Service Code
|
HCPCS 27045
|
| Hospital Charge Code |
76100767
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$152.10 |
| Max. Negotiated Rate |
$3,440.07 |
| Rate for Payer: Aetna Commercial |
$900.90
|
| Rate for Payer: Anthem Medicaid |
$402.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$912.60
|
| 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 |
$585.00
|
| Rate for Payer: Cash Price |
$585.00
|
| Rate for Payer: Cigna Commercial |
$971.10
|
| Rate for Payer: First Health Commercial |
$1,111.50
|
| Rate for Payer: Humana Commercial |
$994.50
|
| Rate for Payer: Humana KY Medicaid |
$402.36
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$406.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$959.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$863.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$410.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,029.60
|
| Rate for Payer: Ohio Health Group HMO |
$877.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$234.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$152.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$362.70
|
| Rate for Payer: PHCS Commercial |
$1,123.20
|
| Rate for Payer: United Healthcare All Payer |
$1,029.60
|
|
|
EXC HIP/PELV TUM DEEP 5 CM/>
|
Facility
|
IP
|
$1,170.00
|
|
|
Service Code
|
HCPCS 27045
|
| Hospital Charge Code |
76100767
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$152.10 |
| Max. Negotiated Rate |
$1,123.20 |
| Rate for Payer: Aetna Commercial |
$900.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$912.60
|
| Rate for Payer: Cash Price |
$585.00
|
| Rate for Payer: Cigna Commercial |
$971.10
|
| Rate for Payer: First Health Commercial |
$1,111.50
|
| Rate for Payer: Humana Commercial |
$994.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$959.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$863.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$351.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,029.60
|
| Rate for Payer: Ohio Health Group HMO |
$877.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$234.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$152.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$362.70
|
| Rate for Payer: PHCS Commercial |
$1,123.20
|
| Rate for Payer: United Healthcare All Payer |
$1,029.60
|
|
|
EXC HIP/PELV TUM DEEP 5 CM/>
|
Professional
|
Both
|
$1,170.00
|
|
|
Service Code
|
HCPCS 27045
|
| Hospital Charge Code |
76100767
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$409.50 |
| Max. Negotiated Rate |
$1,308.51 |
| Rate for Payer: Aetna Commercial |
$1,150.33
|
| Rate for Payer: Anthem Medicaid |
$540.47
|
| 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 |
$1,308.51
|
| Rate for Payer: Healthspan PPO |
$820.77
|
| Rate for Payer: Humana Medicaid |
$540.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$947.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$551.28
|
| Rate for Payer: Molina Healthcare Passport |
$540.47
|
| 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 |
$545.87
|
|
|
EXC HIP/PELV TUM DEEP 5 CM/(P
|
Professional
|
Both
|
$1,170.00
|
|
|
Service Code
|
HCPCS 27045
|
| Hospital Charge Code |
761P0767
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$409.50 |
| Max. Negotiated Rate |
$1,308.51 |
| Rate for Payer: Aetna Commercial |
$1,150.33
|
| Rate for Payer: Anthem Medicaid |
$540.47
|
| 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 |
$1,308.51
|
| Rate for Payer: Healthspan PPO |
$820.77
|
| Rate for Payer: Humana Medicaid |
$540.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$947.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$551.28
|
| Rate for Payer: Molina Healthcare Passport |
$540.47
|
| 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 |
$545.87
|
|
|
EXCH PREVPLCABS/CYST DRAINCATH
|
Facility
|
OP
|
$2,855.00
|
|
|
Service Code
|
HCPCS 49423
|
| Hospital Charge Code |
761T2001
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$371.15 |
| Max. Negotiated Rate |
$2,740.80 |
| Rate for Payer: Aetna Commercial |
$2,198.35
|
| Rate for Payer: Anthem Medicaid |
$981.83
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,645.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,226.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,303.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,221.38
|
| Rate for Payer: Cash Price |
$1,427.50
|
| Rate for Payer: Cash Price |
$1,427.50
|
| Rate for Payer: Cigna Commercial |
$2,369.65
|
| Rate for Payer: First Health Commercial |
$2,712.25
|
| Rate for Payer: Humana Commercial |
$2,426.75
|
| Rate for Payer: Humana KY Medicaid |
$981.83
|
| Rate for Payer: Humana Medicare Advantage |
$1,645.47
|
| Rate for Payer: Kentucky WC Medicaid |
$991.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,341.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,106.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,974.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,001.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,512.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,141.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$571.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$371.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$885.05
|
| Rate for Payer: PHCS Commercial |
$2,740.80
|
| Rate for Payer: United Healthcare All Payer |
$2,512.40
|
|
|
EXCH PREVPLCABS/CYST DRAINCATH
|
Facility
|
OP
|
$3,130.00
|
|
|
Service Code
|
HCPCS 49423
|
| Hospital Charge Code |
76102001
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$406.90 |
| Max. Negotiated Rate |
$3,004.80 |
| Rate for Payer: Aetna Commercial |
$2,410.10
|
| Rate for Payer: Anthem Medicaid |
$1,076.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,645.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,441.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,303.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,221.38
|
| Rate for Payer: Cash Price |
$1,565.00
|
| Rate for Payer: Cash Price |
$1,565.00
|
| Rate for Payer: Cigna Commercial |
$2,597.90
|
| Rate for Payer: First Health Commercial |
$2,973.50
|
| Rate for Payer: Humana Commercial |
$2,660.50
|
| Rate for Payer: Humana KY Medicaid |
$1,076.41
|
| Rate for Payer: Humana Medicare Advantage |
$1,645.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1,087.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,566.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,309.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,974.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,098.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,754.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,347.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$626.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$406.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$970.30
|
| Rate for Payer: PHCS Commercial |
$3,004.80
|
| Rate for Payer: United Healthcare All Payer |
$2,754.40
|
|
|
EXCH PREVPLCABS/CYST DRAINCATH
|
Professional
|
Both
|
$275.00
|
|
|
Service Code
|
HCPCS 49423
|
| Hospital Charge Code |
761P2001
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$67.11 |
| Max. Negotiated Rate |
$679.05 |
| Rate for Payer: Aetna Commercial |
$122.81
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$67.11
|
| Rate for Payer: Anthem Medicaid |
$73.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$275.00
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$110.58
|
| Rate for Payer: Healthspan PPO |
$679.05
|
| Rate for Payer: Humana Medicaid |
$73.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$96.78
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$75.09
|
| Rate for Payer: Molina Healthcare Passport |
$73.62
|
| Rate for Payer: Multiplan PHCS |
$165.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$192.50
|
| Rate for Payer: UHCCP Medicaid |
$70.47
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$74.36
|
|
|
EXCH PREVPLCABS/CYST DRAINCATH
|
Professional
|
Both
|
$3,130.00
|
|
|
Service Code
|
HCPCS 49423
|
| Hospital Charge Code |
76102001
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$67.11 |
| Max. Negotiated Rate |
$3,130.00 |
| Rate for Payer: Aetna Commercial |
$122.81
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$67.11
|
| Rate for Payer: Anthem Medicaid |
$73.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,130.00
|
| Rate for Payer: Cash Price |
$1,565.00
|
| Rate for Payer: Cash Price |
$1,565.00
|
| Rate for Payer: Cigna Commercial |
$110.58
|
| Rate for Payer: Healthspan PPO |
$679.05
|
| Rate for Payer: Humana Medicaid |
$73.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$96.78
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$75.09
|
| Rate for Payer: Molina Healthcare Passport |
$73.62
|
| Rate for Payer: Multiplan PHCS |
$1,878.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,191.00
|
| Rate for Payer: UHCCP Medicaid |
$70.47
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$74.36
|
|
|
EXCH PREVPLCABS/CYST DRAINCATH
|
Facility
|
IP
|
$2,855.00
|
|
|
Service Code
|
HCPCS 49423
|
| Hospital Charge Code |
761T2001
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$371.15 |
| Max. Negotiated Rate |
$2,740.80 |
| Rate for Payer: Aetna Commercial |
$2,198.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,226.90
|
| Rate for Payer: Cash Price |
$1,427.50
|
| Rate for Payer: Cigna Commercial |
$2,369.65
|
| Rate for Payer: First Health Commercial |
$2,712.25
|
| Rate for Payer: Humana Commercial |
$2,426.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,341.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,106.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$856.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,512.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,141.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$571.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$371.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$885.05
|
| Rate for Payer: PHCS Commercial |
$2,740.80
|
| Rate for Payer: United Healthcare All Payer |
$2,512.40
|
|
|
EXCH PREVPLCABS/CYST DRAINCATH
|
Facility
|
IP
|
$3,130.00
|
|
|
Service Code
|
HCPCS 49423
|
| Hospital Charge Code |
76102001
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$406.90 |
| Max. Negotiated Rate |
$3,004.80 |
| Rate for Payer: Aetna Commercial |
$2,410.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,441.40
|
| Rate for Payer: Cash Price |
$1,565.00
|
| Rate for Payer: Cigna Commercial |
$2,597.90
|
| Rate for Payer: First Health Commercial |
$2,973.50
|
| Rate for Payer: Humana Commercial |
$2,660.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,566.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,309.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$939.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,754.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,347.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$626.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$406.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$970.30
|
| Rate for Payer: PHCS Commercial |
$3,004.80
|
| Rate for Payer: United Healthcare All Payer |
$2,754.40
|
|
|
EXC HYRO SPERMATIC CORD
|
Facility
|
OP
|
$1,000.00
|
|
|
Service Code
|
HCPCS 55500
|
| Hospital Charge Code |
76102150
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$130.00 |
| Max. Negotiated Rate |
$4,220.54 |
| Rate for Payer: Aetna Commercial |
$770.00
|
| Rate for Payer: Anthem Medicaid |
$343.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,014.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$780.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,220.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,069.80
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$830.00
|
| Rate for Payer: First Health Commercial |
$950.00
|
| Rate for Payer: Humana Commercial |
$850.00
|
| Rate for Payer: Humana KY Medicaid |
$343.90
|
| Rate for Payer: Humana Medicare Advantage |
$3,014.67
|
| Rate for Payer: Kentucky WC Medicaid |
$347.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$820.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$738.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,617.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$350.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$880.00
|
| Rate for Payer: Ohio Health Group HMO |
$750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$310.00
|
| Rate for Payer: PHCS Commercial |
$960.00
|
| Rate for Payer: United Healthcare All Payer |
$880.00
|
|
|
EXC HYRO SPERMATIC CORD
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 55500
|
| Hospital Charge Code |
76102150
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$282.95 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Aetna Commercial |
$607.62
|
| Rate for Payer: Anthem Medicaid |
$282.95
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,000.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$542.29
|
| Rate for Payer: Healthspan PPO |
$588.33
|
| Rate for Payer: Humana Medicaid |
$282.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$533.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$288.61
|
| Rate for Payer: Molina Healthcare Passport |
$282.95
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$350.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$285.78
|
|
|
EXC HYRO SPERMATIC CORD
|
Facility
|
IP
|
$1,000.00
|
|
|
Service Code
|
HCPCS 55500
|
| Hospital Charge Code |
76102150
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$130.00 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$770.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$780.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$830.00
|
| Rate for Payer: First Health Commercial |
$950.00
|
| Rate for Payer: Humana Commercial |
$850.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$820.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$738.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$300.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$880.00
|
| Rate for Payer: Ohio Health Group HMO |
$750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$310.00
|
| Rate for Payer: PHCS Commercial |
$960.00
|
| Rate for Payer: United Healthcare All Payer |
$880.00
|
|
|
EXC HYRO SPERMATIC CORD(P
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 55500
|
| Hospital Charge Code |
761P2150
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$282.95 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Aetna Commercial |
$607.62
|
| Rate for Payer: Anthem Medicaid |
$282.95
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,000.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$542.29
|
| Rate for Payer: Healthspan PPO |
$588.33
|
| Rate for Payer: Humana Medicaid |
$282.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$533.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$288.61
|
| Rate for Payer: Molina Healthcare Passport |
$282.95
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$350.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$285.78
|
|
|
EXCI BIOPSY SFT TIS BACK FLANK
|
Facility
|
IP
|
$3,424.50
|
|
|
Service Code
|
HCPCS 21920
|
| Hospital Charge Code |
761T0410
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$445.18 |
| Max. Negotiated Rate |
$3,287.52 |
| Rate for Payer: Aetna Commercial |
$2,636.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,671.11
|
| Rate for Payer: Cash Price |
$1,712.25
|
| Rate for Payer: Cigna Commercial |
$2,842.34
|
| Rate for Payer: First Health Commercial |
$3,253.28
|
| Rate for Payer: Humana Commercial |
$2,910.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,808.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,527.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,027.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,013.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,568.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$684.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$445.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,061.60
|
| Rate for Payer: PHCS Commercial |
$3,287.52
|
| Rate for Payer: United Healthcare All Payer |
$3,013.56
|
|
|
EXCI BIOPSY SFT TIS BACK FLANK
|
Professional
|
Both
|
$325.00
|
|
|
Service Code
|
HCPCS 21920
|
| Hospital Charge Code |
761P0410
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$72.25 |
| Max. Negotiated Rate |
$356.32 |
| Rate for Payer: Aetna Commercial |
$225.32
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$87.44
|
| Rate for Payer: Anthem Medicaid |
$72.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$325.00
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cigna Commercial |
$356.32
|
| Rate for Payer: Healthspan PPO |
$315.59
|
| Rate for Payer: Humana Medicaid |
$72.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$200.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$73.70
|
| Rate for Payer: Molina Healthcare Passport |
$72.25
|
| Rate for Payer: Multiplan PHCS |
$195.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$227.50
|
| Rate for Payer: UHCCP Medicaid |
$91.81
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.97
|
|
|
EXCI BIOPSY SFT TIS BACK FLANK
|
Facility
|
IP
|
$3,749.50
|
|
|
Service Code
|
HCPCS 21920
|
| Hospital Charge Code |
76100410
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$487.44 |
| Max. Negotiated Rate |
$3,599.52 |
| Rate for Payer: Aetna Commercial |
$2,887.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,924.61
|
| Rate for Payer: Cash Price |
$1,874.75
|
| Rate for Payer: Cigna Commercial |
$3,112.08
|
| Rate for Payer: First Health Commercial |
$3,562.02
|
| Rate for Payer: Humana Commercial |
$3,187.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,074.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,767.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,124.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,299.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,812.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$749.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$487.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,162.34
|
| Rate for Payer: PHCS Commercial |
$3,599.52
|
| Rate for Payer: United Healthcare All Payer |
$3,299.56
|
|
|
EXCI BIOPSY SFT TIS BACK FLANK
|
Professional
|
Both
|
$3,749.50
|
|
|
Service Code
|
HCPCS 21920
|
| Hospital Charge Code |
76100410
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$72.25 |
| Max. Negotiated Rate |
$3,749.50 |
| Rate for Payer: Aetna Commercial |
$225.32
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$87.44
|
| Rate for Payer: Anthem Medicaid |
$72.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,749.50
|
| Rate for Payer: Cash Price |
$1,874.75
|
| Rate for Payer: Cash Price |
$1,874.75
|
| Rate for Payer: Cigna Commercial |
$356.32
|
| Rate for Payer: Healthspan PPO |
$315.59
|
| Rate for Payer: Humana Medicaid |
$72.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$200.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$73.70
|
| Rate for Payer: Molina Healthcare Passport |
$72.25
|
| Rate for Payer: Multiplan PHCS |
$2,249.70
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,624.65
|
| Rate for Payer: UHCCP Medicaid |
$91.81
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.97
|
|
|
EXCI BIOPSY SFT TIS BACK FLANK
|
Facility
|
OP
|
$3,424.50
|
|
|
Service Code
|
HCPCS 21920
|
| Hospital Charge Code |
761T0410
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$445.18 |
| Max. Negotiated Rate |
$3,287.52 |
| Rate for Payer: Aetna Commercial |
$2,636.86
|
| Rate for Payer: Anthem Medicaid |
$1,177.69
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,671.11
|
| 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 |
$1,712.25
|
| Rate for Payer: Cash Price |
$1,712.25
|
| Rate for Payer: Cigna Commercial |
$2,842.34
|
| Rate for Payer: First Health Commercial |
$3,253.28
|
| Rate for Payer: Humana Commercial |
$2,910.82
|
| Rate for Payer: Humana KY Medicaid |
$1,177.69
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,189.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,808.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,527.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,201.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,013.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,568.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$684.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$445.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,061.60
|
| Rate for Payer: PHCS Commercial |
$3,287.52
|
| Rate for Payer: United Healthcare All Payer |
$3,013.56
|
|
|
EXCI BIOPSY SFT TIS BACK FLANK
|
Facility
|
OP
|
$3,749.50
|
|
|
Service Code
|
HCPCS 21920
|
| Hospital Charge Code |
76100410
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$487.44 |
| Max. Negotiated Rate |
$3,599.52 |
| Rate for Payer: Aetna Commercial |
$2,887.12
|
| Rate for Payer: Anthem Medicaid |
$1,289.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,924.61
|
| 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 |
$1,874.75
|
| Rate for Payer: Cash Price |
$1,874.75
|
| Rate for Payer: Cigna Commercial |
$3,112.08
|
| Rate for Payer: First Health Commercial |
$3,562.02
|
| Rate for Payer: Humana Commercial |
$3,187.08
|
| Rate for Payer: Humana KY Medicaid |
$1,289.45
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,302.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,074.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,767.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,315.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,299.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,812.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$749.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$487.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,162.34
|
| Rate for Payer: PHCS Commercial |
$3,599.52
|
| Rate for Payer: United Healthcare All Payer |
$3,299.56
|
|
