|
EXC LES/TUMOR DENTOALVEOLAR
|
Facility
|
OP
|
$4,862.75
|
|
|
Service Code
|
HCPCS 41825
|
| Hospital Charge Code |
76101666
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$632.16 |
| Max. Negotiated Rate |
$4,668.24 |
| Rate for Payer: Aetna Commercial |
$3,744.32
|
| Rate for Payer: Anthem Medicaid |
$1,672.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,784.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,792.94
|
| 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 |
$2,431.38
|
| Rate for Payer: Cash Price |
$2,431.38
|
| Rate for Payer: Cigna Commercial |
$4,036.08
|
| Rate for Payer: First Health Commercial |
$4,619.61
|
| Rate for Payer: Humana Commercial |
$4,133.34
|
| Rate for Payer: Humana KY Medicaid |
$1,672.30
|
| Rate for Payer: Humana Medicare Advantage |
$2,784.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,689.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,987.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,588.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,341.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,705.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,279.22
|
| Rate for Payer: Ohio Health Group HMO |
$3,647.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$972.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$632.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,507.45
|
| Rate for Payer: PHCS Commercial |
$4,668.24
|
| Rate for Payer: United Healthcare All Payer |
$4,279.22
|
|
|
EXC LES/TUMOR DENTOALVEOLAR(P
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 41825
|
| Hospital Charge Code |
761P1666
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$60.36 |
| Max. Negotiated Rate |
$450.00 |
| Rate for Payer: Aetna Commercial |
$178.52
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$82.05
|
| Rate for Payer: Anthem Medicaid |
$60.36
|
| 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 |
$263.09
|
| Rate for Payer: Healthspan PPO |
$233.60
|
| Rate for Payer: Humana Medicaid |
$60.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$158.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$61.57
|
| Rate for Payer: Molina Healthcare Passport |
$60.36
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$315.00
|
| Rate for Payer: UHCCP Medicaid |
$86.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$60.96
|
|
|
EXC LES/TUMOR DENTOALVEOLAR(T
|
Facility
|
IP
|
$4,412.75
|
|
|
Service Code
|
HCPCS 41825
|
| Hospital Charge Code |
761T1666
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$573.66 |
| Max. Negotiated Rate |
$4,236.24 |
| Rate for Payer: Aetna Commercial |
$3,397.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,441.94
|
| Rate for Payer: Cash Price |
$2,206.38
|
| Rate for Payer: Cigna Commercial |
$3,662.58
|
| Rate for Payer: First Health Commercial |
$4,192.11
|
| Rate for Payer: Humana Commercial |
$3,750.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,618.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,256.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,323.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,883.22
|
| Rate for Payer: Ohio Health Group HMO |
$3,309.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$882.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$573.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,367.95
|
| Rate for Payer: PHCS Commercial |
$4,236.24
|
| Rate for Payer: United Healthcare All Payer |
$3,883.22
|
|
|
EXC LES/TUMOR DENTOALVEOLAR(T
|
Facility
|
OP
|
$4,412.75
|
|
|
Service Code
|
HCPCS 41825
|
| Hospital Charge Code |
761T1666
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$573.66 |
| Max. Negotiated Rate |
$4,236.24 |
| Rate for Payer: Aetna Commercial |
$3,397.82
|
| Rate for Payer: Anthem Medicaid |
$1,517.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,784.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,441.94
|
| 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 |
$2,206.38
|
| Rate for Payer: Cash Price |
$2,206.38
|
| Rate for Payer: Cigna Commercial |
$3,662.58
|
| Rate for Payer: First Health Commercial |
$4,192.11
|
| Rate for Payer: Humana Commercial |
$3,750.84
|
| Rate for Payer: Humana KY Medicaid |
$1,517.54
|
| Rate for Payer: Humana Medicare Advantage |
$2,784.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,532.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,618.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,256.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,341.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,547.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,883.22
|
| Rate for Payer: Ohio Health Group HMO |
$3,309.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$882.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$573.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,367.95
|
| Rate for Payer: PHCS Commercial |
$4,236.24
|
| Rate for Payer: United Healthcare All Payer |
$3,883.22
|
|
|
EXC LIP FULL RCNST W/LOC FLAP
|
Professional
|
Both
|
$1,950.00
|
|
|
Service Code
|
HCPCS 40525
|
| Hospital Charge Code |
76102654
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$497.22 |
| Max. Negotiated Rate |
$1,950.00 |
| Rate for Payer: Aetna Commercial |
$807.58
|
| Rate for Payer: Anthem Medicaid |
$497.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,950.00
|
| Rate for Payer: Cash Price |
$975.00
|
| Rate for Payer: Cash Price |
$975.00
|
| Rate for Payer: Cigna Commercial |
$806.68
|
| Rate for Payer: Healthspan PPO |
$681.05
|
| Rate for Payer: Humana Medicaid |
$497.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$715.04
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$507.16
|
| Rate for Payer: Molina Healthcare Passport |
$497.22
|
| Rate for Payer: Multiplan PHCS |
$1,170.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,365.00
|
| Rate for Payer: UHCCP Medicaid |
$682.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$502.19
|
|
|
EXC LIP FULL RCNST W/LOC FLAP
|
Facility
|
OP
|
$1,950.00
|
|
|
Service Code
|
HCPCS 40525
|
| Hospital Charge Code |
76102654
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$253.50 |
| Max. Negotiated Rate |
$3,897.84 |
| Rate for Payer: Aetna Commercial |
$1,501.50
|
| Rate for Payer: Anthem Medicaid |
$670.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,784.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,521.00
|
| 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 |
$975.00
|
| Rate for Payer: Cash Price |
$975.00
|
| Rate for Payer: Cigna Commercial |
$1,618.50
|
| Rate for Payer: First Health Commercial |
$1,852.50
|
| Rate for Payer: Humana Commercial |
$1,657.50
|
| Rate for Payer: Humana KY Medicaid |
$670.60
|
| Rate for Payer: Humana Medicare Advantage |
$2,784.17
|
| Rate for Payer: Kentucky WC Medicaid |
$677.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,599.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,439.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,341.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$684.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,716.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,462.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$390.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$253.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$604.50
|
| Rate for Payer: PHCS Commercial |
$1,872.00
|
| Rate for Payer: United Healthcare All Payer |
$1,716.00
|
|
|
EXC LIP FULL RCNST W/LOC FLAP
|
Facility
|
IP
|
$1,950.00
|
|
|
Service Code
|
HCPCS 40525
|
| Hospital Charge Code |
76102654
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$253.50 |
| Max. Negotiated Rate |
$1,872.00 |
| Rate for Payer: Aetna Commercial |
$1,501.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,521.00
|
| Rate for Payer: Cash Price |
$975.00
|
| Rate for Payer: Cigna Commercial |
$1,618.50
|
| Rate for Payer: First Health Commercial |
$1,852.50
|
| Rate for Payer: Humana Commercial |
$1,657.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,599.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,439.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$585.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,716.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,462.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$390.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$253.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$604.50
|
| Rate for Payer: PHCS Commercial |
$1,872.00
|
| Rate for Payer: United Healthcare All Payer |
$1,716.00
|
|
|
EXC LIP FULL R/ST W/LOC FLAP(P
|
Professional
|
Both
|
$1,950.00
|
|
|
Service Code
|
HCPCS 40525
|
| Hospital Charge Code |
761P2654
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$497.22 |
| Max. Negotiated Rate |
$1,950.00 |
| Rate for Payer: Aetna Commercial |
$807.58
|
| Rate for Payer: Anthem Medicaid |
$497.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,950.00
|
| Rate for Payer: Cash Price |
$975.00
|
| Rate for Payer: Cash Price |
$975.00
|
| Rate for Payer: Cigna Commercial |
$806.68
|
| Rate for Payer: Healthspan PPO |
$681.05
|
| Rate for Payer: Humana Medicaid |
$497.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$715.04
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$507.16
|
| Rate for Payer: Molina Healthcare Passport |
$497.22
|
| Rate for Payer: Multiplan PHCS |
$1,170.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,365.00
|
| Rate for Payer: UHCCP Medicaid |
$682.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$502.19
|
|
|
EXCL LAA OPN OTH PX ANY METH
|
Professional
|
Both
|
$158.00
|
|
|
Service Code
|
HCPCS 33268
|
| Hospital Charge Code |
76102763
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$55.30 |
| Max. Negotiated Rate |
$158.00 |
| Rate for Payer: Anthem Medicaid |
$108.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$158.00
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Humana Medicaid |
$108.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$110.17
|
| Rate for Payer: Molina Healthcare Passport |
$108.01
|
| Rate for Payer: Multiplan PHCS |
$94.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$110.60
|
| Rate for Payer: UHCCP Medicaid |
$55.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$109.09
|
|
|
EXCLUDER BRANCH 23*12*10CM 16
|
Facility
|
IP
|
$74,158.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,640.54 |
| Max. Negotiated Rate |
$71,191.68 |
| Rate for Payer: Aetna Commercial |
$57,101.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,843.24
|
| Rate for Payer: Cash Price |
$37,079.00
|
| Rate for Payer: Cigna Commercial |
$61,551.14
|
| Rate for Payer: First Health Commercial |
$70,450.10
|
| Rate for Payer: Humana Commercial |
$63,034.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,809.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,728.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,247.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$65,259.04
|
| Rate for Payer: Ohio Health Group HMO |
$55,618.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,831.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,640.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,988.98
|
| Rate for Payer: PHCS Commercial |
$71,191.68
|
| Rate for Payer: United Healthcare All Payer |
$65,259.04
|
|
|
EXCLUDER BRANCH 23*12*10CM 16
|
Facility
|
OP
|
$74,158.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,640.54 |
| Max. Negotiated Rate |
$71,191.68 |
| Rate for Payer: Aetna Commercial |
$57,101.66
|
| Rate for Payer: Anthem Medicaid |
$25,502.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,843.24
|
| Rate for Payer: Cash Price |
$37,079.00
|
| Rate for Payer: Cigna Commercial |
$61,551.14
|
| Rate for Payer: First Health Commercial |
$70,450.10
|
| Rate for Payer: Humana Commercial |
$63,034.30
|
| Rate for Payer: Humana KY Medicaid |
$25,502.94
|
| Rate for Payer: Kentucky WC Medicaid |
$25,762.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,809.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,728.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,247.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$26,014.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$65,259.04
|
| Rate for Payer: Ohio Health Group HMO |
$55,618.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,831.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,640.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22,988.98
|
| Rate for Payer: PHCS Commercial |
$71,191.68
|
| Rate for Payer: United Healthcare All Payer |
$65,259.04
|
|
|
EXCLUDER CON 28.5*14.5*12CM 16
|
Facility
|
OP
|
$82,002.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,660.31 |
| Max. Negotiated Rate |
$78,722.30 |
| Rate for Payer: Aetna Commercial |
$63,141.85
|
| Rate for Payer: Anthem Medicaid |
$28,200.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63,961.87
|
| Rate for Payer: Cash Price |
$41,001.20
|
| Rate for Payer: Cigna Commercial |
$68,061.99
|
| Rate for Payer: First Health Commercial |
$77,902.28
|
| Rate for Payer: Humana Commercial |
$69,702.04
|
| Rate for Payer: Humana KY Medicaid |
$28,200.63
|
| Rate for Payer: Kentucky WC Medicaid |
$28,487.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$67,241.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$60,517.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24,600.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$28,766.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$72,162.11
|
| Rate for Payer: Ohio Health Group HMO |
$61,501.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,400.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,660.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25,420.74
|
| Rate for Payer: PHCS Commercial |
$78,722.30
|
| Rate for Payer: United Healthcare All Payer |
$72,162.11
|
|
|
EXCLUDER CON 28.5*14.5*12CM 16
|
Facility
|
IP
|
$82,002.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,660.31 |
| Max. Negotiated Rate |
$78,722.30 |
| Rate for Payer: Aetna Commercial |
$63,141.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63,961.87
|
| Rate for Payer: Cash Price |
$41,001.20
|
| Rate for Payer: Cigna Commercial |
$68,061.99
|
| Rate for Payer: First Health Commercial |
$77,902.28
|
| Rate for Payer: Humana Commercial |
$69,702.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$67,241.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$60,517.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24,600.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$72,162.11
|
| Rate for Payer: Ohio Health Group HMO |
$61,501.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,400.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,660.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25,420.74
|
| Rate for Payer: PHCS Commercial |
$78,722.30
|
| Rate for Payer: United Healthcare All Payer |
$72,162.11
|
|
|
EXCLUDER CON / 36MMX4.5CM 18FR
|
Facility
|
IP
|
$23,980.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,117.50 |
| Max. Negotiated Rate |
$23,021.52 |
| Rate for Payer: Aetna Commercial |
$18,465.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,704.98
|
| Rate for Payer: Cash Price |
$11,990.38
|
| Rate for Payer: Cigna Commercial |
$19,904.02
|
| Rate for Payer: First Health Commercial |
$22,781.71
|
| Rate for Payer: Humana Commercial |
$20,383.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,664.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,697.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,194.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,103.06
|
| Rate for Payer: Ohio Health Group HMO |
$17,985.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,796.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,117.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,434.03
|
| Rate for Payer: PHCS Commercial |
$23,021.52
|
| Rate for Payer: United Healthcare All Payer |
$21,103.06
|
|
|
EXCLUDER CON / 36MMX4.5CM 18FR
|
Facility
|
OP
|
$23,980.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,117.50 |
| Max. Negotiated Rate |
$23,021.52 |
| Rate for Payer: Aetna Commercial |
$18,465.18
|
| Rate for Payer: Anthem Medicaid |
$8,246.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,704.98
|
| Rate for Payer: Cash Price |
$11,990.38
|
| Rate for Payer: Cigna Commercial |
$19,904.02
|
| Rate for Payer: First Health Commercial |
$22,781.71
|
| Rate for Payer: Humana Commercial |
$20,383.64
|
| Rate for Payer: Humana KY Medicaid |
$8,246.98
|
| Rate for Payer: Kentucky WC Medicaid |
$8,330.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,664.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,697.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,194.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,412.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,103.06
|
| Rate for Payer: Ohio Health Group HMO |
$17,985.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,796.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,117.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,434.03
|
| Rate for Payer: PHCS Commercial |
$23,021.52
|
| Rate for Payer: United Healthcare All Payer |
$21,103.06
|
|
|
EXC LYMPH NODE
|
Facility
|
OP
|
$2,063.00
|
|
|
Service Code
|
HCPCS 38505
|
| Hospital Charge Code |
76101594
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$268.19 |
| Max. Negotiated Rate |
$1,980.48 |
| Rate for Payer: Aetna Commercial |
$1,588.51
|
| Rate for Payer: Anthem Medicaid |
$709.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,609.14
|
| 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 |
$1,031.50
|
| Rate for Payer: Cash Price |
$1,031.50
|
| Rate for Payer: Cigna Commercial |
$1,712.29
|
| Rate for Payer: First Health Commercial |
$1,959.85
|
| Rate for Payer: Humana Commercial |
$1,753.55
|
| Rate for Payer: Humana KY Medicaid |
$709.47
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$716.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,691.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,522.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$723.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,815.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,547.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$412.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$268.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$639.53
|
| Rate for Payer: PHCS Commercial |
$1,980.48
|
| Rate for Payer: United Healthcare All Payer |
$1,815.44
|
|
|
EXC LYMPH NODE
|
Professional
|
Both
|
$2,002.00
|
|
|
Service Code
|
HCPCS 38505
|
| Hospital Charge Code |
76102852
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$43.26 |
| Max. Negotiated Rate |
$2,002.00 |
| Rate for Payer: Aetna Commercial |
$113.43
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$43.26
|
| Rate for Payer: Anthem Medicaid |
$52.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,002.00
|
| Rate for Payer: Cash Price |
$1,001.00
|
| Rate for Payer: Cash Price |
$1,001.00
|
| Rate for Payer: Cigna Commercial |
$107.26
|
| Rate for Payer: Healthspan PPO |
$147.62
|
| Rate for Payer: Humana Medicaid |
$52.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$92.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$53.65
|
| Rate for Payer: Molina Healthcare Passport |
$52.60
|
| Rate for Payer: Multiplan PHCS |
$1,201.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,401.40
|
| Rate for Payer: UHCCP Medicaid |
$45.42
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$53.13
|
|
|
EXC LYMPH NODE
|
Professional
|
Both
|
$2,063.00
|
|
|
Service Code
|
HCPCS 38505
|
| Hospital Charge Code |
76101594
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$43.26 |
| Max. Negotiated Rate |
$2,063.00 |
| Rate for Payer: Aetna Commercial |
$113.43
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$43.26
|
| Rate for Payer: Anthem Medicaid |
$52.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,063.00
|
| Rate for Payer: Cash Price |
$1,031.50
|
| Rate for Payer: Cash Price |
$1,031.50
|
| Rate for Payer: Cigna Commercial |
$107.26
|
| Rate for Payer: Healthspan PPO |
$147.62
|
| Rate for Payer: Humana Medicaid |
$52.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$92.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$53.65
|
| Rate for Payer: Molina Healthcare Passport |
$52.60
|
| Rate for Payer: Multiplan PHCS |
$1,237.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,444.10
|
| Rate for Payer: UHCCP Medicaid |
$45.42
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$53.13
|
|
|
EXC LYMPH NODE
|
Facility
|
IP
|
$2,063.00
|
|
|
Service Code
|
HCPCS 38505
|
| Hospital Charge Code |
76101594
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$268.19 |
| Max. Negotiated Rate |
$1,980.48 |
| Rate for Payer: Aetna Commercial |
$1,588.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,609.14
|
| Rate for Payer: Cash Price |
$1,031.50
|
| Rate for Payer: Cigna Commercial |
$1,712.29
|
| Rate for Payer: First Health Commercial |
$1,959.85
|
| Rate for Payer: Humana Commercial |
$1,753.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,691.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,522.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$618.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,815.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,547.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$412.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$268.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$639.53
|
| Rate for Payer: PHCS Commercial |
$1,980.48
|
| Rate for Payer: United Healthcare All Payer |
$1,815.44
|
|
|
EXC LYMPH NODE
|
Facility
|
IP
|
$2,002.00
|
|
|
Service Code
|
HCPCS 38505
|
| Hospital Charge Code |
76102852
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$260.26 |
| Max. Negotiated Rate |
$1,921.92 |
| Rate for Payer: Aetna Commercial |
$1,541.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,561.56
|
| Rate for Payer: Cash Price |
$1,001.00
|
| Rate for Payer: Cigna Commercial |
$1,661.66
|
| Rate for Payer: First Health Commercial |
$1,901.90
|
| Rate for Payer: Humana Commercial |
$1,701.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,641.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,477.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$600.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,761.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,501.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$400.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$260.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$620.62
|
| Rate for Payer: PHCS Commercial |
$1,921.92
|
| Rate for Payer: United Healthcare All Payer |
$1,761.76
|
|
|
EXC LYMPH NODE
|
Facility
|
OP
|
$2,002.00
|
|
|
Service Code
|
HCPCS 38505
|
| Hospital Charge Code |
76102852
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$260.26 |
| Max. Negotiated Rate |
$1,962.83 |
| Rate for Payer: Aetna Commercial |
$1,541.54
|
| Rate for Payer: Anthem Medicaid |
$688.49
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,561.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$1,001.00
|
| Rate for Payer: Cash Price |
$1,001.00
|
| Rate for Payer: Cigna Commercial |
$1,661.66
|
| Rate for Payer: First Health Commercial |
$1,901.90
|
| Rate for Payer: Humana Commercial |
$1,701.70
|
| Rate for Payer: Humana KY Medicaid |
$688.49
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$695.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,641.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,477.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$702.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,761.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,501.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$400.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$260.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$620.62
|
| Rate for Payer: PHCS Commercial |
$1,921.92
|
| Rate for Payer: United Healthcare All Payer |
$1,761.76
|
|
|
EXC LYMPH NODE (P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 38505
|
| Hospital Charge Code |
761P2852
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$43.26 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Aetna Commercial |
$113.43
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$43.26
|
| Rate for Payer: Anthem Medicaid |
$52.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$107.26
|
| Rate for Payer: Healthspan PPO |
$147.62
|
| Rate for Payer: Humana Medicaid |
$52.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$92.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$53.65
|
| Rate for Payer: Molina Healthcare Passport |
$52.60
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$45.42
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$53.13
|
|
|
EXC LYMPH NODE(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 38505
|
| Hospital Charge Code |
761P1594
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$43.26 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Aetna Commercial |
$113.43
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$43.26
|
| Rate for Payer: Anthem Medicaid |
$52.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$107.26
|
| Rate for Payer: Healthspan PPO |
$147.62
|
| Rate for Payer: Humana Medicaid |
$52.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$92.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$53.65
|
| Rate for Payer: Molina Healthcare Passport |
$52.60
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$45.42
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$53.13
|
|
|
EXC LYMPH NODE (T
|
Facility
|
OP
|
$1,752.00
|
|
|
Service Code
|
HCPCS 38505
|
| Hospital Charge Code |
761T2852
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$227.76 |
| Max. Negotiated Rate |
$1,962.83 |
| Rate for Payer: Aetna Commercial |
$1,349.04
|
| Rate for Payer: Anthem Medicaid |
$602.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$876.00
|
| Rate for Payer: Cash Price |
$876.00
|
| Rate for Payer: Cigna Commercial |
$1,454.16
|
| Rate for Payer: First Health Commercial |
$1,664.40
|
| Rate for Payer: Humana Commercial |
$1,489.20
|
| Rate for Payer: Humana KY Medicaid |
$602.51
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$608.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,436.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,292.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$614.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,541.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.12
|
| Rate for Payer: PHCS Commercial |
$1,681.92
|
| Rate for Payer: United Healthcare All Payer |
$1,541.76
|
|
|
EXC LYMPH NODE (T
|
Facility
|
IP
|
$1,752.00
|
|
|
Service Code
|
HCPCS 38505
|
| Hospital Charge Code |
761T2852
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$227.76 |
| Max. Negotiated Rate |
$1,681.92 |
| Rate for Payer: Aetna Commercial |
$1,349.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.56
|
| Rate for Payer: Cash Price |
$876.00
|
| Rate for Payer: Cigna Commercial |
$1,454.16
|
| Rate for Payer: First Health Commercial |
$1,664.40
|
| Rate for Payer: Humana Commercial |
$1,489.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,436.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,292.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,541.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.12
|
| Rate for Payer: PHCS Commercial |
$1,681.92
|
| Rate for Payer: United Healthcare All Payer |
$1,541.76
|
|
