|
EXC BGN LES 1.1-2.0CM S N H FG
|
Facility
|
IP
|
$2,184.00
|
|
|
Service Code
|
HCPCS 11422
|
| Hospital Charge Code |
761T0059
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$655.20 |
| Max. Negotiated Rate |
$2,096.64 |
| Rate for Payer: Aetna Commercial |
$1,681.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,703.52
|
| Rate for Payer: Cash Price |
$1,092.00
|
| Rate for Payer: Cigna Commercial |
$1,812.72
|
| Rate for Payer: First Health Commercial |
$2,074.80
|
| Rate for Payer: Humana Commercial |
$1,856.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,790.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,611.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$655.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,921.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,638.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,747.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,900.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,506.96
|
| Rate for Payer: PHCS Commercial |
$2,096.64
|
| Rate for Payer: United Healthcare All Payer |
$1,921.92
|
|
|
EXC BGN LES 1.1-2.0CM S N H FG
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 11422
|
| Hospital Charge Code |
761P0059
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$68.70 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: Aetna Commercial |
$186.40
|
| Rate for Payer: Ambetter Exchange |
$127.96
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$68.70
|
| Rate for Payer: Anthem Medicaid |
$77.82
|
| Rate for Payer: Buckeye Individual/Medicaid |
$127.96
|
| Rate for Payer: Buckeye Medicare Advantage |
$127.96
|
| Rate for Payer: CareSource Just4Me Medicare |
$153.55
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$222.72
|
| Rate for Payer: Healthspan PPO |
$186.70
|
| Rate for Payer: Humana Medicaid |
$77.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$164.24
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$127.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$127.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$79.38
|
| Rate for Payer: Molina Healthcare Passport |
$77.82
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$166.35
|
| Rate for Payer: UHCCP Medicaid |
$72.14
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$78.60
|
| Rate for Payer: Wellcare Medicare Advantage |
$127.96
|
|
|
EXC BGNLES TRNKARMEG 0 05CMOR<
|
Facility
|
IP
|
$970.00
|
|
|
Service Code
|
HCPCS 11400
|
| Hospital Charge Code |
45000030
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$291.00 |
| Max. Negotiated Rate |
$931.20 |
| Rate for Payer: Aetna Commercial |
$746.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$756.60
|
| Rate for Payer: Cash Price |
$485.00
|
| Rate for Payer: Cigna Commercial |
$805.10
|
| Rate for Payer: First Health Commercial |
$921.50
|
| Rate for Payer: Humana Commercial |
$824.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$795.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$715.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$291.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$853.60
|
| Rate for Payer: Ohio Health Group HMO |
$727.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$776.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$843.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$669.30
|
| Rate for Payer: PHCS Commercial |
$931.20
|
| Rate for Payer: United Healthcare All Payer |
$853.60
|
|
|
EXC BGNLES TRNKARMEG 0 05CMOR<
|
Facility
|
OP
|
$970.00
|
|
|
Service Code
|
HCPCS 11400
|
| Hospital Charge Code |
45000030
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$333.58 |
| Max. Negotiated Rate |
$931.20 |
| Rate for Payer: Aetna Commercial |
$746.90
|
| Rate for Payer: Anthem Medicaid |
$333.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$650.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$756.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$910.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$877.63
|
| Rate for Payer: Cash Price |
$485.00
|
| Rate for Payer: Cash Price |
$485.00
|
| Rate for Payer: Cigna Commercial |
$805.10
|
| Rate for Payer: First Health Commercial |
$921.50
|
| Rate for Payer: Humana Commercial |
$824.50
|
| Rate for Payer: Humana KY Medicaid |
$333.58
|
| Rate for Payer: Humana Medicare Advantage |
$650.10
|
| Rate for Payer: Kentucky WC Medicaid |
$336.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$795.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$715.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$780.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$340.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$853.60
|
| Rate for Payer: Ohio Health Group HMO |
$727.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$776.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$843.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$669.30
|
| Rate for Payer: PHCS Commercial |
$931.20
|
| Rate for Payer: United Healthcare All Payer |
$853.60
|
|
|
EXC BGNLES TRNKARMEG 0 05CMOR<
|
Professional
|
Both
|
$1,195.00
|
|
|
Service Code
|
HCPCS 11400
|
| Hospital Charge Code |
76100051
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$40.67 |
| Max. Negotiated Rate |
$717.00 |
| Rate for Payer: Aetna Commercial |
$104.28
|
| Rate for Payer: Ambetter Exchange |
$78.84
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$47.22
|
| Rate for Payer: Anthem Medicaid |
$40.67
|
| Rate for Payer: Buckeye Individual/Medicaid |
$78.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$78.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$94.61
|
| Rate for Payer: Cash Price |
$597.50
|
| Rate for Payer: Cash Price |
$597.50
|
| Rate for Payer: Cigna Commercial |
$157.54
|
| Rate for Payer: Healthspan PPO |
$125.31
|
| Rate for Payer: Humana Medicaid |
$40.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$94.53
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$78.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$41.48
|
| Rate for Payer: Molina Healthcare Passport |
$40.67
|
| Rate for Payer: Multiplan PHCS |
$717.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$102.49
|
| Rate for Payer: UHCCP Medicaid |
$49.58
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$41.08
|
| Rate for Payer: Wellcare Medicare Advantage |
$78.84
|
|
|
EXC BGNLES TRNKARMEG 0 05CMOR<
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 11400
|
| Hospital Charge Code |
761P0051
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$40.67 |
| Max. Negotiated Rate |
$157.54 |
| Rate for Payer: Aetna Commercial |
$104.28
|
| Rate for Payer: Ambetter Exchange |
$78.84
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$47.22
|
| Rate for Payer: Anthem Medicaid |
$40.67
|
| Rate for Payer: Buckeye Individual/Medicaid |
$78.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$78.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$94.61
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$157.54
|
| Rate for Payer: Healthspan PPO |
$125.31
|
| Rate for Payer: Humana Medicaid |
$40.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$94.53
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$78.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$41.48
|
| Rate for Payer: Molina Healthcare Passport |
$40.67
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$102.49
|
| Rate for Payer: UHCCP Medicaid |
$49.58
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$41.08
|
| Rate for Payer: Wellcare Medicare Advantage |
$78.84
|
|
|
EXC BGNLES TRNKARMEG 0 05CMOR<
|
Facility
|
IP
|
$1,195.00
|
|
|
Service Code
|
HCPCS 11400
|
| Hospital Charge Code |
76100051
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$358.50 |
| Max. Negotiated Rate |
$1,147.20 |
| Rate for Payer: Aetna Commercial |
$920.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$932.10
|
| Rate for Payer: Cash Price |
$597.50
|
| Rate for Payer: Cigna Commercial |
$991.85
|
| Rate for Payer: First Health Commercial |
$1,135.25
|
| Rate for Payer: Humana Commercial |
$1,015.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$979.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$881.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$358.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,051.60
|
| Rate for Payer: Ohio Health Group HMO |
$896.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$956.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,039.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$824.55
|
| Rate for Payer: PHCS Commercial |
$1,147.20
|
| Rate for Payer: United Healthcare All Payer |
$1,051.60
|
|
|
EXC BGNLES TRNKARMEG 0 05CMOR<
|
Facility
|
IP
|
$970.00
|
|
|
Service Code
|
HCPCS 11400
|
| Hospital Charge Code |
761T0051
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$291.00 |
| Max. Negotiated Rate |
$931.20 |
| Rate for Payer: Aetna Commercial |
$746.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$756.60
|
| Rate for Payer: Cash Price |
$485.00
|
| Rate for Payer: Cigna Commercial |
$805.10
|
| Rate for Payer: First Health Commercial |
$921.50
|
| Rate for Payer: Humana Commercial |
$824.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$795.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$715.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$291.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$853.60
|
| Rate for Payer: Ohio Health Group HMO |
$727.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$776.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$843.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$669.30
|
| Rate for Payer: PHCS Commercial |
$931.20
|
| Rate for Payer: United Healthcare All Payer |
$853.60
|
|
|
EXC BGNLES TRNKARMEG 0 05CMOR<
|
Facility
|
OP
|
$1,195.00
|
|
|
Service Code
|
HCPCS 11400
|
| Hospital Charge Code |
76100051
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$410.96 |
| Max. Negotiated Rate |
$1,147.20 |
| Rate for Payer: Aetna Commercial |
$920.15
|
| Rate for Payer: Anthem Medicaid |
$410.96
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$650.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$932.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$910.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$877.63
|
| Rate for Payer: Cash Price |
$597.50
|
| Rate for Payer: Cash Price |
$597.50
|
| Rate for Payer: Cigna Commercial |
$991.85
|
| Rate for Payer: First Health Commercial |
$1,135.25
|
| Rate for Payer: Humana Commercial |
$1,015.75
|
| Rate for Payer: Humana KY Medicaid |
$410.96
|
| Rate for Payer: Humana Medicare Advantage |
$650.10
|
| Rate for Payer: Kentucky WC Medicaid |
$415.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$979.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$881.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$780.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$419.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,051.60
|
| Rate for Payer: Ohio Health Group HMO |
$896.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$956.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,039.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$824.55
|
| Rate for Payer: PHCS Commercial |
$1,147.20
|
| Rate for Payer: United Healthcare All Payer |
$1,051.60
|
|
|
EXC BGNLES TRNKARMEG 0 05CMOR<
|
Facility
|
OP
|
$970.00
|
|
|
Service Code
|
HCPCS 11400
|
| Hospital Charge Code |
761T0051
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$333.58 |
| Max. Negotiated Rate |
$931.20 |
| Rate for Payer: Aetna Commercial |
$746.90
|
| Rate for Payer: Anthem Medicaid |
$333.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$650.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$756.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$910.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$877.63
|
| Rate for Payer: Cash Price |
$485.00
|
| Rate for Payer: Cash Price |
$485.00
|
| Rate for Payer: Cigna Commercial |
$805.10
|
| Rate for Payer: First Health Commercial |
$921.50
|
| Rate for Payer: Humana Commercial |
$824.50
|
| Rate for Payer: Humana KY Medicaid |
$333.58
|
| Rate for Payer: Humana Medicare Advantage |
$650.10
|
| Rate for Payer: Kentucky WC Medicaid |
$336.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$795.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$715.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$780.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$340.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$853.60
|
| Rate for Payer: Ohio Health Group HMO |
$727.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$776.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$843.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$669.30
|
| Rate for Payer: PHCS Commercial |
$931.20
|
| Rate for Payer: United Healthcare All Payer |
$853.60
|
|
|
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 |
$448.89 |
| Rate for Payer: Aetna Commercial |
$407.04
|
| Rate for Payer: Ambetter Exchange |
$266.01
|
| 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 Individual/Medicaid |
$266.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$266.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$319.21
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$266.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$266.01
|
| 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 |
$345.81
|
| Rate for Payer: UHCCP Medicaid |
$181.44
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$191.44
|
| Rate for Payer: Wellcare Medicare Advantage |
$266.01
|
|
|
EXC BRANCHIAL CLEFT CYST
|
Facility
|
OP
|
$600.00
|
|
|
Service Code
|
HCPCS 42810
|
| Hospital Charge Code |
76101704
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$206.34 |
| Max. Negotiated Rate |
$4,195.14 |
| Rate for Payer: Aetna Commercial |
$462.00
|
| Rate for Payer: Anthem Medicaid |
$206.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,195.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,045.32
|
| 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 |
$2,996.53
|
| 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 |
$3,595.84
|
| 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 |
$480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$414.00
|
| Rate for Payer: PHCS Commercial |
$576.00
|
| Rate for Payer: United Healthcare All Payer |
$528.00
|
|
|
EXC BRANCHIAL CLEFT CYST
|
Facility
|
IP
|
$600.00
|
|
|
Service Code
|
HCPCS 42810
|
| Hospital Charge Code |
76101704
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$180.00 |
| 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 |
$480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$414.00
|
| 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 |
$448.89 |
| Rate for Payer: Aetna Commercial |
$407.04
|
| Rate for Payer: Ambetter Exchange |
$266.01
|
| 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 Individual/Medicaid |
$266.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$266.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$319.21
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$266.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$266.01
|
| 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 |
$345.81
|
| Rate for Payer: UHCCP Medicaid |
$181.44
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$191.44
|
| Rate for Payer: Wellcare Medicare Advantage |
$266.01
|
|
|
EXC BREAST LES IDENT MARKER
|
Facility
|
IP
|
$4,029.00
|
|
|
Service Code
|
HCPCS 19126
|
| Hospital Charge Code |
76100290
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,208.70 |
| Max. Negotiated Rate |
$3,867.84 |
| Rate for Payer: Aetna Commercial |
$3,102.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,142.62
|
| Rate for Payer: Cash Price |
$2,014.50
|
| Rate for Payer: Cigna Commercial |
$3,344.07
|
| Rate for Payer: First Health Commercial |
$3,827.55
|
| Rate for Payer: Humana Commercial |
$3,424.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,303.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,973.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,208.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,545.52
|
| Rate for Payer: Ohio Health Group HMO |
$3,021.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,223.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,505.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,780.01
|
| Rate for Payer: PHCS Commercial |
$3,867.84
|
| Rate for Payer: United Healthcare All Payer |
$3,545.52
|
|
|
EXC BREAST LES IDENT MARKER
|
Professional
|
Both
|
$4,029.00
|
|
|
Service Code
|
HCPCS 19126
|
| Hospital Charge Code |
76100290
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$132.40 |
| Max. Negotiated Rate |
$2,417.40 |
| Rate for Payer: Aetna Commercial |
$241.69
|
| Rate for Payer: Ambetter Exchange |
$152.13
|
| Rate for Payer: Anthem Medicaid |
$132.40
|
| Rate for Payer: Buckeye Individual/Medicaid |
$152.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$152.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.56
|
| Rate for Payer: Cash Price |
$2,014.50
|
| Rate for Payer: Cash Price |
$2,014.50
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$152.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$152.13
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$135.05
|
| Rate for Payer: Molina Healthcare Passport |
$132.40
|
| Rate for Payer: Multiplan PHCS |
$2,417.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$197.77
|
| Rate for Payer: UHCCP Medicaid |
$1,410.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$133.72
|
| Rate for Payer: Wellcare Medicare Advantage |
$152.13
|
|
|
EXC BREAST LES IDENT MARKER
|
Facility
|
OP
|
$4,029.00
|
|
|
Service Code
|
HCPCS 19126
|
| Hospital Charge Code |
76100290
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,208.70 |
| Max. Negotiated Rate |
$3,867.84 |
| Rate for Payer: Aetna Commercial |
$3,102.33
|
| Rate for Payer: Anthem Medicaid |
$1,385.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,142.62
|
| Rate for Payer: Cash Price |
$2,014.50
|
| Rate for Payer: Cigna Commercial |
$3,344.07
|
| Rate for Payer: First Health Commercial |
$3,827.55
|
| Rate for Payer: Humana Commercial |
$3,424.65
|
| Rate for Payer: Humana KY Medicaid |
$1,385.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1,399.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,303.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,973.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,208.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,413.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,545.52
|
| Rate for Payer: Ohio Health Group HMO |
$3,021.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,223.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,505.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,780.01
|
| Rate for Payer: PHCS Commercial |
$3,867.84
|
| Rate for Payer: United Healthcare All Payer |
$3,545.52
|
|
|
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 |
$360.00 |
| Rate for Payer: Aetna Commercial |
$241.69
|
| Rate for Payer: Ambetter Exchange |
$152.13
|
| Rate for Payer: Anthem Medicaid |
$132.40
|
| Rate for Payer: Buckeye Individual/Medicaid |
$152.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$152.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.56
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$152.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$152.13
|
| 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 |
$197.77
|
| Rate for Payer: UHCCP Medicaid |
$210.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$133.72
|
| Rate for Payer: Wellcare Medicare Advantage |
$152.13
|
|
|
EXC BREAST LES IDENT MARKER(T
|
Facility
|
IP
|
$3,429.00
|
|
|
Service Code
|
HCPCS 19126
|
| Hospital Charge Code |
761T0290
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,028.70 |
| Max. Negotiated Rate |
$3,291.84 |
| Rate for Payer: Aetna Commercial |
$2,640.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,674.62
|
| Rate for Payer: Cash Price |
$1,714.50
|
| Rate for Payer: Cigna Commercial |
$2,846.07
|
| Rate for Payer: First Health Commercial |
$3,257.55
|
| Rate for Payer: Humana Commercial |
$2,914.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,811.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,530.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,028.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,017.52
|
| Rate for Payer: Ohio Health Group HMO |
$2,571.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,743.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,983.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,366.01
|
| Rate for Payer: PHCS Commercial |
$3,291.84
|
| Rate for Payer: United Healthcare All Payer |
$3,017.52
|
|
|
EXC BREAST LES IDENT MARKER(T
|
Facility
|
OP
|
$3,429.00
|
|
|
Service Code
|
HCPCS 19126
|
| Hospital Charge Code |
761T0290
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,028.70 |
| Max. Negotiated Rate |
$3,291.84 |
| Rate for Payer: Aetna Commercial |
$2,640.33
|
| Rate for Payer: Anthem Medicaid |
$1,179.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,674.62
|
| Rate for Payer: Cash Price |
$1,714.50
|
| Rate for Payer: Cigna Commercial |
$2,846.07
|
| Rate for Payer: First Health Commercial |
$3,257.55
|
| Rate for Payer: Humana Commercial |
$2,914.65
|
| Rate for Payer: Humana KY Medicaid |
$1,179.23
|
| Rate for Payer: Kentucky WC Medicaid |
$1,191.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,811.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,530.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,028.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,202.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,017.52
|
| Rate for Payer: Ohio Health Group HMO |
$2,571.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,743.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,983.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,366.01
|
| Rate for Payer: PHCS Commercial |
$3,291.84
|
| Rate for Payer: United Healthcare All Payer |
$3,017.52
|
|
|
EXC BRST MASS MAL/FEM
|
Facility
|
IP
|
$7,402.00
|
|
|
Service Code
|
HCPCS 19120
|
| Hospital Charge Code |
76100288
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,220.60 |
| Max. Negotiated Rate |
$7,105.92 |
| Rate for Payer: Aetna Commercial |
$5,699.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,773.56
|
| Rate for Payer: Cash Price |
$3,701.00
|
| Rate for Payer: Cigna Commercial |
$6,143.66
|
| Rate for Payer: First Health Commercial |
$7,031.90
|
| Rate for Payer: Humana Commercial |
$6,291.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,069.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,462.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,220.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,513.76
|
| Rate for Payer: Ohio Health Group HMO |
$5,551.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,921.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,439.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,107.38
|
| Rate for Payer: PHCS Commercial |
$7,105.92
|
| Rate for Payer: United Healthcare All Payer |
$6,513.76
|
|
|
EXC BRST MASS MAL/FEM
|
Facility
|
OP
|
$7,402.00
|
|
|
Service Code
|
HCPCS 19120
|
| Hospital Charge Code |
76100288
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,545.55 |
| Max. Negotiated Rate |
$7,105.92 |
| Rate for Payer: Aetna Commercial |
$5,699.54
|
| Rate for Payer: Anthem Medicaid |
$2,545.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,538.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,773.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,953.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,776.54
|
| Rate for Payer: Cash Price |
$3,701.00
|
| Rate for Payer: Cash Price |
$3,701.00
|
| Rate for Payer: Cigna Commercial |
$6,143.66
|
| Rate for Payer: First Health Commercial |
$7,031.90
|
| Rate for Payer: Humana Commercial |
$6,291.70
|
| Rate for Payer: Humana KY Medicaid |
$2,545.55
|
| Rate for Payer: Humana Medicare Advantage |
$3,538.18
|
| Rate for Payer: Kentucky WC Medicaid |
$2,571.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,069.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,462.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,245.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,596.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,513.76
|
| Rate for Payer: Ohio Health Group HMO |
$5,551.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,921.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,439.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,107.38
|
| Rate for Payer: PHCS Commercial |
$7,105.92
|
| Rate for Payer: United Healthcare All Payer |
$6,513.76
|
|
|
EXC BRST MASS MAL/FEM
|
Professional
|
Both
|
$7,402.00
|
|
|
Service Code
|
HCPCS 19120
|
| Hospital Charge Code |
76100288
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$215.08 |
| Max. Negotiated Rate |
$4,441.20 |
| Rate for Payer: Aetna Commercial |
$568.40
|
| Rate for Payer: Ambetter Exchange |
$398.81
|
| 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 Individual/Medicaid |
$398.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$398.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$478.57
|
| Rate for Payer: Cash Price |
$3,701.00
|
| Rate for Payer: Cash Price |
$3,701.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$398.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$398.81
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$269.00
|
| Rate for Payer: Molina Healthcare Passport |
$263.73
|
| Rate for Payer: Multiplan PHCS |
$4,441.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$518.45
|
| Rate for Payer: UHCCP Medicaid |
$225.83
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$266.37
|
| Rate for Payer: Wellcare Medicare Advantage |
$398.81
|
|
|
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 |
$615.00 |
| Rate for Payer: Aetna Commercial |
$568.40
|
| Rate for Payer: Ambetter Exchange |
$398.81
|
| 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 Individual/Medicaid |
$398.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$398.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$478.57
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$398.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$398.81
|
| 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 |
$518.45
|
| Rate for Payer: UHCCP Medicaid |
$225.83
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$266.37
|
| Rate for Payer: Wellcare Medicare Advantage |
$398.81
|
|
|
EXC BRST MASS MAL/FEM(T
|
Facility
|
IP
|
$6,377.00
|
|
|
Service Code
|
HCPCS 19120
|
| Hospital Charge Code |
761T0288
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,913.10 |
| Max. Negotiated Rate |
$6,121.92 |
| Rate for Payer: Aetna Commercial |
$4,910.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,974.06
|
| Rate for Payer: Cash Price |
$3,188.50
|
| Rate for Payer: Cigna Commercial |
$5,292.91
|
| Rate for Payer: First Health Commercial |
$6,058.15
|
| Rate for Payer: Humana Commercial |
$5,420.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,229.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,706.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,913.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,611.76
|
| Rate for Payer: Ohio Health Group HMO |
$4,782.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,101.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,547.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,400.13
|
| Rate for Payer: PHCS Commercial |
$6,121.92
|
| Rate for Payer: United Healthcare All Payer |
$5,611.76
|
|
