|
EXC LES/TUMOR DENTOALVEOLAR
|
Facility
|
OP
|
$4,863.00
|
|
|
Service Code
|
HCPCS 41825
|
| Hospital Charge Code |
76101666
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,672.39 |
| Max. Negotiated Rate |
$4,668.48 |
| Rate for Payer: Aetna Commercial |
$3,744.51
|
| Rate for Payer: Anthem Medicaid |
$1,672.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,793.14
|
| 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 |
$2,431.50
|
| Rate for Payer: Cash Price |
$2,431.50
|
| Rate for Payer: Cigna Commercial |
$4,036.29
|
| Rate for Payer: First Health Commercial |
$4,619.85
|
| Rate for Payer: Humana Commercial |
$4,133.55
|
| Rate for Payer: Humana KY Medicaid |
$1,672.39
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1,689.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,987.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,588.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,595.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,705.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,279.44
|
| Rate for Payer: Ohio Health Group HMO |
$3,647.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,890.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,230.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,355.47
|
| Rate for Payer: PHCS Commercial |
$4,668.48
|
| Rate for Payer: United Healthcare All Payer |
$4,279.44
|
|
|
EXC LES/TUMOR DENTOALVEOLAR(P
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 41825
|
| Hospital Charge Code |
761P1666
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$80.34 |
| Max. Negotiated Rate |
$270.00 |
| Rate for Payer: Aetna Commercial |
$178.52
|
| Rate for Payer: Ambetter Exchange |
$113.72
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$82.05
|
| Rate for Payer: Anthem Medicaid |
$80.34
|
| Rate for Payer: Buckeye Individual/Medicaid |
$113.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$113.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$136.46
|
| 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 |
$80.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$158.49
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$113.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$113.72
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$81.95
|
| Rate for Payer: Molina Healthcare Passport |
$80.34
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$147.84
|
| Rate for Payer: UHCCP Medicaid |
$86.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$81.14
|
| Rate for Payer: Wellcare Medicare Advantage |
$113.72
|
|
|
EXC LES/TUMOR DENTOALVEOLAR(T
|
Facility
|
OP
|
$4,413.00
|
|
|
Service Code
|
HCPCS 41825
|
| Hospital Charge Code |
761T1666
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,517.63 |
| Max. Negotiated Rate |
$4,236.48 |
| Rate for Payer: Aetna Commercial |
$3,398.01
|
| Rate for Payer: Anthem Medicaid |
$1,517.63
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,442.14
|
| 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 |
$2,206.50
|
| Rate for Payer: Cash Price |
$2,206.50
|
| Rate for Payer: Cigna Commercial |
$3,662.79
|
| Rate for Payer: First Health Commercial |
$4,192.35
|
| Rate for Payer: Humana Commercial |
$3,751.05
|
| Rate for Payer: Humana KY Medicaid |
$1,517.63
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1,533.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,618.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,256.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,595.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,548.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,883.44
|
| Rate for Payer: Ohio Health Group HMO |
$3,309.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,530.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,839.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,044.97
|
| Rate for Payer: PHCS Commercial |
$4,236.48
|
| Rate for Payer: United Healthcare All Payer |
$3,883.44
|
|
|
EXC LES/TUMOR DENTOALVEOLAR(T
|
Facility
|
IP
|
$4,413.00
|
|
|
Service Code
|
HCPCS 41825
|
| Hospital Charge Code |
761T1666
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,323.90 |
| Max. Negotiated Rate |
$4,236.48 |
| Rate for Payer: Aetna Commercial |
$3,398.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,442.14
|
| Rate for Payer: Cash Price |
$2,206.50
|
| Rate for Payer: Cigna Commercial |
$3,662.79
|
| Rate for Payer: First Health Commercial |
$4,192.35
|
| Rate for Payer: Humana Commercial |
$3,751.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,618.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,256.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,323.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,883.44
|
| Rate for Payer: Ohio Health Group HMO |
$3,309.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,530.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,839.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,044.97
|
| Rate for Payer: PHCS Commercial |
$4,236.48
|
| Rate for Payer: United Healthcare All Payer |
$3,883.44
|
|
|
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 |
$1,170.00 |
| Rate for Payer: Aetna Commercial |
$807.58
|
| Rate for Payer: Ambetter Exchange |
$518.99
|
| Rate for Payer: Anthem Medicaid |
$497.22
|
| Rate for Payer: Buckeye Individual/Medicaid |
$518.99
|
| Rate for Payer: Buckeye Medicare Advantage |
$518.99
|
| Rate for Payer: CareSource Just4Me Medicare |
$622.79
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$518.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$518.99
|
| 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 |
$674.69
|
| Rate for Payer: UHCCP Medicaid |
$682.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$502.19
|
| Rate for Payer: Wellcare Medicare Advantage |
$518.99
|
|
|
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 |
$670.61 |
| Max. Negotiated Rate |
$4,195.14 |
| Rate for Payer: Aetna Commercial |
$1,501.50
|
| Rate for Payer: Anthem Medicaid |
$670.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,521.00
|
| 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 |
$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 |
$670.61
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| 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 |
$3,595.84
|
| 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 |
$1,560.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,696.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,345.50
|
| 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 |
$585.00 |
| 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 |
$1,560.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,696.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,345.50
|
| 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 |
$1,170.00 |
| Rate for Payer: Aetna Commercial |
$807.58
|
| Rate for Payer: Ambetter Exchange |
$518.99
|
| Rate for Payer: Anthem Medicaid |
$497.22
|
| Rate for Payer: Buckeye Individual/Medicaid |
$518.99
|
| Rate for Payer: Buckeye Medicare Advantage |
$518.99
|
| Rate for Payer: CareSource Just4Me Medicare |
$622.79
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$518.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$518.99
|
| 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 |
$674.69
|
| Rate for Payer: UHCCP Medicaid |
$682.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$502.19
|
| Rate for Payer: Wellcare Medicare Advantage |
$518.99
|
|
|
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 |
$158.39 |
| Rate for Payer: Ambetter Exchange |
$121.84
|
| Rate for Payer: Anthem Medicaid |
$108.01
|
| Rate for Payer: Buckeye Individual/Medicaid |
$121.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$121.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$146.21
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Humana Medicaid |
$108.01
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$121.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$121.84
|
| 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 |
$158.39
|
| Rate for Payer: UHCCP Medicaid |
$55.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$109.09
|
| Rate for Payer: Wellcare Medicare Advantage |
$121.84
|
|
|
EXCLUDER BRANCH 23*12*10CM 16
|
Facility
|
IP
|
$76,639.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,991.70 |
| Max. Negotiated Rate |
$73,573.44 |
| Rate for Payer: Aetna Commercial |
$59,012.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59,778.42
|
| Rate for Payer: Cash Price |
$38,319.50
|
| Rate for Payer: Cigna Commercial |
$63,610.37
|
| Rate for Payer: First Health Commercial |
$72,807.05
|
| Rate for Payer: Humana Commercial |
$65,143.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62,843.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56,559.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,991.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$67,442.32
|
| Rate for Payer: Ohio Health Group HMO |
$57,479.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61,311.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66,675.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52,880.91
|
| Rate for Payer: PHCS Commercial |
$73,573.44
|
| Rate for Payer: United Healthcare All Payer |
$67,442.32
|
|
|
EXCLUDER BRANCH 23*12*10CM 16
|
Facility
|
OP
|
$76,639.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,991.70 |
| Max. Negotiated Rate |
$73,573.44 |
| Rate for Payer: Aetna Commercial |
$59,012.03
|
| Rate for Payer: Anthem Medicaid |
$26,356.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59,778.42
|
| Rate for Payer: Cash Price |
$38,319.50
|
| Rate for Payer: Cigna Commercial |
$63,610.37
|
| Rate for Payer: First Health Commercial |
$72,807.05
|
| Rate for Payer: Humana Commercial |
$65,143.15
|
| Rate for Payer: Humana KY Medicaid |
$26,356.15
|
| Rate for Payer: Kentucky WC Medicaid |
$26,624.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62,843.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56,559.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,991.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$26,884.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$67,442.32
|
| Rate for Payer: Ohio Health Group HMO |
$57,479.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61,311.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66,675.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52,880.91
|
| Rate for Payer: PHCS Commercial |
$73,573.44
|
| Rate for Payer: United Healthcare All Payer |
$67,442.32
|
|
|
EXCLUDER CON 28.5*14.5*12CM 16
|
Facility
|
OP
|
$84,919.20
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$25,475.76 |
| Max. Negotiated Rate |
$81,522.43 |
| Rate for Payer: Aetna Commercial |
$65,387.78
|
| Rate for Payer: Anthem Medicaid |
$29,203.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66,236.98
|
| Rate for Payer: Cash Price |
$42,459.60
|
| Rate for Payer: Cigna Commercial |
$70,482.94
|
| Rate for Payer: First Health Commercial |
$80,673.24
|
| Rate for Payer: Humana Commercial |
$72,181.32
|
| Rate for Payer: Humana KY Medicaid |
$29,203.71
|
| Rate for Payer: Kentucky WC Medicaid |
$29,500.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69,633.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62,670.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25,475.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$29,789.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$74,728.90
|
| Rate for Payer: Ohio Health Group HMO |
$63,689.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67,935.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73,879.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58,594.25
|
| Rate for Payer: PHCS Commercial |
$81,522.43
|
| Rate for Payer: United Healthcare All Payer |
$74,728.90
|
|
|
EXCLUDER CON 28.5*14.5*12CM 16
|
Facility
|
IP
|
$84,919.20
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$25,475.76 |
| Max. Negotiated Rate |
$81,522.43 |
| Rate for Payer: Aetna Commercial |
$65,387.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66,236.98
|
| Rate for Payer: Cash Price |
$42,459.60
|
| Rate for Payer: Cigna Commercial |
$70,482.94
|
| Rate for Payer: First Health Commercial |
$80,673.24
|
| Rate for Payer: Humana Commercial |
$72,181.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69,633.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62,670.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25,475.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$74,728.90
|
| Rate for Payer: Ohio Health Group HMO |
$63,689.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67,935.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73,879.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58,594.25
|
| Rate for Payer: PHCS Commercial |
$81,522.43
|
| Rate for Payer: United Healthcare All Payer |
$74,728.90
|
|
|
EXCLUDER CON / 36MMX4.5CM 18FR
|
Facility
|
IP
|
$24,706.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,411.88 |
| Max. Negotiated Rate |
$23,718.00 |
| Rate for Payer: Aetna Commercial |
$19,023.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,270.88
|
| Rate for Payer: Cash Price |
$12,353.12
|
| Rate for Payer: Cigna Commercial |
$20,506.19
|
| Rate for Payer: First Health Commercial |
$23,470.94
|
| Rate for Payer: Humana Commercial |
$21,000.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,259.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,233.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,411.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,741.50
|
| Rate for Payer: Ohio Health Group HMO |
$18,529.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,765.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,494.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,047.31
|
| Rate for Payer: PHCS Commercial |
$23,718.00
|
| Rate for Payer: United Healthcare All Payer |
$21,741.50
|
|
|
EXCLUDER CON / 36MMX4.5CM 18FR
|
Facility
|
OP
|
$24,706.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,411.88 |
| Max. Negotiated Rate |
$23,718.00 |
| Rate for Payer: Aetna Commercial |
$19,023.81
|
| Rate for Payer: Anthem Medicaid |
$8,496.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,270.88
|
| Rate for Payer: Cash Price |
$12,353.12
|
| Rate for Payer: Cigna Commercial |
$20,506.19
|
| Rate for Payer: First Health Commercial |
$23,470.94
|
| Rate for Payer: Humana Commercial |
$21,000.31
|
| Rate for Payer: Humana KY Medicaid |
$8,496.48
|
| Rate for Payer: Kentucky WC Medicaid |
$8,582.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,259.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,233.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,411.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,666.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,741.50
|
| Rate for Payer: Ohio Health Group HMO |
$18,529.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,765.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,494.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,047.31
|
| Rate for Payer: PHCS Commercial |
$23,718.00
|
| Rate for Payer: United Healthcare All Payer |
$21,741.50
|
|
|
EXC LYMPH NODE
|
Facility
|
OP
|
$2,180.00
|
|
|
Service Code
|
HCPCS 38505
|
| Hospital Charge Code |
76101594
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$749.70 |
| Max. Negotiated Rate |
$2,095.90 |
| Rate for Payer: Aetna Commercial |
$1,678.60
|
| Rate for Payer: Anthem Medicaid |
$749.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,700.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,095.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,021.04
|
| Rate for Payer: Cash Price |
$1,090.00
|
| Rate for Payer: Cash Price |
$1,090.00
|
| Rate for Payer: Cigna Commercial |
$1,809.40
|
| Rate for Payer: First Health Commercial |
$2,071.00
|
| Rate for Payer: Humana Commercial |
$1,853.00
|
| Rate for Payer: Humana KY Medicaid |
$749.70
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$757.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,787.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,608.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$764.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,918.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,635.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,744.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,896.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,504.20
|
| Rate for Payer: PHCS Commercial |
$2,092.80
|
| Rate for Payer: United Healthcare All Payer |
$1,918.40
|
|
|
EXC LYMPH NODE
|
Professional
|
Both
|
$2,180.00
|
|
|
Service Code
|
HCPCS 38505
|
| Hospital Charge Code |
76101594
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$43.26 |
| Max. Negotiated Rate |
$1,308.00 |
| Rate for Payer: Aetna Commercial |
$113.43
|
| Rate for Payer: Ambetter Exchange |
$80.35
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$43.26
|
| Rate for Payer: Anthem Medicaid |
$67.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$80.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$80.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$96.42
|
| Rate for Payer: Cash Price |
$1,090.00
|
| Rate for Payer: Cash Price |
$1,090.00
|
| Rate for Payer: Cigna Commercial |
$107.26
|
| Rate for Payer: Healthspan PPO |
$147.62
|
| Rate for Payer: Humana Medicaid |
$67.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$92.91
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$80.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$80.35
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$68.97
|
| Rate for Payer: Molina Healthcare Passport |
$67.62
|
| Rate for Payer: Multiplan PHCS |
$1,308.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$104.45
|
| Rate for Payer: UHCCP Medicaid |
$45.42
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$68.30
|
| Rate for Payer: Wellcare Medicare Advantage |
$80.35
|
|
|
EXC LYMPH NODE
|
Facility
|
IP
|
$2,002.00
|
|
|
Service Code
|
HCPCS 38505
|
| Hospital Charge Code |
76102852
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$600.60 |
| 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 |
$1,601.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,741.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,381.38
|
| Rate for Payer: PHCS Commercial |
$1,921.92
|
| Rate for Payer: United Healthcare All Payer |
$1,761.76
|
|
|
EXC LYMPH NODE
|
Facility
|
IP
|
$2,180.00
|
|
|
Service Code
|
HCPCS 38505
|
| Hospital Charge Code |
76101594
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$654.00 |
| Max. Negotiated Rate |
$2,092.80 |
| Rate for Payer: Aetna Commercial |
$1,678.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,700.40
|
| Rate for Payer: Cash Price |
$1,090.00
|
| Rate for Payer: Cigna Commercial |
$1,809.40
|
| Rate for Payer: First Health Commercial |
$2,071.00
|
| Rate for Payer: Humana Commercial |
$1,853.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,787.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,608.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$654.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,918.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,635.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,744.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,896.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,504.20
|
| Rate for Payer: PHCS Commercial |
$2,092.80
|
| Rate for Payer: United Healthcare All Payer |
$1,918.40
|
|
|
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 |
$1,201.20 |
| Rate for Payer: Aetna Commercial |
$113.43
|
| Rate for Payer: Ambetter Exchange |
$80.35
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$43.26
|
| Rate for Payer: Anthem Medicaid |
$67.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$80.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$80.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$96.42
|
| 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 |
$67.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$92.91
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$80.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$80.35
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$68.97
|
| Rate for Payer: Molina Healthcare Passport |
$67.62
|
| Rate for Payer: Multiplan PHCS |
$1,201.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$104.45
|
| Rate for Payer: UHCCP Medicaid |
$45.42
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$68.30
|
| Rate for Payer: Wellcare Medicare Advantage |
$80.35
|
|
|
EXC LYMPH NODE
|
Facility
|
OP
|
$2,002.00
|
|
|
Service Code
|
HCPCS 38505
|
| Hospital Charge Code |
76102852
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$688.49 |
| Max. Negotiated Rate |
$2,095.90 |
| Rate for Payer: Aetna Commercial |
$1,541.54
|
| Rate for Payer: Anthem Medicaid |
$688.49
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,561.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,095.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,021.04
|
| 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 |
$1,497.07
|
| 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 |
$1,796.48
|
| 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 |
$1,601.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,741.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,381.38
|
| 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 |
$150.00 |
| Rate for Payer: Aetna Commercial |
$113.43
|
| Rate for Payer: Ambetter Exchange |
$80.35
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$43.26
|
| Rate for Payer: Anthem Medicaid |
$67.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$80.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$80.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$96.42
|
| 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 |
$67.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$92.91
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$80.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$80.35
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$68.97
|
| Rate for Payer: Molina Healthcare Passport |
$67.62
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$104.45
|
| Rate for Payer: UHCCP Medicaid |
$45.42
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$68.30
|
| Rate for Payer: Wellcare Medicare Advantage |
$80.35
|
|
|
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 |
$150.00 |
| Rate for Payer: Aetna Commercial |
$113.43
|
| Rate for Payer: Ambetter Exchange |
$80.35
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$43.26
|
| Rate for Payer: Anthem Medicaid |
$67.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$80.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$80.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$96.42
|
| 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 |
$67.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$92.91
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$80.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$80.35
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$68.97
|
| Rate for Payer: Molina Healthcare Passport |
$67.62
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$104.45
|
| Rate for Payer: UHCCP Medicaid |
$45.42
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$68.30
|
| Rate for Payer: Wellcare Medicare Advantage |
$80.35
|
|
|
EXC LYMPH NODE (T
|
Facility
|
IP
|
$1,752.00
|
|
|
Service Code
|
HCPCS 38505
|
| Hospital Charge Code |
761T2852
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$525.60 |
| 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 |
$1,401.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,524.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,208.88
|
| Rate for Payer: PHCS Commercial |
$1,681.92
|
| Rate for Payer: United Healthcare All Payer |
$1,541.76
|
|
|
EXC LYMPH NODE (T
|
Facility
|
OP
|
$1,752.00
|
|
|
Service Code
|
HCPCS 38505
|
| Hospital Charge Code |
761T2852
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$602.51 |
| Max. Negotiated Rate |
$2,095.90 |
| Rate for Payer: Aetna Commercial |
$1,349.04
|
| Rate for Payer: Anthem Medicaid |
$602.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,095.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,021.04
|
| 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 |
$1,497.07
|
| 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 |
$1,796.48
|
| 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 |
$1,401.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,524.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,208.88
|
| Rate for Payer: PHCS Commercial |
$1,681.92
|
| Rate for Payer: United Healthcare All Payer |
$1,541.76
|
|
