|
EXC MALIGN INCL MARGINS
|
Facility
|
IP
|
$3,074.00
|
|
|
Service Code
|
HCPCS 11622
|
| Hospital Charge Code |
76100083
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$922.20 |
| Max. Negotiated Rate |
$2,951.04 |
| Rate for Payer: Aetna Commercial |
$2,366.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,397.72
|
| Rate for Payer: Cash Price |
$1,537.00
|
| Rate for Payer: Cigna Commercial |
$2,551.42
|
| Rate for Payer: First Health Commercial |
$2,920.30
|
| Rate for Payer: Humana Commercial |
$2,612.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,520.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,268.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$922.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,705.12
|
| Rate for Payer: Ohio Health Group HMO |
$2,305.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,459.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,674.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,121.06
|
| Rate for Payer: PHCS Commercial |
$2,951.04
|
| Rate for Payer: United Healthcare All Payer |
$2,705.12
|
|
|
EXC MALIGN INCL MARGINS
|
Professional
|
Both
|
$3,074.00
|
|
|
Service Code
|
HCPCS 11622
|
| Hospital Charge Code |
76100083
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$93.59 |
| Max. Negotiated Rate |
$1,844.40 |
| Rate for Payer: Aetna Commercial |
$237.74
|
| Rate for Payer: Ambetter Exchange |
$158.33
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$93.59
|
| Rate for Payer: Anthem Medicaid |
$130.82
|
| Rate for Payer: Buckeye Individual/Medicaid |
$158.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$158.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$190.00
|
| Rate for Payer: Cash Price |
$1,537.00
|
| Rate for Payer: Cash Price |
$1,537.00
|
| Rate for Payer: Cigna Commercial |
$309.55
|
| Rate for Payer: Healthspan PPO |
$273.97
|
| Rate for Payer: Humana Medicaid |
$130.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$213.96
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$158.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$158.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$133.44
|
| Rate for Payer: Molina Healthcare Passport |
$130.82
|
| Rate for Payer: Multiplan PHCS |
$1,844.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$205.83
|
| Rate for Payer: UHCCP Medicaid |
$98.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$132.13
|
| Rate for Payer: Wellcare Medicare Advantage |
$158.33
|
|
|
EXC MALIGN INCL MARGINS(P
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 11622
|
| Hospital Charge Code |
761P0083
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$93.59 |
| Max. Negotiated Rate |
$309.55 |
| Rate for Payer: Aetna Commercial |
$237.74
|
| Rate for Payer: Ambetter Exchange |
$158.33
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$93.59
|
| Rate for Payer: Anthem Medicaid |
$130.82
|
| Rate for Payer: Buckeye Individual/Medicaid |
$158.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$158.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$190.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$309.55
|
| Rate for Payer: Healthspan PPO |
$273.97
|
| Rate for Payer: Humana Medicaid |
$130.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$213.96
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$158.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$158.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$133.44
|
| Rate for Payer: Molina Healthcare Passport |
$130.82
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$205.83
|
| Rate for Payer: UHCCP Medicaid |
$98.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$132.13
|
| Rate for Payer: Wellcare Medicare Advantage |
$158.33
|
|
|
EXC MALIGN INCL MARGINS(T
|
Facility
|
OP
|
$2,624.00
|
|
|
Service Code
|
HCPCS 11622
|
| Hospital Charge Code |
761T0083
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$650.10 |
| Max. Negotiated Rate |
$2,519.04 |
| Rate for Payer: Aetna Commercial |
$2,020.48
|
| Rate for Payer: Anthem Medicaid |
$902.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$650.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,046.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$910.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$877.63
|
| Rate for Payer: Cash Price |
$1,312.00
|
| Rate for Payer: Cash Price |
$1,312.00
|
| Rate for Payer: Cigna Commercial |
$2,177.92
|
| Rate for Payer: First Health Commercial |
$2,492.80
|
| Rate for Payer: Humana Commercial |
$2,230.40
|
| Rate for Payer: Humana KY Medicaid |
$902.39
|
| Rate for Payer: Humana Medicare Advantage |
$650.10
|
| Rate for Payer: Kentucky WC Medicaid |
$911.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,151.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,936.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$780.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$920.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,309.12
|
| Rate for Payer: Ohio Health Group HMO |
$1,968.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,099.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,282.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,810.56
|
| Rate for Payer: PHCS Commercial |
$2,519.04
|
| Rate for Payer: United Healthcare All Payer |
$2,309.12
|
|
|
EXC MALIGN INCL MARGINS(T
|
Facility
|
IP
|
$2,624.00
|
|
|
Service Code
|
HCPCS 11622
|
| Hospital Charge Code |
761T0083
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$787.20 |
| Max. Negotiated Rate |
$2,519.04 |
| Rate for Payer: Aetna Commercial |
$2,020.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,046.72
|
| Rate for Payer: Cash Price |
$1,312.00
|
| Rate for Payer: Cigna Commercial |
$2,177.92
|
| Rate for Payer: First Health Commercial |
$2,492.80
|
| Rate for Payer: Humana Commercial |
$2,230.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,151.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,936.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$787.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,309.12
|
| Rate for Payer: Ohio Health Group HMO |
$1,968.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,099.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,282.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,810.56
|
| Rate for Payer: PHCS Commercial |
$2,519.04
|
| Rate for Payer: United Healthcare All Payer |
$2,309.12
|
|
|
EXC MALIGN LESION HEAD AREA
|
Facility
|
OP
|
$4,432.00
|
|
|
Service Code
|
HCPCS 11643
|
| Hospital Charge Code |
76100090
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,497.07 |
| Max. Negotiated Rate |
$4,254.72 |
| Rate for Payer: Aetna Commercial |
$3,412.64
|
| Rate for Payer: Anthem Medicaid |
$1,524.16
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,456.96
|
| 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 |
$2,216.00
|
| Rate for Payer: Cash Price |
$2,216.00
|
| Rate for Payer: Cigna Commercial |
$3,678.56
|
| Rate for Payer: First Health Commercial |
$4,210.40
|
| Rate for Payer: Humana Commercial |
$3,767.20
|
| Rate for Payer: Humana KY Medicaid |
$1,524.16
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,539.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,634.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,270.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,554.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,900.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,324.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,545.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,855.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,058.08
|
| Rate for Payer: PHCS Commercial |
$4,254.72
|
| Rate for Payer: United Healthcare All Payer |
$3,900.16
|
|
|
EXC MALIGN LESION HEAD AREA
|
Facility
|
IP
|
$4,432.00
|
|
|
Service Code
|
HCPCS 11643
|
| Hospital Charge Code |
76100090
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,329.60 |
| Max. Negotiated Rate |
$4,254.72 |
| Rate for Payer: Aetna Commercial |
$3,412.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,456.96
|
| Rate for Payer: Cash Price |
$2,216.00
|
| Rate for Payer: Cigna Commercial |
$3,678.56
|
| Rate for Payer: First Health Commercial |
$4,210.40
|
| Rate for Payer: Humana Commercial |
$3,767.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,634.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,270.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,329.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,900.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,324.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,545.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,855.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,058.08
|
| Rate for Payer: PHCS Commercial |
$4,254.72
|
| Rate for Payer: United Healthcare All Payer |
$3,900.16
|
|
|
EXC MALIGN LESION HEAD AREA
|
Professional
|
Both
|
$4,432.00
|
|
|
Service Code
|
HCPCS 11643
|
| Hospital Charge Code |
76100090
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$133.36 |
| Max. Negotiated Rate |
$2,659.20 |
| Rate for Payer: Aetna Commercial |
$327.06
|
| Rate for Payer: Ambetter Exchange |
$213.89
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$133.36
|
| Rate for Payer: Anthem Medicaid |
$188.77
|
| Rate for Payer: Buckeye Individual/Medicaid |
$213.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$213.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$256.67
|
| Rate for Payer: Cash Price |
$2,216.00
|
| Rate for Payer: Cash Price |
$2,216.00
|
| Rate for Payer: Cigna Commercial |
$409.78
|
| Rate for Payer: Healthspan PPO |
$348.83
|
| Rate for Payer: Humana Medicaid |
$188.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$288.89
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$213.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$213.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$192.55
|
| Rate for Payer: Molina Healthcare Passport |
$188.77
|
| Rate for Payer: Multiplan PHCS |
$2,659.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$278.06
|
| Rate for Payer: UHCCP Medicaid |
$140.03
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$190.66
|
| Rate for Payer: Wellcare Medicare Advantage |
$213.89
|
|
|
EXC MALIGN LESION HEAD AREA(P
|
Professional
|
Both
|
$700.00
|
|
|
Service Code
|
HCPCS 11643
|
| Hospital Charge Code |
761P0090
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$133.36 |
| Max. Negotiated Rate |
$420.00 |
| Rate for Payer: Aetna Commercial |
$327.06
|
| Rate for Payer: Ambetter Exchange |
$213.89
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$133.36
|
| Rate for Payer: Anthem Medicaid |
$188.77
|
| Rate for Payer: Buckeye Individual/Medicaid |
$213.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$213.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$256.67
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$409.78
|
| Rate for Payer: Healthspan PPO |
$348.83
|
| Rate for Payer: Humana Medicaid |
$188.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$288.89
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$213.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$213.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$192.55
|
| Rate for Payer: Molina Healthcare Passport |
$188.77
|
| Rate for Payer: Multiplan PHCS |
$420.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$278.06
|
| Rate for Payer: UHCCP Medicaid |
$140.03
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$190.66
|
| Rate for Payer: Wellcare Medicare Advantage |
$213.89
|
|
|
EXC MALIGN LESION HEAD AREA(T
|
Facility
|
OP
|
$3,732.00
|
|
|
Service Code
|
HCPCS 11643
|
| Hospital Charge Code |
761T0090
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,283.43 |
| Max. Negotiated Rate |
$3,582.72 |
| Rate for Payer: Aetna Commercial |
$2,873.64
|
| Rate for Payer: Anthem Medicaid |
$1,283.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,910.96
|
| 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 |
$1,866.00
|
| Rate for Payer: Cash Price |
$1,866.00
|
| Rate for Payer: Cigna Commercial |
$3,097.56
|
| Rate for Payer: First Health Commercial |
$3,545.40
|
| Rate for Payer: Humana Commercial |
$3,172.20
|
| Rate for Payer: Humana KY Medicaid |
$1,283.43
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,296.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,060.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,754.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,309.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,284.16
|
| Rate for Payer: Ohio Health Group HMO |
$2,799.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,985.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,246.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,575.08
|
| Rate for Payer: PHCS Commercial |
$3,582.72
|
| Rate for Payer: United Healthcare All Payer |
$3,284.16
|
|
|
EXC MALIGN LESION HEAD AREA(T
|
Facility
|
IP
|
$3,732.00
|
|
|
Service Code
|
HCPCS 11643
|
| Hospital Charge Code |
761T0090
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,119.60 |
| Max. Negotiated Rate |
$3,582.72 |
| Rate for Payer: Aetna Commercial |
$2,873.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,910.96
|
| Rate for Payer: Cash Price |
$1,866.00
|
| Rate for Payer: Cigna Commercial |
$3,097.56
|
| Rate for Payer: First Health Commercial |
$3,545.40
|
| Rate for Payer: Humana Commercial |
$3,172.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,060.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,754.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,119.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,284.16
|
| Rate for Payer: Ohio Health Group HMO |
$2,799.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,985.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,246.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,575.08
|
| Rate for Payer: PHCS Commercial |
$3,582.72
|
| Rate for Payer: United Healthcare All Payer |
$3,284.16
|
|
|
EXC MAL LESION - FACE - EAR
|
Facility
|
IP
|
$4,792.00
|
|
|
Service Code
|
HCPCS 11644
|
| Hospital Charge Code |
76100091
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,437.60 |
| Max. Negotiated Rate |
$4,600.32 |
| Rate for Payer: Aetna Commercial |
$3,689.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,737.76
|
| Rate for Payer: Cash Price |
$2,396.00
|
| Rate for Payer: Cigna Commercial |
$3,977.36
|
| Rate for Payer: First Health Commercial |
$4,552.40
|
| Rate for Payer: Humana Commercial |
$4,073.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,929.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,536.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,437.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,216.96
|
| Rate for Payer: Ohio Health Group HMO |
$3,594.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,833.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,169.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,306.48
|
| Rate for Payer: PHCS Commercial |
$4,600.32
|
| Rate for Payer: United Healthcare All Payer |
$4,216.96
|
|
|
EXC MAL LESION - FACE - EAR
|
Professional
|
Both
|
$4,792.00
|
|
|
Service Code
|
HCPCS 11644
|
| Hospital Charge Code |
76100091
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$165.23 |
| Max. Negotiated Rate |
$2,875.20 |
| Rate for Payer: Aetna Commercial |
$409.41
|
| Rate for Payer: Ambetter Exchange |
$264.57
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$165.23
|
| Rate for Payer: Anthem Medicaid |
$234.21
|
| Rate for Payer: Buckeye Individual/Medicaid |
$264.57
|
| Rate for Payer: Buckeye Medicare Advantage |
$264.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$317.48
|
| Rate for Payer: Cash Price |
$2,396.00
|
| Rate for Payer: Cash Price |
$2,396.00
|
| Rate for Payer: Cigna Commercial |
$512.44
|
| Rate for Payer: Healthspan PPO |
$432.22
|
| Rate for Payer: Humana Medicaid |
$234.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$358.76
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$264.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$264.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$238.89
|
| Rate for Payer: Molina Healthcare Passport |
$234.21
|
| Rate for Payer: Multiplan PHCS |
$2,875.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$343.94
|
| Rate for Payer: UHCCP Medicaid |
$173.49
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$236.55
|
| Rate for Payer: Wellcare Medicare Advantage |
$264.57
|
|
|
EXC MAL LESION - FACE - EAR
|
Facility
|
OP
|
$4,792.00
|
|
|
Service Code
|
HCPCS 11644
|
| Hospital Charge Code |
76100091
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,497.07 |
| Max. Negotiated Rate |
$4,600.32 |
| Rate for Payer: Aetna Commercial |
$3,689.84
|
| Rate for Payer: Anthem Medicaid |
$1,647.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,737.76
|
| 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 |
$2,396.00
|
| Rate for Payer: Cash Price |
$2,396.00
|
| Rate for Payer: Cigna Commercial |
$3,977.36
|
| Rate for Payer: First Health Commercial |
$4,552.40
|
| Rate for Payer: Humana Commercial |
$4,073.20
|
| Rate for Payer: Humana KY Medicaid |
$1,647.97
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,664.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,929.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,536.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,681.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,216.96
|
| Rate for Payer: Ohio Health Group HMO |
$3,594.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,833.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,169.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,306.48
|
| Rate for Payer: PHCS Commercial |
$4,600.32
|
| Rate for Payer: United Healthcare All Payer |
$4,216.96
|
|
|
EXC MAL LESION - FACE - EAR(P
|
Professional
|
Both
|
$850.00
|
|
|
Service Code
|
HCPCS 11644
|
| Hospital Charge Code |
761P0091
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$165.23 |
| Max. Negotiated Rate |
$512.44 |
| Rate for Payer: Aetna Commercial |
$409.41
|
| Rate for Payer: Ambetter Exchange |
$264.57
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$165.23
|
| Rate for Payer: Anthem Medicaid |
$234.21
|
| Rate for Payer: Buckeye Individual/Medicaid |
$264.57
|
| Rate for Payer: Buckeye Medicare Advantage |
$264.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$317.48
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$512.44
|
| Rate for Payer: Healthspan PPO |
$432.22
|
| Rate for Payer: Humana Medicaid |
$234.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$358.76
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$264.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$264.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$238.89
|
| Rate for Payer: Molina Healthcare Passport |
$234.21
|
| Rate for Payer: Multiplan PHCS |
$510.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$343.94
|
| Rate for Payer: UHCCP Medicaid |
$173.49
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$236.55
|
| Rate for Payer: Wellcare Medicare Advantage |
$264.57
|
|
|
EXC MAL LESION - FACE - EAR(T
|
Facility
|
IP
|
$3,942.00
|
|
|
Service Code
|
HCPCS 11644
|
| Hospital Charge Code |
761T0091
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,182.60 |
| Max. Negotiated Rate |
$3,784.32 |
| Rate for Payer: Aetna Commercial |
$3,035.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,074.76
|
| Rate for Payer: Cash Price |
$1,971.00
|
| Rate for Payer: Cigna Commercial |
$3,271.86
|
| Rate for Payer: First Health Commercial |
$3,744.90
|
| Rate for Payer: Humana Commercial |
$3,350.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,232.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,909.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,182.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,468.96
|
| Rate for Payer: Ohio Health Group HMO |
$2,956.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,153.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,429.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,719.98
|
| Rate for Payer: PHCS Commercial |
$3,784.32
|
| Rate for Payer: United Healthcare All Payer |
$3,468.96
|
|
|
EXC MAL LESION - FACE - EAR(T
|
Facility
|
OP
|
$3,942.00
|
|
|
Service Code
|
HCPCS 11644
|
| Hospital Charge Code |
761T0091
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,355.65 |
| Max. Negotiated Rate |
$3,784.32 |
| Rate for Payer: Aetna Commercial |
$3,035.34
|
| Rate for Payer: Anthem Medicaid |
$1,355.65
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,074.76
|
| 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 |
$1,971.00
|
| Rate for Payer: Cash Price |
$1,971.00
|
| Rate for Payer: Cigna Commercial |
$3,271.86
|
| Rate for Payer: First Health Commercial |
$3,744.90
|
| Rate for Payer: Humana Commercial |
$3,350.70
|
| Rate for Payer: Humana KY Medicaid |
$1,355.65
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,369.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,232.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,909.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,382.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,468.96
|
| Rate for Payer: Ohio Health Group HMO |
$2,956.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,153.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,429.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,719.98
|
| Rate for Payer: PHCS Commercial |
$3,784.32
|
| Rate for Payer: United Healthcare All Payer |
$3,468.96
|
|
|
EXC MUCOSA & SUBMUCOSA MOUTH
|
Facility
|
IP
|
$6,310.00
|
|
|
Service Code
|
HCPCS 40810
|
| Hospital Charge Code |
76101635
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,893.00 |
| Max. Negotiated Rate |
$6,057.60 |
| Rate for Payer: Aetna Commercial |
$4,858.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,921.80
|
| Rate for Payer: Cash Price |
$3,155.00
|
| Rate for Payer: Cigna Commercial |
$5,237.30
|
| Rate for Payer: First Health Commercial |
$5,994.50
|
| Rate for Payer: Humana Commercial |
$5,363.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,174.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,656.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,893.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,552.80
|
| Rate for Payer: Ohio Health Group HMO |
$4,732.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,048.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,489.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,353.90
|
| Rate for Payer: PHCS Commercial |
$6,057.60
|
| Rate for Payer: United Healthcare All Payer |
$5,552.80
|
|
|
EXC MUCOSA & SUBMUCOSA MOUTH
|
Facility
|
OP
|
$6,310.00
|
|
|
Service Code
|
HCPCS 40810
|
| Hospital Charge Code |
76101635
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,170.01 |
| Max. Negotiated Rate |
$6,057.60 |
| Rate for Payer: Aetna Commercial |
$4,858.70
|
| Rate for Payer: Anthem Medicaid |
$2,170.01
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,921.80
|
| 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 |
$3,155.00
|
| Rate for Payer: Cash Price |
$3,155.00
|
| Rate for Payer: Cigna Commercial |
$5,237.30
|
| Rate for Payer: First Health Commercial |
$5,994.50
|
| Rate for Payer: Humana Commercial |
$5,363.50
|
| Rate for Payer: Humana KY Medicaid |
$2,170.01
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| Rate for Payer: Kentucky WC Medicaid |
$2,192.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,174.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,656.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,595.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,213.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,552.80
|
| Rate for Payer: Ohio Health Group HMO |
$4,732.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,048.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,489.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,353.90
|
| Rate for Payer: PHCS Commercial |
$6,057.60
|
| Rate for Payer: United Healthcare All Payer |
$5,552.80
|
|
|
EXC MUCOSA & SUBMUCOSA MOUTH
|
Professional
|
Both
|
$6,310.00
|
|
|
Service Code
|
HCPCS 40810
|
| Hospital Charge Code |
76101635
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$71.30 |
| Max. Negotiated Rate |
$3,786.00 |
| Rate for Payer: Aetna Commercial |
$177.56
|
| Rate for Payer: Ambetter Exchange |
$113.87
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$76.45
|
| Rate for Payer: Anthem Medicaid |
$71.30
|
| Rate for Payer: Buckeye Individual/Medicaid |
$113.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$113.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$136.64
|
| Rate for Payer: Cash Price |
$3,155.00
|
| Rate for Payer: Cash Price |
$3,155.00
|
| Rate for Payer: Cigna Commercial |
$252.83
|
| Rate for Payer: Healthspan PPO |
$228.73
|
| Rate for Payer: Humana Medicaid |
$71.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$161.08
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$113.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$113.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$72.73
|
| Rate for Payer: Molina Healthcare Passport |
$71.30
|
| Rate for Payer: Multiplan PHCS |
$3,786.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$148.03
|
| Rate for Payer: UHCCP Medicaid |
$80.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.01
|
| Rate for Payer: Wellcare Medicare Advantage |
$113.87
|
|
|
EXC MUCOSA & SUBMUCOSA MOUTH(P
|
Professional
|
Both
|
$490.00
|
|
|
Service Code
|
HCPCS 40810
|
| Hospital Charge Code |
761P1635
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$71.30 |
| Max. Negotiated Rate |
$294.00 |
| Rate for Payer: Aetna Commercial |
$177.56
|
| Rate for Payer: Ambetter Exchange |
$113.87
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$76.45
|
| Rate for Payer: Anthem Medicaid |
$71.30
|
| Rate for Payer: Buckeye Individual/Medicaid |
$113.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$113.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$136.64
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: Cigna Commercial |
$252.83
|
| Rate for Payer: Healthspan PPO |
$228.73
|
| Rate for Payer: Humana Medicaid |
$71.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$161.08
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$113.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$113.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$72.73
|
| Rate for Payer: Molina Healthcare Passport |
$71.30
|
| Rate for Payer: Multiplan PHCS |
$294.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$148.03
|
| Rate for Payer: UHCCP Medicaid |
$80.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.01
|
| Rate for Payer: Wellcare Medicare Advantage |
$113.87
|
|
|
EXC MUCOSA & SUBMUCOSA MOUTH(T
|
Facility
|
IP
|
$5,820.00
|
|
|
Service Code
|
HCPCS 40810
|
| Hospital Charge Code |
761T1635
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,746.00 |
| Max. Negotiated Rate |
$5,587.20 |
| Rate for Payer: Aetna Commercial |
$4,481.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,539.60
|
| Rate for Payer: Cash Price |
$2,910.00
|
| Rate for Payer: Cigna Commercial |
$4,830.60
|
| Rate for Payer: First Health Commercial |
$5,529.00
|
| Rate for Payer: Humana Commercial |
$4,947.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,772.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,295.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,746.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,121.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,365.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,063.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,015.80
|
| Rate for Payer: PHCS Commercial |
$5,587.20
|
| Rate for Payer: United Healthcare All Payer |
$5,121.60
|
|
|
EXC MUCOSA & SUBMUCOSA MOUTH(T
|
Facility
|
OP
|
$5,820.00
|
|
|
Service Code
|
HCPCS 40810
|
| Hospital Charge Code |
761T1635
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,001.50 |
| Max. Negotiated Rate |
$5,587.20 |
| Rate for Payer: Aetna Commercial |
$4,481.40
|
| Rate for Payer: Anthem Medicaid |
$2,001.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,539.60
|
| 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 |
$2,910.00
|
| Rate for Payer: Cash Price |
$2,910.00
|
| Rate for Payer: Cigna Commercial |
$4,830.60
|
| Rate for Payer: First Health Commercial |
$5,529.00
|
| Rate for Payer: Humana Commercial |
$4,947.00
|
| Rate for Payer: Humana KY Medicaid |
$2,001.50
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| Rate for Payer: Kentucky WC Medicaid |
$2,021.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,772.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,295.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,595.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,041.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,121.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,365.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,063.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,015.80
|
| Rate for Payer: PHCS Commercial |
$5,587.20
|
| Rate for Payer: United Healthcare All Payer |
$5,121.60
|
|
|
EXC NASAL POLYP
|
Facility
|
OP
|
$750.00
|
|
|
Service Code
|
HCPCS 30115
|
| Hospital Charge Code |
76101121
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$257.93 |
| Max. Negotiated Rate |
$4,195.14 |
| Rate for Payer: Aetna Commercial |
$577.50
|
| Rate for Payer: Anthem Medicaid |
$257.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$585.00
|
| 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 |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$622.50
|
| Rate for Payer: First Health Commercial |
$712.50
|
| Rate for Payer: Humana Commercial |
$637.50
|
| Rate for Payer: Humana KY Medicaid |
$257.93
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| Rate for Payer: Kentucky WC Medicaid |
$260.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$615.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$553.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,595.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$263.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$660.00
|
| Rate for Payer: Ohio Health Group HMO |
$562.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$652.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$517.50
|
| Rate for Payer: PHCS Commercial |
$720.00
|
| Rate for Payer: United Healthcare All Payer |
$660.00
|
|
|
EXC NASAL POLYP
|
Facility
|
IP
|
$750.00
|
|
|
Service Code
|
HCPCS 30115
|
| Hospital Charge Code |
76101121
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Aetna Commercial |
$577.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$585.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$622.50
|
| Rate for Payer: First Health Commercial |
$712.50
|
| Rate for Payer: Humana Commercial |
$637.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$615.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$553.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$225.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$660.00
|
| Rate for Payer: Ohio Health Group HMO |
$562.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$652.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$517.50
|
| Rate for Payer: PHCS Commercial |
$720.00
|
| Rate for Payer: United Healthcare All Payer |
$660.00
|
|
