|
FOOT/TOES SURGERY PROCEDURE
|
Professional
|
Both
|
$4,146.03
|
|
|
Service Code
|
HCPCS 28899
|
| Hospital Charge Code |
76101045
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2,902.22 |
| Rate for Payer: Cash Price |
$2,073.01
|
| Rate for Payer: Cash Price |
$2,073.01
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$2,487.62
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,902.22
|
| Rate for Payer: UHCCP Medicaid |
$1,451.11
|
|
|
FOOT/TOES SURGERY PROCEDURE(T
|
Facility
|
IP
|
$4,146.03
|
|
|
Service Code
|
HCPCS 28899
|
| Hospital Charge Code |
761T1045
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,243.81 |
| Max. Negotiated Rate |
$3,980.19 |
| Rate for Payer: Aetna Commercial |
$3,192.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,233.90
|
| Rate for Payer: Cash Price |
$2,073.01
|
| Rate for Payer: Cigna Commercial |
$3,441.20
|
| Rate for Payer: First Health Commercial |
$3,938.73
|
| Rate for Payer: Humana Commercial |
$3,524.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,399.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,059.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,243.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,648.51
|
| Rate for Payer: Ohio Health Group HMO |
$3,109.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,316.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,607.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,860.76
|
| Rate for Payer: PHCS Commercial |
$3,980.19
|
| Rate for Payer: United Healthcare All Payer |
$3,648.51
|
|
|
FOOT/TOES SURGERY PROCEDURE(T
|
Facility
|
OP
|
$4,146.03
|
|
|
Service Code
|
HCPCS 28899
|
| Hospital Charge Code |
761T1045
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$221.64 |
| Max. Negotiated Rate |
$3,980.19 |
| Rate for Payer: Aetna Commercial |
$3,192.44
|
| Rate for Payer: Anthem Medicaid |
$1,425.82
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$221.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,233.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$310.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$299.21
|
| Rate for Payer: Cash Price |
$2,073.01
|
| Rate for Payer: Cash Price |
$2,073.01
|
| Rate for Payer: Cigna Commercial |
$3,441.20
|
| Rate for Payer: First Health Commercial |
$3,938.73
|
| Rate for Payer: Humana Commercial |
$3,524.13
|
| Rate for Payer: Humana KY Medicaid |
$1,425.82
|
| Rate for Payer: Humana Medicare Advantage |
$221.64
|
| Rate for Payer: Kentucky WC Medicaid |
$1,440.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,399.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,059.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,454.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,648.51
|
| Rate for Payer: Ohio Health Group HMO |
$3,109.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,316.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,607.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,860.76
|
| Rate for Payer: PHCS Commercial |
$3,980.19
|
| Rate for Payer: United Healthcare All Payer |
$3,648.51
|
|
|
FOREFOOT IB IMPLANT SYSTEM PE
|
Facility
|
IP
|
$8,091.75
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,427.53 |
| Max. Negotiated Rate |
$7,768.08 |
| Rate for Payer: Aetna Commercial |
$6,230.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,311.56
|
| Rate for Payer: Cash Price |
$4,045.88
|
| Rate for Payer: Cigna Commercial |
$6,716.15
|
| Rate for Payer: First Health Commercial |
$7,687.16
|
| Rate for Payer: Humana Commercial |
$6,877.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,635.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,971.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,427.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,120.74
|
| Rate for Payer: Ohio Health Group HMO |
$6,068.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,473.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,039.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,583.31
|
| Rate for Payer: PHCS Commercial |
$7,768.08
|
| Rate for Payer: United Healthcare All Payer |
$7,120.74
|
|
|
FOREFOOT IB IMPLANT SYSTEM PE
|
Facility
|
OP
|
$8,091.75
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,427.53 |
| Max. Negotiated Rate |
$7,768.08 |
| Rate for Payer: Aetna Commercial |
$6,230.65
|
| Rate for Payer: Anthem Medicaid |
$2,782.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,311.56
|
| Rate for Payer: Cash Price |
$4,045.88
|
| Rate for Payer: Cigna Commercial |
$6,716.15
|
| Rate for Payer: First Health Commercial |
$7,687.16
|
| Rate for Payer: Humana Commercial |
$6,877.99
|
| Rate for Payer: Humana KY Medicaid |
$2,782.75
|
| Rate for Payer: Kentucky WC Medicaid |
$2,811.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,635.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,971.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,427.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,838.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,120.74
|
| Rate for Payer: Ohio Health Group HMO |
$6,068.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,473.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,039.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,583.31
|
| Rate for Payer: PHCS Commercial |
$7,768.08
|
| Rate for Payer: United Healthcare All Payer |
$7,120.74
|
|
|
FOREIGN BODYEYE SCRNG FOR MRI
|
Facility
|
OP
|
$554.00
|
|
|
Service Code
|
HCPCS 70030
|
| Hospital Charge Code |
32000010
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$531.84 |
| Rate for Payer: Aetna Commercial |
$426.58
|
| Rate for Payer: Anthem Medicaid |
$190.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$432.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$277.00
|
| Rate for Payer: Cash Price |
$277.00
|
| Rate for Payer: Cigna Commercial |
$459.82
|
| Rate for Payer: First Health Commercial |
$526.30
|
| Rate for Payer: Humana Commercial |
$470.90
|
| Rate for Payer: Humana KY Medicaid |
$190.52
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$192.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$454.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$408.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$194.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$487.52
|
| Rate for Payer: Ohio Health Group HMO |
$415.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$443.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$481.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$382.26
|
| Rate for Payer: PHCS Commercial |
$531.84
|
| Rate for Payer: United Healthcare All Payer |
$487.52
|
|
|
FOREIGN BODYEYE SCRNG FOR MRI
|
Professional
|
Both
|
$554.00
|
|
|
Service Code
|
HCPCS 70030
|
| Hospital Charge Code |
32000010
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$10.82 |
| Max. Negotiated Rate |
$332.40 |
| Rate for Payer: Aetna Commercial |
$42.45
|
| Rate for Payer: Ambetter Exchange |
$29.77
|
| Rate for Payer: Anthem Medicaid |
$18.83
|
| Rate for Payer: Buckeye Individual/Medicaid |
$29.77
|
| Rate for Payer: Buckeye Medicare Advantage |
$29.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$35.72
|
| Rate for Payer: Cash Price |
$277.00
|
| Rate for Payer: Cash Price |
$277.00
|
| Rate for Payer: Cigna Commercial |
$38.68
|
| Rate for Payer: Healthspan PPO |
$39.78
|
| Rate for Payer: Humana Medicaid |
$18.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$10.82
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$29.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.77
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$19.21
|
| Rate for Payer: Molina Healthcare Passport |
$18.83
|
| Rate for Payer: Multiplan PHCS |
$332.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$38.70
|
| Rate for Payer: UHCCP Medicaid |
$193.90
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$19.02
|
| Rate for Payer: Wellcare Medicare Advantage |
$29.77
|
|
|
FOREIGN BODYEYE SCRNG FOR MRI
|
Facility
|
IP
|
$554.00
|
|
|
Service Code
|
HCPCS 70030
|
| Hospital Charge Code |
32000010
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$166.20 |
| Max. Negotiated Rate |
$531.84 |
| Rate for Payer: Aetna Commercial |
$426.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$432.12
|
| Rate for Payer: Cash Price |
$277.00
|
| Rate for Payer: Cigna Commercial |
$459.82
|
| Rate for Payer: First Health Commercial |
$526.30
|
| Rate for Payer: Humana Commercial |
$470.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$454.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$408.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$166.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$487.52
|
| Rate for Payer: Ohio Health Group HMO |
$415.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$443.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$481.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$382.26
|
| Rate for Payer: PHCS Commercial |
$531.84
|
| Rate for Payer: United Healthcare All Payer |
$487.52
|
|
|
FOREIGN BODYEYE SCRNG FOR MR(P
|
Professional
|
Both
|
$50.00
|
|
|
Service Code
|
HCPCS 70030
|
| Hospital Charge Code |
320P0010
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$10.82 |
| Max. Negotiated Rate |
$42.45 |
| Rate for Payer: Aetna Commercial |
$42.45
|
| Rate for Payer: Ambetter Exchange |
$29.77
|
| Rate for Payer: Anthem Medicaid |
$18.83
|
| Rate for Payer: Buckeye Individual/Medicaid |
$29.77
|
| Rate for Payer: Buckeye Medicare Advantage |
$29.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$35.72
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$38.68
|
| Rate for Payer: Healthspan PPO |
$39.78
|
| Rate for Payer: Humana Medicaid |
$18.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$10.82
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$29.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.77
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$19.21
|
| Rate for Payer: Molina Healthcare Passport |
$18.83
|
| Rate for Payer: Multiplan PHCS |
$30.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$38.70
|
| Rate for Payer: UHCCP Medicaid |
$17.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$19.02
|
| Rate for Payer: Wellcare Medicare Advantage |
$29.77
|
|
|
FOREIGN BODYEYE SCRNG FOR MR(T
|
Facility
|
OP
|
$504.00
|
|
|
Service Code
|
HCPCS 70030
|
| Hospital Charge Code |
320T0010
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$483.84 |
| Rate for Payer: Aetna Commercial |
$388.08
|
| Rate for Payer: Anthem Medicaid |
$173.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$393.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Cigna Commercial |
$418.32
|
| Rate for Payer: First Health Commercial |
$478.80
|
| Rate for Payer: Humana Commercial |
$428.40
|
| Rate for Payer: Humana KY Medicaid |
$173.33
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$175.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$413.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$371.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$176.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$443.52
|
| Rate for Payer: Ohio Health Group HMO |
$378.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$403.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$438.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$347.76
|
| Rate for Payer: PHCS Commercial |
$483.84
|
| Rate for Payer: United Healthcare All Payer |
$443.52
|
|
|
FOREIGN BODYEYE SCRNG FOR MR(T
|
Facility
|
IP
|
$504.00
|
|
|
Service Code
|
HCPCS 70030
|
| Hospital Charge Code |
320T0010
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$151.20 |
| Max. Negotiated Rate |
$483.84 |
| Rate for Payer: Aetna Commercial |
$388.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$393.12
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Cigna Commercial |
$418.32
|
| Rate for Payer: First Health Commercial |
$478.80
|
| Rate for Payer: Humana Commercial |
$428.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$413.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$371.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$151.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$443.52
|
| Rate for Payer: Ohio Health Group HMO |
$378.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$403.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$438.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$347.76
|
| Rate for Payer: PHCS Commercial |
$483.84
|
| Rate for Payer: United Healthcare All Payer |
$443.52
|
|
|
FORESKIN MANIPULATION
|
Facility
|
IP
|
$1,271.00
|
|
|
Service Code
|
HCPCS 54450
|
| Hospital Charge Code |
76102136
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$381.30 |
| Max. Negotiated Rate |
$1,220.16 |
| Rate for Payer: Aetna Commercial |
$978.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$991.38
|
| Rate for Payer: Cash Price |
$635.50
|
| Rate for Payer: Cigna Commercial |
$1,054.93
|
| Rate for Payer: First Health Commercial |
$1,207.45
|
| Rate for Payer: Humana Commercial |
$1,080.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,042.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$938.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$381.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,118.48
|
| Rate for Payer: Ohio Health Group HMO |
$953.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,016.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,105.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$876.99
|
| Rate for Payer: PHCS Commercial |
$1,220.16
|
| Rate for Payer: United Healthcare All Payer |
$1,118.48
|
|
|
FORESKIN MANIPULATION
|
Facility
|
IP
|
$921.00
|
|
|
Service Code
|
HCPCS 54450
|
| Hospital Charge Code |
45000285
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$276.30 |
| Max. Negotiated Rate |
$884.16 |
| Rate for Payer: Aetna Commercial |
$709.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$718.38
|
| Rate for Payer: Cash Price |
$460.50
|
| Rate for Payer: Cigna Commercial |
$764.43
|
| Rate for Payer: First Health Commercial |
$874.95
|
| Rate for Payer: Humana Commercial |
$782.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$755.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$679.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$276.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$810.48
|
| Rate for Payer: Ohio Health Group HMO |
$690.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$736.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$801.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.49
|
| Rate for Payer: PHCS Commercial |
$884.16
|
| Rate for Payer: United Healthcare All Payer |
$810.48
|
|
|
FORESKIN MANIPULATION
|
Facility
|
OP
|
$921.00
|
|
|
Service Code
|
HCPCS 54450
|
| Hospital Charge Code |
45000285
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$224.72 |
| Max. Negotiated Rate |
$884.16 |
| Rate for Payer: Aetna Commercial |
$709.17
|
| Rate for Payer: Anthem Medicaid |
$316.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$224.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$718.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$314.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$303.37
|
| Rate for Payer: Cash Price |
$460.50
|
| Rate for Payer: Cash Price |
$460.50
|
| Rate for Payer: Cigna Commercial |
$764.43
|
| Rate for Payer: First Health Commercial |
$874.95
|
| Rate for Payer: Humana Commercial |
$782.85
|
| Rate for Payer: Humana KY Medicaid |
$316.73
|
| Rate for Payer: Humana Medicare Advantage |
$224.72
|
| Rate for Payer: Kentucky WC Medicaid |
$319.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$755.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$679.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$269.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$323.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$810.48
|
| Rate for Payer: Ohio Health Group HMO |
$690.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$736.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$801.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.49
|
| Rate for Payer: PHCS Commercial |
$884.16
|
| Rate for Payer: United Healthcare All Payer |
$810.48
|
|
|
FORESKIN MANIPULATION
|
Professional
|
Both
|
$1,271.00
|
|
|
Service Code
|
HCPCS 54450
|
| Hospital Charge Code |
76102136
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$38.73 |
| Max. Negotiated Rate |
$762.60 |
| Rate for Payer: Aetna Commercial |
$97.12
|
| Rate for Payer: Ambetter Exchange |
$54.21
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$38.73
|
| Rate for Payer: Anthem Medicaid |
$52.80
|
| Rate for Payer: Buckeye Individual/Medicaid |
$54.21
|
| Rate for Payer: Buckeye Medicare Advantage |
$54.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$65.05
|
| Rate for Payer: Cash Price |
$635.50
|
| Rate for Payer: Cash Price |
$635.50
|
| Rate for Payer: Cigna Commercial |
$115.45
|
| Rate for Payer: Healthspan PPO |
$114.76
|
| Rate for Payer: Humana Medicaid |
$52.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$78.93
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$54.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.21
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$53.86
|
| Rate for Payer: Molina Healthcare Passport |
$52.80
|
| Rate for Payer: Multiplan PHCS |
$762.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$70.47
|
| Rate for Payer: UHCCP Medicaid |
$40.67
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$53.33
|
| Rate for Payer: Wellcare Medicare Advantage |
$54.21
|
|
|
FORESKIN MANIPULATION
|
Facility
|
OP
|
$1,271.00
|
|
|
Service Code
|
HCPCS 54450
|
| Hospital Charge Code |
76102136
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$224.72 |
| Max. Negotiated Rate |
$1,220.16 |
| Rate for Payer: Aetna Commercial |
$978.67
|
| Rate for Payer: Anthem Medicaid |
$437.10
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$224.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$991.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$314.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$303.37
|
| Rate for Payer: Cash Price |
$635.50
|
| Rate for Payer: Cash Price |
$635.50
|
| Rate for Payer: Cigna Commercial |
$1,054.93
|
| Rate for Payer: First Health Commercial |
$1,207.45
|
| Rate for Payer: Humana Commercial |
$1,080.35
|
| Rate for Payer: Humana KY Medicaid |
$437.10
|
| Rate for Payer: Humana Medicare Advantage |
$224.72
|
| Rate for Payer: Kentucky WC Medicaid |
$441.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,042.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$938.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$269.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$445.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,118.48
|
| Rate for Payer: Ohio Health Group HMO |
$953.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,016.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,105.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$876.99
|
| Rate for Payer: PHCS Commercial |
$1,220.16
|
| Rate for Payer: United Healthcare All Payer |
$1,118.48
|
|
|
FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS AND STRETCHING
|
Facility
|
OP
|
$314.61
|
|
|
Service Code
|
CPT 54450
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$224.72 |
| Max. Negotiated Rate |
$314.61 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$224.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$314.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$303.37
|
| Rate for Payer: Humana Medicare Advantage |
$224.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$269.66
|
|
|
FORESKIN MANIPULATION(P
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
HCPCS 54450
|
| Hospital Charge Code |
761P2136
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$38.73 |
| Max. Negotiated Rate |
$210.00 |
| Rate for Payer: Aetna Commercial |
$97.12
|
| Rate for Payer: Ambetter Exchange |
$54.21
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$38.73
|
| Rate for Payer: Anthem Medicaid |
$52.80
|
| Rate for Payer: Buckeye Individual/Medicaid |
$54.21
|
| Rate for Payer: Buckeye Medicare Advantage |
$54.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$65.05
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna Commercial |
$115.45
|
| Rate for Payer: Healthspan PPO |
$114.76
|
| Rate for Payer: Humana Medicaid |
$52.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$78.93
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$54.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.21
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$53.86
|
| Rate for Payer: Molina Healthcare Passport |
$52.80
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$70.47
|
| Rate for Payer: UHCCP Medicaid |
$40.67
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$53.33
|
| Rate for Payer: Wellcare Medicare Advantage |
$54.21
|
|
|
FORESKIN MANIPULATION(T
|
Facility
|
OP
|
$921.00
|
|
|
Service Code
|
HCPCS 54450
|
| Hospital Charge Code |
761T2136
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$224.72 |
| Max. Negotiated Rate |
$884.16 |
| Rate for Payer: Aetna Commercial |
$709.17
|
| Rate for Payer: Anthem Medicaid |
$316.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$224.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$718.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$314.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$303.37
|
| Rate for Payer: Cash Price |
$460.50
|
| Rate for Payer: Cash Price |
$460.50
|
| Rate for Payer: Cigna Commercial |
$764.43
|
| Rate for Payer: First Health Commercial |
$874.95
|
| Rate for Payer: Humana Commercial |
$782.85
|
| Rate for Payer: Humana KY Medicaid |
$316.73
|
| Rate for Payer: Humana Medicare Advantage |
$224.72
|
| Rate for Payer: Kentucky WC Medicaid |
$319.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$755.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$679.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$269.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$323.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$810.48
|
| Rate for Payer: Ohio Health Group HMO |
$690.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$736.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$801.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.49
|
| Rate for Payer: PHCS Commercial |
$884.16
|
| Rate for Payer: United Healthcare All Payer |
$810.48
|
|
|
FORESKIN MANIPULATION(T
|
Facility
|
IP
|
$921.00
|
|
|
Service Code
|
HCPCS 54450
|
| Hospital Charge Code |
761T2136
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$276.30 |
| Max. Negotiated Rate |
$884.16 |
| Rate for Payer: Aetna Commercial |
$709.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$718.38
|
| Rate for Payer: Cash Price |
$460.50
|
| Rate for Payer: Cigna Commercial |
$764.43
|
| Rate for Payer: First Health Commercial |
$874.95
|
| Rate for Payer: Humana Commercial |
$782.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$755.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$679.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$276.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$810.48
|
| Rate for Payer: Ohio Health Group HMO |
$690.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$736.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$801.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.49
|
| Rate for Payer: PHCS Commercial |
$884.16
|
| Rate for Payer: United Healthcare All Payer |
$810.48
|
|
|
FORTAZ 500MG (1 GRAM)
|
Facility
|
IP
|
$80.50
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
25003810
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.15 |
| Max. Negotiated Rate |
$77.28 |
| Rate for Payer: Aetna Commercial |
$61.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.79
|
| Rate for Payer: Cash Price |
$40.25
|
| Rate for Payer: Cigna Commercial |
$66.81
|
| Rate for Payer: First Health Commercial |
$76.47
|
| Rate for Payer: Humana Commercial |
$68.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.84
|
| Rate for Payer: Ohio Health Group HMO |
$60.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.55
|
| Rate for Payer: PHCS Commercial |
$77.28
|
| Rate for Payer: United Healthcare All Payer |
$70.84
|
|
|
FORTAZ 500MG (1 GRAM)
|
Facility
|
OP
|
$80.50
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
25003810
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.15 |
| Max. Negotiated Rate |
$77.28 |
| Rate for Payer: Aetna Commercial |
$61.98
|
| Rate for Payer: Anthem Medicaid |
$27.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.79
|
| Rate for Payer: Cash Price |
$40.25
|
| Rate for Payer: Cigna Commercial |
$66.81
|
| Rate for Payer: First Health Commercial |
$76.47
|
| Rate for Payer: Humana Commercial |
$68.42
|
| Rate for Payer: Humana KY Medicaid |
$27.68
|
| Rate for Payer: Kentucky WC Medicaid |
$27.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.84
|
| Rate for Payer: Ohio Health Group HMO |
$60.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.55
|
| Rate for Payer: PHCS Commercial |
$77.28
|
| Rate for Payer: United Healthcare All Payer |
$70.84
|
|
|
FORTRESS DEST SHTH ST 4F 45CM
|
Facility
|
OP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem Medicaid |
$530.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Humana KY Medicaid |
$530.29
|
| Rate for Payer: Kentucky WC Medicaid |
$535.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$540.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
FORTRESS DEST SHTH ST 4F 45CM
|
Facility
|
IP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
FORTRESS DEST SHTH ST 6F 45CM
|
Facility
|
IP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
