|
APPENDIX ULTRASOUND LTD(P
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
402P0016
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$37.18 |
| Max. Negotiated Rate |
$157.49 |
| Rate for Payer: Aetna Commercial |
$157.49
|
| Rate for Payer: Anthem Medicaid |
$63.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$125.00
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$135.13
|
| Rate for Payer: Healthspan PPO |
$147.57
|
| Rate for Payer: Humana Medicaid |
$63.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$37.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.20
|
| Rate for Payer: Molina Healthcare Passport |
$63.92
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.50
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$64.56
|
|
|
APPENDIX ULTRASOUND LTD(T
|
Facility
|
OP
|
$979.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
402T0016
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$939.84 |
| Rate for Payer: Aetna Commercial |
$753.83
|
| Rate for Payer: Anthem Medicaid |
$336.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$763.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$489.50
|
| Rate for Payer: Cash Price |
$489.50
|
| Rate for Payer: Cigna Commercial |
$812.57
|
| Rate for Payer: First Health Commercial |
$930.05
|
| Rate for Payer: Humana Commercial |
$832.15
|
| Rate for Payer: Humana KY Medicaid |
$336.68
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$340.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$802.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$722.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$343.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$861.52
|
| Rate for Payer: Ohio Health Group HMO |
$734.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$195.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$303.49
|
| Rate for Payer: PHCS Commercial |
$939.84
|
| Rate for Payer: United Healthcare All Payer |
$861.52
|
|
|
APPENDIX ULTRASOUND LTD(T
|
Facility
|
IP
|
$979.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
402T0016
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$127.27 |
| Max. Negotiated Rate |
$939.84 |
| Rate for Payer: Aetna Commercial |
$753.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$763.62
|
| Rate for Payer: Cash Price |
$489.50
|
| Rate for Payer: Cigna Commercial |
$812.57
|
| Rate for Payer: First Health Commercial |
$930.05
|
| Rate for Payer: Humana Commercial |
$832.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$802.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$722.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$293.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$861.52
|
| Rate for Payer: Ohio Health Group HMO |
$734.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$195.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$303.49
|
| Rate for Payer: PHCS Commercial |
$939.84
|
| Rate for Payer: United Healthcare All Payer |
$861.52
|
|
|
APP FINGER SPLINT DYNAMIC
|
Facility
|
OP
|
$134.00
|
|
|
Service Code
|
HCPCS 29131
|
| Hospital Charge Code |
76101054
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$17.42 |
| Max. Negotiated Rate |
$128.64 |
| Rate for Payer: Aetna Commercial |
$103.18
|
| Rate for Payer: Anthem Medicaid |
$46.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$52.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$104.52
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$74.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$71.40
|
| Rate for Payer: Cash Price |
$67.00
|
| Rate for Payer: Cash Price |
$67.00
|
| Rate for Payer: Cigna Commercial |
$111.22
|
| Rate for Payer: First Health Commercial |
$127.30
|
| Rate for Payer: Humana Commercial |
$113.90
|
| Rate for Payer: Humana KY Medicaid |
$46.08
|
| Rate for Payer: Humana Medicare Advantage |
$52.89
|
| Rate for Payer: Kentucky WC Medicaid |
$46.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$109.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$98.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$63.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$47.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$117.92
|
| Rate for Payer: Ohio Health Group HMO |
$100.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.54
|
| Rate for Payer: PHCS Commercial |
$128.64
|
| Rate for Payer: United Healthcare All Payer |
$117.92
|
|
|
APP FINGER SPLINT DYNAMIC
|
Facility
|
IP
|
$134.00
|
|
|
Service Code
|
HCPCS 29131
|
| Hospital Charge Code |
76101054
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$17.42 |
| Max. Negotiated Rate |
$128.64 |
| Rate for Payer: Aetna Commercial |
$103.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$104.52
|
| Rate for Payer: Cash Price |
$67.00
|
| Rate for Payer: Cigna Commercial |
$111.22
|
| Rate for Payer: First Health Commercial |
$127.30
|
| Rate for Payer: Humana Commercial |
$113.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$109.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$98.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$117.92
|
| Rate for Payer: Ohio Health Group HMO |
$100.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.54
|
| Rate for Payer: PHCS Commercial |
$128.64
|
| Rate for Payer: United Healthcare All Payer |
$117.92
|
|
|
APP FINGER SPLINT DYNAMIC
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
HCPCS 29131
|
| Hospital Charge Code |
45000191
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$134.40 |
| Rate for Payer: Aetna Commercial |
$107.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$109.20
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Cigna Commercial |
$116.20
|
| Rate for Payer: First Health Commercial |
$133.00
|
| Rate for Payer: Humana Commercial |
$119.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$114.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$103.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$123.20
|
| Rate for Payer: Ohio Health Group HMO |
$105.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.40
|
| Rate for Payer: PHCS Commercial |
$134.40
|
| Rate for Payer: United Healthcare All Payer |
$123.20
|
|
|
APP FINGER SPLINT DYNAMIC
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
HCPCS 29131
|
| Hospital Charge Code |
45000191
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$134.40 |
| Rate for Payer: Aetna Commercial |
$107.80
|
| Rate for Payer: Anthem Medicaid |
$48.15
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$52.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$109.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$74.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$71.40
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Cigna Commercial |
$116.20
|
| Rate for Payer: First Health Commercial |
$133.00
|
| Rate for Payer: Humana Commercial |
$119.00
|
| Rate for Payer: Humana KY Medicaid |
$48.15
|
| Rate for Payer: Humana Medicare Advantage |
$52.89
|
| Rate for Payer: Kentucky WC Medicaid |
$48.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$114.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$103.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$63.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$49.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$123.20
|
| Rate for Payer: Ohio Health Group HMO |
$105.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.40
|
| Rate for Payer: PHCS Commercial |
$134.40
|
| Rate for Payer: United Healthcare All Payer |
$123.20
|
|
|
APP FINGER SPLINT STATIC
|
Facility
|
IP
|
$372.00
|
|
|
Service Code
|
HCPCS 29130
|
| Hospital Charge Code |
76101053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$48.36 |
| Max. Negotiated Rate |
$357.12 |
| Rate for Payer: Aetna Commercial |
$286.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$290.16
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cigna Commercial |
$308.76
|
| Rate for Payer: First Health Commercial |
$353.40
|
| Rate for Payer: Humana Commercial |
$316.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$305.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$274.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$111.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$327.36
|
| Rate for Payer: Ohio Health Group HMO |
$279.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$115.32
|
| Rate for Payer: PHCS Commercial |
$357.12
|
| Rate for Payer: United Healthcare All Payer |
$327.36
|
|
|
APP FINGER SPLINT STATIC
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
HCPCS 29130
|
| Hospital Charge Code |
45000190
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$134.40 |
| Rate for Payer: Aetna Commercial |
$107.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$109.20
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Cigna Commercial |
$116.20
|
| Rate for Payer: First Health Commercial |
$133.00
|
| Rate for Payer: Humana Commercial |
$119.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$114.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$103.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$123.20
|
| Rate for Payer: Ohio Health Group HMO |
$105.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.40
|
| Rate for Payer: PHCS Commercial |
$134.40
|
| Rate for Payer: United Healthcare All Payer |
$123.20
|
|
|
APP FINGER SPLINT STATIC
|
Facility
|
OP
|
$372.00
|
|
|
Service Code
|
HCPCS 29130
|
| Hospital Charge Code |
76101053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$48.36 |
| Max. Negotiated Rate |
$357.12 |
| Rate for Payer: Aetna Commercial |
$286.44
|
| Rate for Payer: Anthem Medicaid |
$127.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$290.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cigna Commercial |
$308.76
|
| Rate for Payer: First Health Commercial |
$353.40
|
| Rate for Payer: Humana Commercial |
$316.20
|
| Rate for Payer: Humana KY Medicaid |
$127.93
|
| Rate for Payer: Humana Medicare Advantage |
$110.46
|
| Rate for Payer: Kentucky WC Medicaid |
$129.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$305.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$274.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$130.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$327.36
|
| Rate for Payer: Ohio Health Group HMO |
$279.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$115.32
|
| Rate for Payer: PHCS Commercial |
$357.12
|
| Rate for Payer: United Healthcare All Payer |
$327.36
|
|
|
APP FINGER SPLINT STATIC
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
HCPCS 29130
|
| Hospital Charge Code |
45000190
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$154.64 |
| Rate for Payer: Aetna Commercial |
$107.80
|
| Rate for Payer: Anthem Medicaid |
$48.15
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$109.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Cigna Commercial |
$116.20
|
| Rate for Payer: First Health Commercial |
$133.00
|
| Rate for Payer: Humana Commercial |
$119.00
|
| Rate for Payer: Humana KY Medicaid |
$48.15
|
| Rate for Payer: Humana Medicare Advantage |
$110.46
|
| Rate for Payer: Kentucky WC Medicaid |
$48.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$114.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$103.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$49.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$123.20
|
| Rate for Payer: Ohio Health Group HMO |
$105.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.40
|
| Rate for Payer: PHCS Commercial |
$134.40
|
| Rate for Payer: United Healthcare All Payer |
$123.20
|
|
|
APP FINGER SPLINT STATIC
|
Professional
|
Both
|
$372.00
|
|
|
Service Code
|
HCPCS 29130
|
| Hospital Charge Code |
76101053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$17.44 |
| Max. Negotiated Rate |
$372.00 |
| Rate for Payer: Aetna Commercial |
$43.30
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$23.18
|
| Rate for Payer: Anthem Medicaid |
$17.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$372.00
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cigna Commercial |
$62.54
|
| Rate for Payer: Healthspan PPO |
$51.34
|
| Rate for Payer: Humana Medicaid |
$17.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$35.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$17.79
|
| Rate for Payer: Molina Healthcare Passport |
$17.44
|
| Rate for Payer: Multiplan PHCS |
$223.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$260.40
|
| Rate for Payer: UHCCP Medicaid |
$24.34
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$17.61
|
|
|
APP FINGER SPLINT STATIC(P
|
Professional
|
Both
|
$85.00
|
|
|
Service Code
|
HCPCS 29130
|
| Hospital Charge Code |
761P1053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$17.44 |
| Max. Negotiated Rate |
$85.00 |
| Rate for Payer: Aetna Commercial |
$43.30
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$23.18
|
| Rate for Payer: Anthem Medicaid |
$17.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$85.00
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Cigna Commercial |
$62.54
|
| Rate for Payer: Healthspan PPO |
$51.34
|
| Rate for Payer: Humana Medicaid |
$17.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$35.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$17.79
|
| Rate for Payer: Molina Healthcare Passport |
$17.44
|
| Rate for Payer: Multiplan PHCS |
$51.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$59.50
|
| Rate for Payer: UHCCP Medicaid |
$24.34
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$17.61
|
|
|
APP FINGER SPLINT STATIC(T
|
Facility
|
OP
|
$287.00
|
|
|
Service Code
|
HCPCS 29130
|
| Hospital Charge Code |
761T1053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$37.31 |
| Max. Negotiated Rate |
$275.52 |
| Rate for Payer: Aetna Commercial |
$220.99
|
| Rate for Payer: Anthem Medicaid |
$98.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$223.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cigna Commercial |
$238.21
|
| Rate for Payer: First Health Commercial |
$272.65
|
| Rate for Payer: Humana Commercial |
$243.95
|
| Rate for Payer: Humana KY Medicaid |
$98.70
|
| Rate for Payer: Humana Medicare Advantage |
$110.46
|
| Rate for Payer: Kentucky WC Medicaid |
$99.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$235.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$211.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$100.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$252.56
|
| Rate for Payer: Ohio Health Group HMO |
$215.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$88.97
|
| Rate for Payer: PHCS Commercial |
$275.52
|
| Rate for Payer: United Healthcare All Payer |
$252.56
|
|
|
APP FINGER SPLINT STATIC(T
|
Facility
|
IP
|
$287.00
|
|
|
Service Code
|
HCPCS 29130
|
| Hospital Charge Code |
761T1053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$37.31 |
| Max. Negotiated Rate |
$275.52 |
| Rate for Payer: Aetna Commercial |
$220.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$223.86
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cigna Commercial |
$238.21
|
| Rate for Payer: First Health Commercial |
$272.65
|
| Rate for Payer: Humana Commercial |
$243.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$235.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$211.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$86.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$252.56
|
| Rate for Payer: Ohio Health Group HMO |
$215.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$88.97
|
| Rate for Payer: PHCS Commercial |
$275.52
|
| Rate for Payer: United Healthcare All Payer |
$252.56
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
|
Facility
|
OP
|
$2,207.77
|
|
|
Service Code
|
CPT 15275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,576.98 |
| Max. Negotiated Rate |
$2,207.77 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
|
Facility
|
OP
|
$2,207.77
|
|
|
Service Code
|
CPT 15271
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,576.98 |
| Max. Negotiated Rate |
$2,207.77 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
|
|
APPLICATION OF STRAPP/CASTING
|
Facility
|
OP
|
$288.00
|
|
| Hospital Charge Code |
76102554
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$37.44 |
| Max. Negotiated Rate |
$276.48 |
| Rate for Payer: Aetna Commercial |
$221.76
|
| Rate for Payer: Anthem Medicaid |
$99.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$224.64
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cigna Commercial |
$239.04
|
| Rate for Payer: First Health Commercial |
$273.60
|
| Rate for Payer: Humana Commercial |
$244.80
|
| Rate for Payer: Humana KY Medicaid |
$99.04
|
| Rate for Payer: Kentucky WC Medicaid |
$100.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$236.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$212.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$86.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$101.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$253.44
|
| Rate for Payer: Ohio Health Group HMO |
$216.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$89.28
|
| Rate for Payer: PHCS Commercial |
$276.48
|
| Rate for Payer: United Healthcare All Payer |
$253.44
|
|
|
APPLICATION OF STRAPP/CASTING
|
Facility
|
IP
|
$288.00
|
|
| Hospital Charge Code |
76102554
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$37.44 |
| Max. Negotiated Rate |
$276.48 |
| Rate for Payer: Aetna Commercial |
$221.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$224.64
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cigna Commercial |
$239.04
|
| Rate for Payer: First Health Commercial |
$273.60
|
| Rate for Payer: Humana Commercial |
$244.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$236.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$212.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$86.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$253.44
|
| Rate for Payer: Ohio Health Group HMO |
$216.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$89.28
|
| Rate for Payer: PHCS Commercial |
$276.48
|
| Rate for Payer: United Healthcare All Payer |
$253.44
|
|
|
APPLICATION OF UNNABOOT
|
Facility
|
OP
|
$198.00
|
|
|
Service Code
|
HCPCS 29580
|
| Hospital Charge Code |
42000066
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$25.74 |
| Max. Negotiated Rate |
$190.76 |
| Rate for Payer: Aetna Commercial |
$152.46
|
| Rate for Payer: Anthem Medicaid |
$68.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$136.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$154.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$190.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$183.95
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$164.34
|
| Rate for Payer: First Health Commercial |
$188.10
|
| Rate for Payer: Humana Commercial |
$168.30
|
| Rate for Payer: Humana KY Medicaid |
$68.09
|
| Rate for Payer: Humana Medicare Advantage |
$136.26
|
| Rate for Payer: Kentucky WC Medicaid |
$68.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$162.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$146.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$69.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$174.24
|
| Rate for Payer: Ohio Health Group HMO |
$148.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$39.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$61.38
|
| Rate for Payer: PHCS Commercial |
$190.08
|
| Rate for Payer: United Healthcare All Payer |
$174.24
|
|
|
APPLICATION OF UNNABOOT
|
Professional
|
Both
|
$307.00
|
|
|
Service Code
|
HCPCS 29580
|
| Hospital Charge Code |
76101070
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$21.68 |
| Max. Negotiated Rate |
$307.00 |
| Rate for Payer: Aetna Commercial |
$54.92
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$21.68
|
| Rate for Payer: Anthem Medicaid |
$28.29
|
| Rate for Payer: Buckeye Medicare Advantage |
$307.00
|
| Rate for Payer: Cash Price |
$153.50
|
| Rate for Payer: Cash Price |
$153.50
|
| Rate for Payer: Cigna Commercial |
$78.96
|
| Rate for Payer: Healthspan PPO |
$66.73
|
| Rate for Payer: Humana Medicaid |
$28.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$44.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$28.86
|
| Rate for Payer: Molina Healthcare Passport |
$28.29
|
| Rate for Payer: Multiplan PHCS |
$184.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$214.90
|
| Rate for Payer: UHCCP Medicaid |
$22.76
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$28.57
|
|
|
APPLICATION OF UNNABOOT
|
Facility
|
IP
|
$198.00
|
|
|
Service Code
|
HCPCS 29580
|
| Hospital Charge Code |
42000066
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$25.74 |
| Max. Negotiated Rate |
$190.08 |
| Rate for Payer: Aetna Commercial |
$152.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$154.44
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$164.34
|
| Rate for Payer: First Health Commercial |
$188.10
|
| Rate for Payer: Humana Commercial |
$168.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$162.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$146.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$174.24
|
| Rate for Payer: Ohio Health Group HMO |
$148.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$39.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$61.38
|
| Rate for Payer: PHCS Commercial |
$190.08
|
| Rate for Payer: United Healthcare All Payer |
$174.24
|
|
|
APPLICATION OF UNNABOOT
|
Facility
|
OP
|
$307.00
|
|
|
Service Code
|
HCPCS 29580
|
| Hospital Charge Code |
76101070
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$39.91 |
| Max. Negotiated Rate |
$294.72 |
| Rate for Payer: Aetna Commercial |
$236.39
|
| Rate for Payer: Anthem Medicaid |
$105.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$136.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$239.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$190.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$183.95
|
| Rate for Payer: Cash Price |
$153.50
|
| Rate for Payer: Cash Price |
$153.50
|
| Rate for Payer: Cigna Commercial |
$254.81
|
| Rate for Payer: First Health Commercial |
$291.65
|
| Rate for Payer: Humana Commercial |
$260.95
|
| Rate for Payer: Humana KY Medicaid |
$105.58
|
| Rate for Payer: Humana Medicare Advantage |
$136.26
|
| Rate for Payer: Kentucky WC Medicaid |
$106.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$251.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$226.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$107.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$270.16
|
| Rate for Payer: Ohio Health Group HMO |
$230.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$95.17
|
| Rate for Payer: PHCS Commercial |
$294.72
|
| Rate for Payer: United Healthcare All Payer |
$270.16
|
|
|
APPLICATION OF UNNABOOT
|
Facility
|
IP
|
$307.00
|
|
|
Service Code
|
HCPCS 29580
|
| Hospital Charge Code |
76101070
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$39.91 |
| Max. Negotiated Rate |
$294.72 |
| Rate for Payer: Aetna Commercial |
$236.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$239.46
|
| Rate for Payer: Cash Price |
$153.50
|
| Rate for Payer: Cigna Commercial |
$254.81
|
| Rate for Payer: First Health Commercial |
$291.65
|
| Rate for Payer: Humana Commercial |
$260.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$251.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$226.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$92.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$270.16
|
| Rate for Payer: Ohio Health Group HMO |
$230.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$95.17
|
| Rate for Payer: PHCS Commercial |
$294.72
|
| Rate for Payer: United Healthcare All Payer |
$270.16
|
|
|
APPLICATION OF UNNABOOT(P
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 29580
|
| Hospital Charge Code |
761P1070
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$21.68 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna Commercial |
$54.92
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$21.68
|
| Rate for Payer: Anthem Medicaid |
$28.29
|
| Rate for Payer: Buckeye Medicare Advantage |
$100.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$78.96
|
| Rate for Payer: Healthspan PPO |
$66.73
|
| Rate for Payer: Humana Medicaid |
$28.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$44.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$28.86
|
| Rate for Payer: Molina Healthcare Passport |
$28.29
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$70.00
|
| Rate for Payer: UHCCP Medicaid |
$22.76
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$28.57
|
|
