|
APP FINGER SPLINT STATIC
|
Facility
|
OP
|
$390.00
|
|
|
Service Code
|
HCPCS 29130
|
| Hospital Charge Code |
76101053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$119.10 |
| Max. Negotiated Rate |
$374.40 |
| Rate for Payer: Aetna Commercial |
$300.30
|
| Rate for Payer: Anthem Medicaid |
$134.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$304.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.78
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cigna Commercial |
$323.70
|
| Rate for Payer: First Health Commercial |
$370.50
|
| Rate for Payer: Humana Commercial |
$331.50
|
| Rate for Payer: Humana KY Medicaid |
$134.12
|
| Rate for Payer: Humana Medicare Advantage |
$119.10
|
| Rate for Payer: Kentucky WC Medicaid |
$135.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$319.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$287.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$136.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$343.20
|
| Rate for Payer: Ohio Health Group HMO |
$292.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$312.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$339.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$269.10
|
| Rate for Payer: PHCS Commercial |
$374.40
|
| Rate for Payer: United Healthcare All Payer |
$343.20
|
|
|
APP FINGER SPLINT STATIC
|
Facility
|
IP
|
$390.00
|
|
|
Service Code
|
HCPCS 29130
|
| Hospital Charge Code |
76101053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$117.00 |
| Max. Negotiated Rate |
$374.40 |
| Rate for Payer: Aetna Commercial |
$300.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$304.20
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cigna Commercial |
$323.70
|
| Rate for Payer: First Health Commercial |
$370.50
|
| Rate for Payer: Humana Commercial |
$331.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$319.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$287.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$343.20
|
| Rate for Payer: Ohio Health Group HMO |
$292.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$312.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$339.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$269.10
|
| Rate for Payer: PHCS Commercial |
$374.40
|
| Rate for Payer: United Healthcare All Payer |
$343.20
|
|
|
APP FINGER SPLINT STATIC
|
Professional
|
Both
|
$390.00
|
|
|
Service Code
|
HCPCS 29130
|
| Hospital Charge Code |
76101053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$19.72 |
| Max. Negotiated Rate |
$234.00 |
| Rate for Payer: Aetna Commercial |
$43.30
|
| Rate for Payer: Ambetter Exchange |
$27.39
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$23.18
|
| Rate for Payer: Anthem Medicaid |
$19.72
|
| Rate for Payer: Buckeye Individual/Medicaid |
$27.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$27.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$32.87
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cigna Commercial |
$62.54
|
| Rate for Payer: Healthspan PPO |
$51.34
|
| Rate for Payer: Humana Medicaid |
$19.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$35.44
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$27.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$20.11
|
| Rate for Payer: Molina Healthcare Passport |
$19.72
|
| Rate for Payer: Multiplan PHCS |
$234.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$35.61
|
| Rate for Payer: UHCCP Medicaid |
$24.34
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$19.92
|
| Rate for Payer: Wellcare Medicare Advantage |
$27.39
|
|
|
APP FINGER SPLINT STATIC
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
HCPCS 29130
|
| Hospital Charge Code |
45000190
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$91.50 |
| Max. Negotiated Rate |
$292.80 |
| Rate for Payer: Aetna Commercial |
$234.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.90
|
| Rate for Payer: Cash Price |
$152.50
|
| Rate for Payer: Cigna Commercial |
$253.15
|
| Rate for Payer: First Health Commercial |
$289.75
|
| Rate for Payer: Humana Commercial |
$259.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$250.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$225.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$91.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$268.40
|
| Rate for Payer: Ohio Health Group HMO |
$228.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$244.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$265.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$210.45
|
| Rate for Payer: PHCS Commercial |
$292.80
|
| Rate for Payer: United Healthcare All Payer |
$268.40
|
|
|
APP FINGER SPLINT STATIC(P
|
Professional
|
Both
|
$85.00
|
|
|
Service Code
|
HCPCS 29130
|
| Hospital Charge Code |
761P1053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$19.72 |
| Max. Negotiated Rate |
$62.54 |
| Rate for Payer: Aetna Commercial |
$43.30
|
| Rate for Payer: Ambetter Exchange |
$27.39
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$23.18
|
| Rate for Payer: Anthem Medicaid |
$19.72
|
| Rate for Payer: Buckeye Individual/Medicaid |
$27.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$27.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$32.87
|
| 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 |
$19.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$35.44
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$27.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$20.11
|
| Rate for Payer: Molina Healthcare Passport |
$19.72
|
| Rate for Payer: Multiplan PHCS |
$51.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$35.61
|
| Rate for Payer: UHCCP Medicaid |
$24.34
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$19.92
|
| Rate for Payer: Wellcare Medicare Advantage |
$27.39
|
|
|
APP FINGER SPLINT STATIC(T
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
HCPCS 29130
|
| Hospital Charge Code |
761T1053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$91.50 |
| Max. Negotiated Rate |
$292.80 |
| Rate for Payer: Aetna Commercial |
$234.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.90
|
| Rate for Payer: Cash Price |
$152.50
|
| Rate for Payer: Cigna Commercial |
$253.15
|
| Rate for Payer: First Health Commercial |
$289.75
|
| Rate for Payer: Humana Commercial |
$259.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$250.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$225.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$91.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$268.40
|
| Rate for Payer: Ohio Health Group HMO |
$228.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$244.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$265.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$210.45
|
| Rate for Payer: PHCS Commercial |
$292.80
|
| Rate for Payer: United Healthcare All Payer |
$268.40
|
|
|
APP FINGER SPLINT STATIC(T
|
Facility
|
OP
|
$305.00
|
|
|
Service Code
|
HCPCS 29130
|
| Hospital Charge Code |
761T1053
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$104.89 |
| Max. Negotiated Rate |
$292.80 |
| Rate for Payer: Aetna Commercial |
$234.85
|
| Rate for Payer: Anthem Medicaid |
$104.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.78
|
| Rate for Payer: Cash Price |
$152.50
|
| Rate for Payer: Cash Price |
$152.50
|
| Rate for Payer: Cigna Commercial |
$253.15
|
| Rate for Payer: First Health Commercial |
$289.75
|
| Rate for Payer: Humana Commercial |
$259.25
|
| Rate for Payer: Humana KY Medicaid |
$104.89
|
| Rate for Payer: Humana Medicare Advantage |
$119.10
|
| Rate for Payer: Kentucky WC Medicaid |
$105.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$250.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$225.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$106.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$268.40
|
| Rate for Payer: Ohio Health Group HMO |
$228.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$244.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$265.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$210.45
|
| Rate for Payer: PHCS Commercial |
$292.80
|
| Rate for Payer: United Healthcare All Payer |
$268.40
|
|
|
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
|
$2,366.24
|
|
|
Service Code
|
CPT 15275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,690.17 |
| Max. Negotiated Rate |
$2,366.24 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
|
|
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
|
$2,366.24
|
|
|
Service Code
|
CPT 15271
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,690.17 |
| Max. Negotiated Rate |
$2,366.24 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
|
|
APPLICATION OF STRAPP/CASTING
|
Facility
|
IP
|
$288.00
|
|
| Hospital Charge Code |
76102554
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$86.40 |
| 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 |
$230.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$250.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$198.72
|
| Rate for Payer: PHCS Commercial |
$276.48
|
| Rate for Payer: United Healthcare All Payer |
$253.44
|
|
|
APPLICATION OF STRAPP/CASTING
|
Facility
|
OP
|
$288.00
|
|
| Hospital Charge Code |
76102554
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$86.40 |
| 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 |
$230.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$250.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$198.72
|
| Rate for Payer: PHCS Commercial |
$276.48
|
| Rate for Payer: United Healthcare All Payer |
$253.44
|
|
|
APPLICATION OF UNNABOOT
|
Facility
|
IP
|
$198.00
|
|
|
Service Code
|
HCPCS 29580
|
| Hospital Charge Code |
42000066
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$59.40 |
| 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 |
$158.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$172.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$136.62
|
| Rate for Payer: PHCS Commercial |
$190.08
|
| Rate for Payer: United Healthcare All Payer |
$174.24
|
|
|
APPLICATION OF UNNABOOT
|
Facility
|
OP
|
$198.00
|
|
|
Service Code
|
HCPCS 29580
|
| Hospital Charge Code |
42000066
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$68.09 |
| Max. Negotiated Rate |
$204.11 |
| Rate for Payer: Aetna Commercial |
$152.46
|
| Rate for Payer: Anthem Medicaid |
$68.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$145.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$154.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$204.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$196.82
|
| 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 |
$145.79
|
| 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 |
$174.95
|
| 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 |
$158.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$172.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$136.62
|
| Rate for Payer: PHCS Commercial |
$190.08
|
| Rate for Payer: United Healthcare All Payer |
$174.24
|
|
|
APPLICATION OF UNNABOOT
|
Facility
|
OP
|
$320.00
|
|
|
Service Code
|
HCPCS 29580
|
| Hospital Charge Code |
76101070
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$110.05 |
| Max. Negotiated Rate |
$307.20 |
| Rate for Payer: Aetna Commercial |
$246.40
|
| Rate for Payer: Anthem Medicaid |
$110.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$145.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$249.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$204.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$196.82
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cigna Commercial |
$265.60
|
| Rate for Payer: First Health Commercial |
$304.00
|
| Rate for Payer: Humana Commercial |
$272.00
|
| Rate for Payer: Humana KY Medicaid |
$110.05
|
| Rate for Payer: Humana Medicare Advantage |
$145.79
|
| Rate for Payer: Kentucky WC Medicaid |
$111.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$262.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$236.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$174.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$112.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$281.60
|
| Rate for Payer: Ohio Health Group HMO |
$240.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$256.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$278.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$220.80
|
| Rate for Payer: PHCS Commercial |
$307.20
|
| Rate for Payer: United Healthcare All Payer |
$281.60
|
|
|
APPLICATION OF UNNABOOT
|
Facility
|
IP
|
$320.00
|
|
|
Service Code
|
HCPCS 29580
|
| Hospital Charge Code |
76101070
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$96.00 |
| Max. Negotiated Rate |
$307.20 |
| Rate for Payer: Aetna Commercial |
$246.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$249.60
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cigna Commercial |
$265.60
|
| Rate for Payer: First Health Commercial |
$304.00
|
| Rate for Payer: Humana Commercial |
$272.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$262.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$236.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$281.60
|
| Rate for Payer: Ohio Health Group HMO |
$240.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$256.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$278.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$220.80
|
| Rate for Payer: PHCS Commercial |
$307.20
|
| Rate for Payer: United Healthcare All Payer |
$281.60
|
|
|
APPLICATION OF UNNABOOT
|
Professional
|
Both
|
$320.00
|
|
|
Service Code
|
HCPCS 29580
|
| Hospital Charge Code |
76101070
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$21.68 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial |
$54.92
|
| Rate for Payer: Ambetter Exchange |
$24.80
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$21.68
|
| Rate for Payer: Anthem Medicaid |
$38.89
|
| Rate for Payer: Buckeye Individual/Medicaid |
$24.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$24.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$29.76
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cigna Commercial |
$78.96
|
| Rate for Payer: Healthspan PPO |
$66.73
|
| Rate for Payer: Humana Medicaid |
$38.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$44.49
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$24.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$39.67
|
| Rate for Payer: Molina Healthcare Passport |
$38.89
|
| Rate for Payer: Multiplan PHCS |
$192.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$32.24
|
| Rate for Payer: UHCCP Medicaid |
$22.76
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$39.28
|
| Rate for Payer: Wellcare Medicare Advantage |
$24.80
|
|
|
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 |
$78.96 |
| Rate for Payer: Aetna Commercial |
$54.92
|
| Rate for Payer: Ambetter Exchange |
$24.80
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$21.68
|
| Rate for Payer: Anthem Medicaid |
$38.89
|
| Rate for Payer: Buckeye Individual/Medicaid |
$24.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$24.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$29.76
|
| 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 |
$38.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$44.49
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$24.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$39.67
|
| Rate for Payer: Molina Healthcare Passport |
$38.89
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$32.24
|
| Rate for Payer: UHCCP Medicaid |
$22.76
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$39.28
|
| Rate for Payer: Wellcare Medicare Advantage |
$24.80
|
|
|
APPLICATION OF UNNABOOT(T
|
Facility
|
OP
|
$220.00
|
|
|
Service Code
|
HCPCS 29580
|
| Hospital Charge Code |
761T1070
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$75.66 |
| Max. Negotiated Rate |
$211.20 |
| Rate for Payer: Aetna Commercial |
$169.40
|
| Rate for Payer: Anthem Medicaid |
$75.66
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$145.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$171.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$204.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$196.82
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cigna Commercial |
$182.60
|
| Rate for Payer: First Health Commercial |
$209.00
|
| Rate for Payer: Humana Commercial |
$187.00
|
| Rate for Payer: Humana KY Medicaid |
$75.66
|
| Rate for Payer: Humana Medicare Advantage |
$145.79
|
| Rate for Payer: Kentucky WC Medicaid |
$76.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$180.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$162.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$174.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$77.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$193.60
|
| Rate for Payer: Ohio Health Group HMO |
$165.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$176.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$191.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$151.80
|
| Rate for Payer: PHCS Commercial |
$211.20
|
| Rate for Payer: United Healthcare All Payer |
$193.60
|
|
|
APPLICATION OF UNNABOOT(T
|
Facility
|
IP
|
$220.00
|
|
|
Service Code
|
HCPCS 29580
|
| Hospital Charge Code |
761T1070
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$66.00 |
| Max. Negotiated Rate |
$211.20 |
| Rate for Payer: Aetna Commercial |
$169.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$171.60
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cigna Commercial |
$182.60
|
| Rate for Payer: First Health Commercial |
$209.00
|
| Rate for Payer: Humana Commercial |
$187.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$180.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$162.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$66.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$193.60
|
| Rate for Payer: Ohio Health Group HMO |
$165.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$176.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$191.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$151.80
|
| Rate for Payer: PHCS Commercial |
$211.20
|
| Rate for Payer: United Healthcare All Payer |
$193.60
|
|
|
APP LONG ARM SPLTSHOULDERHAND
|
Facility
|
OP
|
$435.00
|
|
|
Service Code
|
HCPCS 29105
|
| Hospital Charge Code |
45000187
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$145.79 |
| Max. Negotiated Rate |
$417.60 |
| Rate for Payer: Aetna Commercial |
$334.95
|
| Rate for Payer: Anthem Medicaid |
$149.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$145.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$339.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$204.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$196.82
|
| Rate for Payer: Cash Price |
$217.50
|
| Rate for Payer: Cash Price |
$217.50
|
| Rate for Payer: Cigna Commercial |
$361.05
|
| Rate for Payer: First Health Commercial |
$413.25
|
| Rate for Payer: Humana Commercial |
$369.75
|
| Rate for Payer: Humana KY Medicaid |
$149.60
|
| Rate for Payer: Humana Medicare Advantage |
$145.79
|
| Rate for Payer: Kentucky WC Medicaid |
$151.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$356.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$321.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$174.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$152.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$382.80
|
| Rate for Payer: Ohio Health Group HMO |
$326.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$348.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$378.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$300.15
|
| Rate for Payer: PHCS Commercial |
$417.60
|
| Rate for Payer: United Healthcare All Payer |
$382.80
|
|
|
APP LONG ARM SPLTSHOULDERHAND
|
Facility
|
IP
|
$435.00
|
|
|
Service Code
|
HCPCS 29105
|
| Hospital Charge Code |
45000187
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$130.50 |
| Max. Negotiated Rate |
$417.60 |
| Rate for Payer: Aetna Commercial |
$334.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$339.30
|
| Rate for Payer: Cash Price |
$217.50
|
| Rate for Payer: Cigna Commercial |
$361.05
|
| Rate for Payer: First Health Commercial |
$413.25
|
| Rate for Payer: Humana Commercial |
$369.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$356.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$321.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$130.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$382.80
|
| Rate for Payer: Ohio Health Group HMO |
$326.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$348.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$378.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$300.15
|
| Rate for Payer: PHCS Commercial |
$417.60
|
| Rate for Payer: United Healthcare All Payer |
$382.80
|
|
|
APP LONG ARM SPLTSHOULDERHAND
|
Facility
|
OP
|
$610.00
|
|
|
Service Code
|
HCPCS 29105
|
| Hospital Charge Code |
76101050
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$145.79 |
| Max. Negotiated Rate |
$585.60 |
| Rate for Payer: Aetna Commercial |
$469.70
|
| Rate for Payer: Anthem Medicaid |
$209.78
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$145.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$475.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$204.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$196.82
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cigna Commercial |
$506.30
|
| Rate for Payer: First Health Commercial |
$579.50
|
| Rate for Payer: Humana Commercial |
$518.50
|
| Rate for Payer: Humana KY Medicaid |
$209.78
|
| Rate for Payer: Humana Medicare Advantage |
$145.79
|
| Rate for Payer: Kentucky WC Medicaid |
$211.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$500.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$450.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$174.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$213.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$536.80
|
| Rate for Payer: Ohio Health Group HMO |
$457.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$488.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$530.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$420.90
|
| Rate for Payer: PHCS Commercial |
$585.60
|
| Rate for Payer: United Healthcare All Payer |
$536.80
|
|
|
APP LONG ARM SPLTSHOULDERHAND
|
Professional
|
Both
|
$610.00
|
|
|
Service Code
|
HCPCS 29105
|
| Hospital Charge Code |
76101050
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$39.77 |
| Max. Negotiated Rate |
$366.00 |
| Rate for Payer: Aetna Commercial |
$87.13
|
| Rate for Payer: Ambetter Exchange |
$39.77
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$42.22
|
| Rate for Payer: Anthem Medicaid |
$40.88
|
| Rate for Payer: Buckeye Individual/Medicaid |
$39.77
|
| Rate for Payer: Buckeye Medicare Advantage |
$39.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$47.72
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cigna Commercial |
$134.54
|
| Rate for Payer: Healthspan PPO |
$107.53
|
| Rate for Payer: Humana Medicaid |
$40.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$72.71
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$39.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.77
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$41.70
|
| Rate for Payer: Molina Healthcare Passport |
$40.88
|
| Rate for Payer: Multiplan PHCS |
$366.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$51.70
|
| Rate for Payer: UHCCP Medicaid |
$44.33
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$41.29
|
| Rate for Payer: Wellcare Medicare Advantage |
$39.77
|
|
|
APP LONG ARM SPLTSHOULDERHAND
|
Facility
|
IP
|
$610.00
|
|
|
Service Code
|
HCPCS 29105
|
| Hospital Charge Code |
76101050
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$183.00 |
| Max. Negotiated Rate |
$585.60 |
| Rate for Payer: Aetna Commercial |
$469.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$475.80
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cigna Commercial |
$506.30
|
| Rate for Payer: First Health Commercial |
$579.50
|
| Rate for Payer: Humana Commercial |
$518.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$500.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$450.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$183.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$536.80
|
| Rate for Payer: Ohio Health Group HMO |
$457.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$488.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$530.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$420.90
|
| Rate for Payer: PHCS Commercial |
$585.60
|
| Rate for Payer: United Healthcare All Payer |
$536.80
|
|
|
APP LONG ARM SPLTSHOULDERHAN(P
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
HCPCS 29105
|
| Hospital Charge Code |
761P1050
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$39.77 |
| Max. Negotiated Rate |
$134.54 |
| Rate for Payer: Aetna Commercial |
$87.13
|
| Rate for Payer: Ambetter Exchange |
$39.77
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$42.22
|
| Rate for Payer: Anthem Medicaid |
$40.88
|
| Rate for Payer: Buckeye Individual/Medicaid |
$39.77
|
| Rate for Payer: Buckeye Medicare Advantage |
$39.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$47.72
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cigna Commercial |
$134.54
|
| Rate for Payer: Healthspan PPO |
$107.53
|
| Rate for Payer: Humana Medicaid |
$40.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$72.71
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$39.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.77
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$41.70
|
| Rate for Payer: Molina Healthcare Passport |
$40.88
|
| Rate for Payer: Multiplan PHCS |
$105.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$51.70
|
| Rate for Payer: UHCCP Medicaid |
$44.33
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$41.29
|
| Rate for Payer: Wellcare Medicare Advantage |
$39.77
|
|
