|
APPROACH HYDRO ST WIRE 300CM
|
Facility
|
IP
|
$2,069.46
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$620.84 |
| Max. Negotiated Rate |
$1,986.68 |
| Rate for Payer: Aetna Commercial |
$1,593.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,614.18
|
| Rate for Payer: Cash Price |
$1,034.73
|
| Rate for Payer: Cigna Commercial |
$1,717.65
|
| Rate for Payer: First Health Commercial |
$1,965.99
|
| Rate for Payer: Humana Commercial |
$1,759.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,696.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,527.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$620.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,821.12
|
| Rate for Payer: Ohio Health Group HMO |
$1,552.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,800.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,427.93
|
| Rate for Payer: PHCS Commercial |
$1,986.68
|
| Rate for Payer: United Healthcare All Payer |
$1,821.12
|
|
|
APPROACH HYDRO ST WIRE 300CM
|
Facility
|
OP
|
$2,069.46
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$620.84 |
| Max. Negotiated Rate |
$1,986.68 |
| Rate for Payer: Aetna Commercial |
$1,593.48
|
| Rate for Payer: Anthem Medicaid |
$711.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,614.18
|
| Rate for Payer: Cash Price |
$1,034.73
|
| Rate for Payer: Cigna Commercial |
$1,717.65
|
| Rate for Payer: First Health Commercial |
$1,965.99
|
| Rate for Payer: Humana Commercial |
$1,759.04
|
| Rate for Payer: Humana KY Medicaid |
$711.69
|
| Rate for Payer: Kentucky WC Medicaid |
$718.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,696.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,527.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$620.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$725.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,821.12
|
| Rate for Payer: Ohio Health Group HMO |
$1,552.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,800.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,427.93
|
| Rate for Payer: PHCS Commercial |
$1,986.68
|
| Rate for Payer: United Healthcare All Payer |
$1,821.12
|
|
|
APP SHORT ARM SPLINT (DYNAMIC)
|
Facility
|
IP
|
$187.00
|
|
|
Service Code
|
HCPCS 29126
|
| Hospital Charge Code |
45000189
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$56.10 |
| Max. Negotiated Rate |
$179.52 |
| Rate for Payer: Aetna Commercial |
$143.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$145.86
|
| Rate for Payer: Cash Price |
$93.50
|
| Rate for Payer: Cigna Commercial |
$155.21
|
| Rate for Payer: First Health Commercial |
$177.65
|
| Rate for Payer: Humana Commercial |
$158.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$153.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$138.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$164.56
|
| Rate for Payer: Ohio Health Group HMO |
$140.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$149.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$162.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$129.03
|
| Rate for Payer: PHCS Commercial |
$179.52
|
| Rate for Payer: United Healthcare All Payer |
$164.56
|
|
|
APP SHORT ARM SPLINT (DYNAMIC)
|
Facility
|
OP
|
$187.00
|
|
|
Service Code
|
HCPCS 29126
|
| Hospital Charge Code |
45000189
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$64.31 |
| Max. Negotiated Rate |
$179.52 |
| Rate for Payer: Aetna Commercial |
$143.99
|
| Rate for Payer: Anthem Medicaid |
$64.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$145.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.78
|
| Rate for Payer: Cash Price |
$93.50
|
| Rate for Payer: Cash Price |
$93.50
|
| Rate for Payer: Cigna Commercial |
$155.21
|
| Rate for Payer: First Health Commercial |
$177.65
|
| Rate for Payer: Humana Commercial |
$158.95
|
| Rate for Payer: Humana KY Medicaid |
$64.31
|
| Rate for Payer: Humana Medicare Advantage |
$119.10
|
| Rate for Payer: Kentucky WC Medicaid |
$64.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$153.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$138.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$65.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$164.56
|
| Rate for Payer: Ohio Health Group HMO |
$140.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$149.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$162.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$129.03
|
| Rate for Payer: PHCS Commercial |
$179.52
|
| Rate for Payer: United Healthcare All Payer |
$164.56
|
|
|
APP SHORT ARM SPLINT (DYNAMIC)
|
Facility
|
IP
|
$186.00
|
|
|
Service Code
|
HCPCS 29126
|
| Hospital Charge Code |
76101052
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$55.80 |
| Max. Negotiated Rate |
$178.56 |
| Rate for Payer: Aetna Commercial |
$143.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$145.08
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$154.38
|
| Rate for Payer: First Health Commercial |
$176.70
|
| Rate for Payer: Humana Commercial |
$158.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$152.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$137.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$163.68
|
| Rate for Payer: Ohio Health Group HMO |
$139.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$148.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$161.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$128.34
|
| Rate for Payer: PHCS Commercial |
$178.56
|
| Rate for Payer: United Healthcare All Payer |
$163.68
|
|
|
APP SHORT ARM SPLINT (DYNAMIC)
|
Facility
|
OP
|
$186.00
|
|
|
Service Code
|
HCPCS 29126
|
| Hospital Charge Code |
76101052
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$63.97 |
| Max. Negotiated Rate |
$178.56 |
| Rate for Payer: Aetna Commercial |
$143.22
|
| Rate for Payer: Anthem Medicaid |
$63.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$145.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.78
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$154.38
|
| Rate for Payer: First Health Commercial |
$176.70
|
| Rate for Payer: Humana Commercial |
$158.10
|
| Rate for Payer: Humana KY Medicaid |
$63.97
|
| Rate for Payer: Humana Medicare Advantage |
$119.10
|
| Rate for Payer: Kentucky WC Medicaid |
$64.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$152.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$137.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$65.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$163.68
|
| Rate for Payer: Ohio Health Group HMO |
$139.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$148.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$161.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$128.34
|
| Rate for Payer: PHCS Commercial |
$178.56
|
| Rate for Payer: United Healthcare All Payer |
$163.68
|
|
|
APP SHORTARM SPLNT (STATIC)
|
Facility
|
OP
|
$670.00
|
|
|
Service Code
|
HCPCS 29125
|
| Hospital Charge Code |
76101051
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$119.10 |
| Max. Negotiated Rate |
$643.20 |
| Rate for Payer: Aetna Commercial |
$515.90
|
| Rate for Payer: Anthem Medicaid |
$230.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$522.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.78
|
| Rate for Payer: Cash Price |
$335.00
|
| Rate for Payer: Cash Price |
$335.00
|
| Rate for Payer: Cigna Commercial |
$556.10
|
| Rate for Payer: First Health Commercial |
$636.50
|
| Rate for Payer: Humana Commercial |
$569.50
|
| Rate for Payer: Humana KY Medicaid |
$230.41
|
| Rate for Payer: Humana Medicare Advantage |
$119.10
|
| Rate for Payer: Kentucky WC Medicaid |
$232.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$549.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$494.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$235.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$589.60
|
| Rate for Payer: Ohio Health Group HMO |
$502.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$536.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$582.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$462.30
|
| Rate for Payer: PHCS Commercial |
$643.20
|
| Rate for Payer: United Healthcare All Payer |
$589.60
|
|
|
APP SHORTARM SPLNT (STATIC)
|
Professional
|
Both
|
$670.00
|
|
|
Service Code
|
HCPCS 29125
|
| Hospital Charge Code |
76101051
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$28.45 |
| Max. Negotiated Rate |
$402.00 |
| Rate for Payer: Aetna Commercial |
$61.52
|
| Rate for Payer: Ambetter Exchange |
$38.00
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$31.44
|
| Rate for Payer: Anthem Medicaid |
$28.45
|
| Rate for Payer: Buckeye Individual/Medicaid |
$38.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$38.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$45.60
|
| Rate for Payer: Cash Price |
$335.00
|
| Rate for Payer: Cash Price |
$335.00
|
| Rate for Payer: Cigna Commercial |
$102.82
|
| Rate for Payer: Healthspan PPO |
$82.39
|
| Rate for Payer: Humana Medicaid |
$28.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$53.04
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$38.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$29.02
|
| Rate for Payer: Molina Healthcare Passport |
$28.45
|
| Rate for Payer: Multiplan PHCS |
$402.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$49.40
|
| Rate for Payer: UHCCP Medicaid |
$33.01
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$28.73
|
| Rate for Payer: Wellcare Medicare Advantage |
$38.00
|
|
|
APP SHORTARM SPLNT (STATIC)
|
Facility
|
IP
|
$670.00
|
|
|
Service Code
|
HCPCS 29125
|
| Hospital Charge Code |
76101051
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$201.00 |
| Max. Negotiated Rate |
$643.20 |
| Rate for Payer: Aetna Commercial |
$515.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$522.60
|
| Rate for Payer: Cash Price |
$335.00
|
| Rate for Payer: Cigna Commercial |
$556.10
|
| Rate for Payer: First Health Commercial |
$636.50
|
| Rate for Payer: Humana Commercial |
$569.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$549.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$494.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$201.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$589.60
|
| Rate for Payer: Ohio Health Group HMO |
$502.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$536.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$582.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$462.30
|
| Rate for Payer: PHCS Commercial |
$643.20
|
| Rate for Payer: United Healthcare All Payer |
$589.60
|
|
|
APP SHORTARM SPLNT (STATIC)
|
Facility
|
IP
|
$370.00
|
|
|
Service Code
|
HCPCS 29125
|
| Hospital Charge Code |
45000188
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$111.00 |
| Max. Negotiated Rate |
$355.20 |
| Rate for Payer: Aetna Commercial |
$284.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$288.60
|
| Rate for Payer: Cash Price |
$185.00
|
| Rate for Payer: Cigna Commercial |
$307.10
|
| Rate for Payer: First Health Commercial |
$351.50
|
| Rate for Payer: Humana Commercial |
$314.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$303.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$273.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$111.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$325.60
|
| Rate for Payer: Ohio Health Group HMO |
$277.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$296.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$321.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$255.30
|
| Rate for Payer: PHCS Commercial |
$355.20
|
| Rate for Payer: United Healthcare All Payer |
$325.60
|
|
|
APP SHORTARM SPLNT (STATIC)
|
Facility
|
OP
|
$370.00
|
|
|
Service Code
|
HCPCS 29125
|
| Hospital Charge Code |
45000188
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$119.10 |
| Max. Negotiated Rate |
$355.20 |
| Rate for Payer: Aetna Commercial |
$284.90
|
| Rate for Payer: Anthem Medicaid |
$127.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$288.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.78
|
| Rate for Payer: Cash Price |
$185.00
|
| Rate for Payer: Cash Price |
$185.00
|
| Rate for Payer: Cigna Commercial |
$307.10
|
| Rate for Payer: First Health Commercial |
$351.50
|
| Rate for Payer: Humana Commercial |
$314.50
|
| Rate for Payer: Humana KY Medicaid |
$127.24
|
| Rate for Payer: Humana Medicare Advantage |
$119.10
|
| Rate for Payer: Kentucky WC Medicaid |
$128.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$303.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$273.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$129.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$325.60
|
| Rate for Payer: Ohio Health Group HMO |
$277.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$296.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$321.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$255.30
|
| Rate for Payer: PHCS Commercial |
$355.20
|
| Rate for Payer: United Healthcare All Payer |
$325.60
|
|
|
APP SHORTARM SPLNT (STATIC)(P
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 29125
|
| Hospital Charge Code |
761P1051
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$28.45 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Aetna Commercial |
$61.52
|
| Rate for Payer: Ambetter Exchange |
$38.00
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$31.44
|
| Rate for Payer: Anthem Medicaid |
$28.45
|
| Rate for Payer: Buckeye Individual/Medicaid |
$38.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$38.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$45.60
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$102.82
|
| Rate for Payer: Healthspan PPO |
$82.39
|
| Rate for Payer: Humana Medicaid |
$28.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$53.04
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$38.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$29.02
|
| Rate for Payer: Molina Healthcare Passport |
$28.45
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$49.40
|
| Rate for Payer: UHCCP Medicaid |
$33.01
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$28.73
|
| Rate for Payer: Wellcare Medicare Advantage |
$38.00
|
|
|
APP SHORTARM SPLNT (STATIC)(T
|
Facility
|
OP
|
$370.00
|
|
|
Service Code
|
HCPCS 29125
|
| Hospital Charge Code |
761T1051
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$119.10 |
| Max. Negotiated Rate |
$355.20 |
| Rate for Payer: Aetna Commercial |
$284.90
|
| Rate for Payer: Anthem Medicaid |
$127.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$288.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.78
|
| Rate for Payer: Cash Price |
$185.00
|
| Rate for Payer: Cash Price |
$185.00
|
| Rate for Payer: Cigna Commercial |
$307.10
|
| Rate for Payer: First Health Commercial |
$351.50
|
| Rate for Payer: Humana Commercial |
$314.50
|
| Rate for Payer: Humana KY Medicaid |
$127.24
|
| Rate for Payer: Humana Medicare Advantage |
$119.10
|
| Rate for Payer: Kentucky WC Medicaid |
$128.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$303.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$273.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$129.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$325.60
|
| Rate for Payer: Ohio Health Group HMO |
$277.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$296.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$321.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$255.30
|
| Rate for Payer: PHCS Commercial |
$355.20
|
| Rate for Payer: United Healthcare All Payer |
$325.60
|
|
|
APP SHORTARM SPLNT (STATIC)(T
|
Facility
|
IP
|
$370.00
|
|
|
Service Code
|
HCPCS 29125
|
| Hospital Charge Code |
761T1051
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$111.00 |
| Max. Negotiated Rate |
$355.20 |
| Rate for Payer: Aetna Commercial |
$284.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$288.60
|
| Rate for Payer: Cash Price |
$185.00
|
| Rate for Payer: Cigna Commercial |
$307.10
|
| Rate for Payer: First Health Commercial |
$351.50
|
| Rate for Payer: Humana Commercial |
$314.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$303.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$273.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$111.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$325.60
|
| Rate for Payer: Ohio Health Group HMO |
$277.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$296.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$321.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$255.30
|
| Rate for Payer: PHCS Commercial |
$355.20
|
| Rate for Payer: United Healthcare All Payer |
$325.60
|
|
|
APP SHORT LEG CAS(KNEE TO TOES
|
Facility
|
OP
|
$746.00
|
|
|
Service Code
|
HCPCS 29405
|
| Hospital Charge Code |
761T1060
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$245.39 |
| Max. Negotiated Rate |
$716.16 |
| Rate for Payer: Aetna Commercial |
$574.42
|
| Rate for Payer: Anthem Medicaid |
$256.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$245.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$581.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$343.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$331.28
|
| Rate for Payer: Cash Price |
$373.00
|
| Rate for Payer: Cash Price |
$373.00
|
| Rate for Payer: Cigna Commercial |
$619.18
|
| Rate for Payer: First Health Commercial |
$708.70
|
| Rate for Payer: Humana Commercial |
$634.10
|
| Rate for Payer: Humana KY Medicaid |
$256.55
|
| Rate for Payer: Humana Medicare Advantage |
$245.39
|
| Rate for Payer: Kentucky WC Medicaid |
$259.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$611.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$550.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$294.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$261.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$656.48
|
| Rate for Payer: Ohio Health Group HMO |
$559.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$596.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$649.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$514.74
|
| Rate for Payer: PHCS Commercial |
$716.16
|
| Rate for Payer: United Healthcare All Payer |
$656.48
|
|
|
APP SHORT LEG CAS(KNEE TO TOES
|
Facility
|
IP
|
$1,146.00
|
|
|
Service Code
|
HCPCS 29405
|
| Hospital Charge Code |
76101060
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$343.80 |
| Max. Negotiated Rate |
$1,100.16 |
| Rate for Payer: Aetna Commercial |
$882.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$893.88
|
| Rate for Payer: Cash Price |
$573.00
|
| Rate for Payer: Cigna Commercial |
$951.18
|
| Rate for Payer: First Health Commercial |
$1,088.70
|
| Rate for Payer: Humana Commercial |
$974.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$939.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$845.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$343.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,008.48
|
| Rate for Payer: Ohio Health Group HMO |
$859.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$916.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$997.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$790.74
|
| Rate for Payer: PHCS Commercial |
$1,100.16
|
| Rate for Payer: United Healthcare All Payer |
$1,008.48
|
|
|
APP SHORT LEG CAS(KNEE TO TOES
|
Facility
|
OP
|
$746.00
|
|
|
Service Code
|
HCPCS 29405
|
| Hospital Charge Code |
45000197
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$245.39 |
| Max. Negotiated Rate |
$716.16 |
| Rate for Payer: Aetna Commercial |
$574.42
|
| Rate for Payer: Anthem Medicaid |
$256.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$245.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$581.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$343.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$331.28
|
| Rate for Payer: Cash Price |
$373.00
|
| Rate for Payer: Cash Price |
$373.00
|
| Rate for Payer: Cigna Commercial |
$619.18
|
| Rate for Payer: First Health Commercial |
$708.70
|
| Rate for Payer: Humana Commercial |
$634.10
|
| Rate for Payer: Humana KY Medicaid |
$256.55
|
| Rate for Payer: Humana Medicare Advantage |
$245.39
|
| Rate for Payer: Kentucky WC Medicaid |
$259.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$611.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$550.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$294.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$261.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$656.48
|
| Rate for Payer: Ohio Health Group HMO |
$559.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$596.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$649.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$514.74
|
| Rate for Payer: PHCS Commercial |
$716.16
|
| Rate for Payer: United Healthcare All Payer |
$656.48
|
|
|
APP SHORT LEG CAS(KNEE TO TOES
|
Facility
|
OP
|
$1,146.00
|
|
|
Service Code
|
HCPCS 29405
|
| Hospital Charge Code |
76101060
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$245.39 |
| Max. Negotiated Rate |
$1,100.16 |
| Rate for Payer: Aetna Commercial |
$882.42
|
| Rate for Payer: Anthem Medicaid |
$394.11
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$245.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$893.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$343.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$331.28
|
| Rate for Payer: Cash Price |
$573.00
|
| Rate for Payer: Cash Price |
$573.00
|
| Rate for Payer: Cigna Commercial |
$951.18
|
| Rate for Payer: First Health Commercial |
$1,088.70
|
| Rate for Payer: Humana Commercial |
$974.10
|
| Rate for Payer: Humana KY Medicaid |
$394.11
|
| Rate for Payer: Humana Medicare Advantage |
$245.39
|
| Rate for Payer: Kentucky WC Medicaid |
$398.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$939.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$845.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$294.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$402.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,008.48
|
| Rate for Payer: Ohio Health Group HMO |
$859.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$916.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$997.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$790.74
|
| Rate for Payer: PHCS Commercial |
$1,100.16
|
| Rate for Payer: United Healthcare All Payer |
$1,008.48
|
|
|
APP SHORT LEG CAS(KNEE TO TOES
|
Professional
|
Both
|
$1,146.00
|
|
|
Service Code
|
HCPCS 29405
|
| Hospital Charge Code |
76101060
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$47.61 |
| Max. Negotiated Rate |
$687.60 |
| Rate for Payer: Aetna Commercial |
$95.47
|
| Rate for Payer: Ambetter Exchange |
$55.56
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$47.61
|
| Rate for Payer: Anthem Medicaid |
$49.34
|
| Rate for Payer: Buckeye Individual/Medicaid |
$55.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$55.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$66.67
|
| Rate for Payer: Cash Price |
$573.00
|
| Rate for Payer: Cash Price |
$573.00
|
| Rate for Payer: Cigna Commercial |
$136.41
|
| Rate for Payer: Healthspan PPO |
$111.68
|
| Rate for Payer: Humana Medicaid |
$49.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$77.75
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$55.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.56
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$50.33
|
| Rate for Payer: Molina Healthcare Passport |
$49.34
|
| Rate for Payer: Multiplan PHCS |
$687.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$72.23
|
| Rate for Payer: UHCCP Medicaid |
$49.99
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$49.83
|
| Rate for Payer: Wellcare Medicare Advantage |
$55.56
|
|
|
APP SHORT LEG CAS(KNEE TO TOES
|
Facility
|
IP
|
$746.00
|
|
|
Service Code
|
HCPCS 29405
|
| Hospital Charge Code |
45000197
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$223.80 |
| Max. Negotiated Rate |
$716.16 |
| Rate for Payer: Aetna Commercial |
$574.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$581.88
|
| Rate for Payer: Cash Price |
$373.00
|
| Rate for Payer: Cigna Commercial |
$619.18
|
| Rate for Payer: First Health Commercial |
$708.70
|
| Rate for Payer: Humana Commercial |
$634.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$611.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$550.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$223.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$656.48
|
| Rate for Payer: Ohio Health Group HMO |
$559.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$596.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$649.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$514.74
|
| Rate for Payer: PHCS Commercial |
$716.16
|
| Rate for Payer: United Healthcare All Payer |
$656.48
|
|
|
APP SHORT LEG CAS(KNEE TO TOES
|
Facility
|
IP
|
$746.00
|
|
|
Service Code
|
HCPCS 29405
|
| Hospital Charge Code |
761T1060
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$223.80 |
| Max. Negotiated Rate |
$716.16 |
| Rate for Payer: Aetna Commercial |
$574.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$581.88
|
| Rate for Payer: Cash Price |
$373.00
|
| Rate for Payer: Cigna Commercial |
$619.18
|
| Rate for Payer: First Health Commercial |
$708.70
|
| Rate for Payer: Humana Commercial |
$634.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$611.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$550.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$223.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$656.48
|
| Rate for Payer: Ohio Health Group HMO |
$559.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$596.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$649.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$514.74
|
| Rate for Payer: PHCS Commercial |
$716.16
|
| Rate for Payer: United Healthcare All Payer |
$656.48
|
|
|
APP SHORT LEG CAS(KNEE TO TOES
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 29405
|
| Hospital Charge Code |
761P1060
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$47.61 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: Aetna Commercial |
$95.47
|
| Rate for Payer: Ambetter Exchange |
$55.56
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$47.61
|
| Rate for Payer: Anthem Medicaid |
$49.34
|
| Rate for Payer: Buckeye Individual/Medicaid |
$55.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$55.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$66.67
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$136.41
|
| Rate for Payer: Healthspan PPO |
$111.68
|
| Rate for Payer: Humana Medicaid |
$49.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$77.75
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$55.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.56
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$50.33
|
| Rate for Payer: Molina Healthcare Passport |
$49.34
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$72.23
|
| Rate for Payer: UHCCP Medicaid |
$49.99
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$49.83
|
| Rate for Payer: Wellcare Medicare Advantage |
$55.56
|
|
|
APP SHORT LEG SPLNTCALFTOFOO(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
761P1065
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$35.49 |
| Max. Negotiated Rate |
$105.29 |
| Rate for Payer: Aetna Commercial |
$73.17
|
| Rate for Payer: Ambetter Exchange |
$47.37
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$39.99
|
| Rate for Payer: Anthem Medicaid |
$35.49
|
| Rate for Payer: Buckeye Individual/Medicaid |
$47.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$47.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$56.84
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$105.29
|
| Rate for Payer: Healthspan PPO |
$88.58
|
| Rate for Payer: Humana Medicaid |
$35.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$60.61
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$47.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.37
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$36.20
|
| Rate for Payer: Molina Healthcare Passport |
$35.49
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$61.58
|
| Rate for Payer: UHCCP Medicaid |
$41.99
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$35.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$47.37
|
|
|
APP SHORT LEG SPLNTCALFTOFOO(T
|
Facility
|
IP
|
$398.00
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
761T1065
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$119.40 |
| Max. Negotiated Rate |
$382.08 |
| Rate for Payer: Aetna Commercial |
$306.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$310.44
|
| Rate for Payer: Cash Price |
$199.00
|
| Rate for Payer: Cigna Commercial |
$330.34
|
| Rate for Payer: First Health Commercial |
$378.10
|
| Rate for Payer: Humana Commercial |
$338.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$326.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$293.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$119.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$350.24
|
| Rate for Payer: Ohio Health Group HMO |
$298.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$318.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$346.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$274.62
|
| Rate for Payer: PHCS Commercial |
$382.08
|
| Rate for Payer: United Healthcare All Payer |
$350.24
|
|
|
APP SHORT LEG SPLNTCALFTOFOO(T
|
Facility
|
OP
|
$398.00
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
761T1065
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$136.87 |
| Max. Negotiated Rate |
$382.08 |
| Rate for Payer: Aetna Commercial |
$306.46
|
| Rate for Payer: Anthem Medicaid |
$136.87
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$145.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$310.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$204.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$196.82
|
| Rate for Payer: Cash Price |
$199.00
|
| Rate for Payer: Cash Price |
$199.00
|
| Rate for Payer: Cigna Commercial |
$330.34
|
| Rate for Payer: First Health Commercial |
$378.10
|
| Rate for Payer: Humana Commercial |
$338.30
|
| Rate for Payer: Humana KY Medicaid |
$136.87
|
| Rate for Payer: Humana Medicare Advantage |
$145.79
|
| Rate for Payer: Kentucky WC Medicaid |
$138.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$326.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$293.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$174.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$139.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$350.24
|
| Rate for Payer: Ohio Health Group HMO |
$298.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$318.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$346.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$274.62
|
| Rate for Payer: PHCS Commercial |
$382.08
|
| Rate for Payer: United Healthcare All Payer |
$350.24
|
|
