|
APP SHORT LEG CAS(KNEE TO TOES
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
HCPCS 29405
|
| Hospital Charge Code |
761T1060
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$91.00 |
| Max. Negotiated Rate |
$672.00 |
| Rate for Payer: Aetna Commercial |
$539.00
|
| Rate for Payer: Anthem Medicaid |
$240.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$232.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$546.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$325.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$313.52
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$581.00
|
| Rate for Payer: First Health Commercial |
$665.00
|
| Rate for Payer: Humana Commercial |
$595.00
|
| Rate for Payer: Humana KY Medicaid |
$240.73
|
| Rate for Payer: Humana Medicare Advantage |
$232.24
|
| Rate for Payer: Kentucky WC Medicaid |
$243.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$574.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$516.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$278.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$245.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$616.00
|
| Rate for Payer: Ohio Health Group HMO |
$525.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$91.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$217.00
|
| Rate for Payer: PHCS Commercial |
$672.00
|
| Rate for Payer: United Healthcare All Payer |
$616.00
|
|
|
APP SHORT LEG CAS(KNEE TO TOES
|
Facility
|
IP
|
$1,100.00
|
|
|
Service Code
|
HCPCS 29405
|
| Hospital Charge Code |
76101060
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$341.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
APP SHORT LEG CAS(KNEE TO TOES
|
Facility
|
IP
|
$371.00
|
|
|
Service Code
|
HCPCS 29405
|
| Hospital Charge Code |
45000197
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$48.23 |
| Max. Negotiated Rate |
$356.16 |
| Rate for Payer: Aetna Commercial |
$285.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$289.38
|
| Rate for Payer: Cash Price |
$185.50
|
| Rate for Payer: Cigna Commercial |
$307.93
|
| Rate for Payer: First Health Commercial |
$352.45
|
| Rate for Payer: Humana Commercial |
$315.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$304.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$273.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$111.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$326.48
|
| Rate for Payer: Ohio Health Group HMO |
$278.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$115.01
|
| Rate for Payer: PHCS Commercial |
$356.16
|
| Rate for Payer: United Healthcare All Payer |
$326.48
|
|
|
APP SHORT LEG CAS(KNEE TO TOES
|
Facility
|
IP
|
$700.00
|
|
|
Service Code
|
HCPCS 29405
|
| Hospital Charge Code |
761T1060
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$91.00 |
| Max. Negotiated Rate |
$672.00 |
| Rate for Payer: Aetna Commercial |
$539.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$546.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$581.00
|
| Rate for Payer: First Health Commercial |
$665.00
|
| Rate for Payer: Humana Commercial |
$595.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$574.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$516.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$210.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$616.00
|
| Rate for Payer: Ohio Health Group HMO |
$525.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$91.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$217.00
|
| Rate for Payer: PHCS Commercial |
$672.00
|
| Rate for Payer: United Healthcare All Payer |
$616.00
|
|
|
APP SHORT LEG CAS(KNEE TO TOES
|
Facility
|
OP
|
$371.00
|
|
|
Service Code
|
HCPCS 29405
|
| Hospital Charge Code |
45000197
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$48.23 |
| Max. Negotiated Rate |
$356.16 |
| Rate for Payer: Aetna Commercial |
$285.67
|
| Rate for Payer: Anthem Medicaid |
$127.59
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$232.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$289.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$325.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$313.52
|
| Rate for Payer: Cash Price |
$185.50
|
| Rate for Payer: Cash Price |
$185.50
|
| Rate for Payer: Cigna Commercial |
$307.93
|
| Rate for Payer: First Health Commercial |
$352.45
|
| Rate for Payer: Humana Commercial |
$315.35
|
| Rate for Payer: Humana KY Medicaid |
$127.59
|
| Rate for Payer: Humana Medicare Advantage |
$232.24
|
| Rate for Payer: Kentucky WC Medicaid |
$128.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$304.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$273.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$278.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$130.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$326.48
|
| Rate for Payer: Ohio Health Group HMO |
$278.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$115.01
|
| Rate for Payer: PHCS Commercial |
$356.16
|
| Rate for Payer: United Healthcare All Payer |
$326.48
|
|
|
APP SHORT LEG SPLNTCALFTOFOO(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
761P1065
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$29.18 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Aetna Commercial |
$73.17
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$39.99
|
| Rate for Payer: Anthem Medicaid |
$29.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$150.00
|
| 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 |
$29.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$60.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$29.76
|
| Rate for Payer: Molina Healthcare Passport |
$29.18
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$41.99
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$29.47
|
|
|
APP SHORT LEG SPLNTCALFTOFOO(T
|
Facility
|
OP
|
$374.00
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
761T1065
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$48.62 |
| Max. Negotiated Rate |
$359.04 |
| Rate for Payer: Aetna Commercial |
$287.98
|
| Rate for Payer: Anthem Medicaid |
$128.62
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$136.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$291.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$190.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$183.95
|
| Rate for Payer: Cash Price |
$187.00
|
| Rate for Payer: Cash Price |
$187.00
|
| Rate for Payer: Cigna Commercial |
$310.42
|
| Rate for Payer: First Health Commercial |
$355.30
|
| Rate for Payer: Humana Commercial |
$317.90
|
| Rate for Payer: Humana KY Medicaid |
$128.62
|
| Rate for Payer: Humana Medicare Advantage |
$136.26
|
| Rate for Payer: Kentucky WC Medicaid |
$129.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$306.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$276.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$131.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$329.12
|
| Rate for Payer: Ohio Health Group HMO |
$280.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$115.94
|
| Rate for Payer: PHCS Commercial |
$359.04
|
| Rate for Payer: United Healthcare All Payer |
$329.12
|
|
|
APP SHORT LEG SPLNTCALFTOFOO(T
|
Facility
|
IP
|
$374.00
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
761T1065
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$48.62 |
| Max. Negotiated Rate |
$359.04 |
| Rate for Payer: Aetna Commercial |
$287.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$291.72
|
| Rate for Payer: Cash Price |
$187.00
|
| Rate for Payer: Cigna Commercial |
$310.42
|
| Rate for Payer: First Health Commercial |
$355.30
|
| Rate for Payer: Humana Commercial |
$317.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$306.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$276.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$112.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$329.12
|
| Rate for Payer: Ohio Health Group HMO |
$280.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$115.94
|
| Rate for Payer: PHCS Commercial |
$359.04
|
| Rate for Payer: United Healthcare All Payer |
$329.12
|
|
|
APP SHORT LEG SPLNTCALFTOFOOT
|
Facility
|
IP
|
$524.00
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
76101065
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$68.12 |
| Max. Negotiated Rate |
$503.04 |
| Rate for Payer: Aetna Commercial |
$403.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$408.72
|
| Rate for Payer: Cash Price |
$262.00
|
| Rate for Payer: Cigna Commercial |
$434.92
|
| Rate for Payer: First Health Commercial |
$497.80
|
| Rate for Payer: Humana Commercial |
$445.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$429.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$386.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$157.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$461.12
|
| Rate for Payer: Ohio Health Group HMO |
$393.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$104.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$162.44
|
| Rate for Payer: PHCS Commercial |
$503.04
|
| Rate for Payer: United Healthcare All Payer |
$461.12
|
|
|
APP SHORT LEG SPLNTCALFTOFOOT
|
Facility
|
IP
|
$209.00
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
45000200
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$27.17 |
| Max. Negotiated Rate |
$200.64 |
| Rate for Payer: Aetna Commercial |
$160.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$163.02
|
| Rate for Payer: Cash Price |
$104.50
|
| Rate for Payer: Cigna Commercial |
$173.47
|
| Rate for Payer: First Health Commercial |
$198.55
|
| Rate for Payer: Humana Commercial |
$177.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$171.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$154.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$62.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$183.92
|
| Rate for Payer: Ohio Health Group HMO |
$156.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$41.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$27.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$64.79
|
| Rate for Payer: PHCS Commercial |
$200.64
|
| Rate for Payer: United Healthcare All Payer |
$183.92
|
|
|
APP SHORT LEG SPLNTCALFTOFOOT
|
Professional
|
Both
|
$524.00
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
76101065
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$29.18 |
| Max. Negotiated Rate |
$524.00 |
| Rate for Payer: Aetna Commercial |
$73.17
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$39.99
|
| Rate for Payer: Anthem Medicaid |
$29.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$524.00
|
| Rate for Payer: Cash Price |
$262.00
|
| Rate for Payer: Cash Price |
$262.00
|
| Rate for Payer: Cigna Commercial |
$105.29
|
| Rate for Payer: Healthspan PPO |
$88.58
|
| Rate for Payer: Humana Medicaid |
$29.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$60.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$29.76
|
| Rate for Payer: Molina Healthcare Passport |
$29.18
|
| Rate for Payer: Multiplan PHCS |
$314.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$366.80
|
| Rate for Payer: UHCCP Medicaid |
$41.99
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$29.47
|
|
|
APP SHORT LEG SPLNTCALFTOFOOT
|
Facility
|
OP
|
$209.00
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
45000200
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$27.17 |
| Max. Negotiated Rate |
$200.64 |
| Rate for Payer: Aetna Commercial |
$160.93
|
| Rate for Payer: Anthem Medicaid |
$71.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$136.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$163.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$190.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$183.95
|
| Rate for Payer: Cash Price |
$104.50
|
| Rate for Payer: Cash Price |
$104.50
|
| Rate for Payer: Cigna Commercial |
$173.47
|
| Rate for Payer: First Health Commercial |
$198.55
|
| Rate for Payer: Humana Commercial |
$177.65
|
| Rate for Payer: Humana KY Medicaid |
$71.88
|
| Rate for Payer: Humana Medicare Advantage |
$136.26
|
| Rate for Payer: Kentucky WC Medicaid |
$72.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$171.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$154.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$73.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$183.92
|
| Rate for Payer: Ohio Health Group HMO |
$156.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$41.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$27.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$64.79
|
| Rate for Payer: PHCS Commercial |
$200.64
|
| Rate for Payer: United Healthcare All Payer |
$183.92
|
|
|
APP SHORT LEG SPLNTCALFTOFOOT
|
Facility
|
OP
|
$524.00
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
76101065
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$68.12 |
| Max. Negotiated Rate |
$503.04 |
| Rate for Payer: Aetna Commercial |
$403.48
|
| Rate for Payer: Anthem Medicaid |
$180.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$136.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$408.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$190.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$183.95
|
| Rate for Payer: Cash Price |
$262.00
|
| Rate for Payer: Cash Price |
$262.00
|
| Rate for Payer: Cigna Commercial |
$434.92
|
| Rate for Payer: First Health Commercial |
$497.80
|
| Rate for Payer: Humana Commercial |
$445.40
|
| Rate for Payer: Humana KY Medicaid |
$180.20
|
| Rate for Payer: Humana Medicare Advantage |
$136.26
|
| Rate for Payer: Kentucky WC Medicaid |
$182.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$429.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$386.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$183.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$461.12
|
| Rate for Payer: Ohio Health Group HMO |
$393.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$104.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$162.44
|
| Rate for Payer: PHCS Commercial |
$503.04
|
| Rate for Payer: United Healthcare All Payer |
$461.12
|
|
|
APP SKINSUB T/A/L >=100SCM HC
|
Professional
|
Both
|
$4,864.00
|
|
|
Service Code
|
HCPCS 15273
|
| Hospital Charge Code |
76100192
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$100.71 |
| Max. Negotiated Rate |
$4,864.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$100.71
|
| Rate for Payer: Anthem Medicaid |
$167.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,864.00
|
| Rate for Payer: Cash Price |
$2,432.00
|
| Rate for Payer: Cash Price |
$2,432.00
|
| Rate for Payer: Cigna Commercial |
$354.01
|
| Rate for Payer: Healthspan PPO |
$268.95
|
| Rate for Payer: Humana Medicaid |
$167.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$261.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$170.47
|
| Rate for Payer: Molina Healthcare Passport |
$167.13
|
| Rate for Payer: Multiplan PHCS |
$2,918.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,404.80
|
| Rate for Payer: UHCCP Medicaid |
$105.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$168.80
|
|
|
APP SKINSUB T/A/L >=100SCM HC
|
Facility
|
OP
|
$4,864.00
|
|
|
Service Code
|
HCPCS 15273
|
| Hospital Charge Code |
76100192
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$632.32 |
| Max. Negotiated Rate |
$4,669.44 |
| Rate for Payer: Aetna Commercial |
$3,745.28
|
| Rate for Payer: Anthem Medicaid |
$1,672.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,102.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,793.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,343.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,188.25
|
| Rate for Payer: Cash Price |
$2,432.00
|
| Rate for Payer: Cash Price |
$2,432.00
|
| Rate for Payer: Cigna Commercial |
$4,037.12
|
| Rate for Payer: First Health Commercial |
$4,620.80
|
| Rate for Payer: Humana Commercial |
$4,134.40
|
| Rate for Payer: Humana KY Medicaid |
$1,672.73
|
| Rate for Payer: Humana Medicare Advantage |
$3,102.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1,689.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,988.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,589.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,706.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,280.32
|
| Rate for Payer: Ohio Health Group HMO |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$972.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$632.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,507.84
|
| Rate for Payer: PHCS Commercial |
$4,669.44
|
| Rate for Payer: United Healthcare All Payer |
$4,280.32
|
|
|
APP SKINSUB T/A/L >=100SCM HC
|
Facility
|
IP
|
$4,864.00
|
|
|
Service Code
|
HCPCS 15273
|
| Hospital Charge Code |
76100192
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$632.32 |
| Max. Negotiated Rate |
$4,669.44 |
| Rate for Payer: Aetna Commercial |
$3,745.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,793.92
|
| Rate for Payer: Cash Price |
$2,432.00
|
| Rate for Payer: Cigna Commercial |
$4,037.12
|
| Rate for Payer: First Health Commercial |
$4,620.80
|
| Rate for Payer: Humana Commercial |
$4,134.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,988.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,589.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,459.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,280.32
|
| Rate for Payer: Ohio Health Group HMO |
$3,648.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$972.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$632.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,507.84
|
| Rate for Payer: PHCS Commercial |
$4,669.44
|
| Rate for Payer: United Healthcare All Payer |
$4,280.32
|
|
|
APP SKINSUB T/A/L >=100SCM H(P
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 15273
|
| Hospital Charge Code |
761P0192
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$100.71 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$100.71
|
| Rate for Payer: Anthem Medicaid |
$167.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$600.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$354.01
|
| Rate for Payer: Healthspan PPO |
$268.95
|
| Rate for Payer: Humana Medicaid |
$167.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$261.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$170.47
|
| Rate for Payer: Molina Healthcare Passport |
$167.13
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$105.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$168.80
|
|
|
APP SKINSUB T/A/L >=100SCM H(T
|
Facility
|
IP
|
$4,264.00
|
|
|
Service Code
|
HCPCS 15273
|
| Hospital Charge Code |
761T0192
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$554.32 |
| Max. Negotiated Rate |
$4,093.44 |
| Rate for Payer: Aetna Commercial |
$3,283.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,325.92
|
| Rate for Payer: Cash Price |
$2,132.00
|
| Rate for Payer: Cigna Commercial |
$3,539.12
|
| Rate for Payer: First Health Commercial |
$4,050.80
|
| Rate for Payer: Humana Commercial |
$3,624.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,496.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,146.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,279.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,752.32
|
| Rate for Payer: Ohio Health Group HMO |
$3,198.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$852.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$554.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,321.84
|
| Rate for Payer: PHCS Commercial |
$4,093.44
|
| Rate for Payer: United Healthcare All Payer |
$3,752.32
|
|
|
APP SKINSUB T/A/L >=100SCM H(T
|
Facility
|
OP
|
$4,264.00
|
|
|
Service Code
|
HCPCS 15273
|
| Hospital Charge Code |
761T0192
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$554.32 |
| Max. Negotiated Rate |
$4,343.37 |
| Rate for Payer: Aetna Commercial |
$3,283.28
|
| Rate for Payer: Anthem Medicaid |
$1,466.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,102.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,325.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,343.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,188.25
|
| Rate for Payer: Cash Price |
$2,132.00
|
| Rate for Payer: Cash Price |
$2,132.00
|
| Rate for Payer: Cigna Commercial |
$3,539.12
|
| Rate for Payer: First Health Commercial |
$4,050.80
|
| Rate for Payer: Humana Commercial |
$3,624.40
|
| Rate for Payer: Humana KY Medicaid |
$1,466.39
|
| Rate for Payer: Humana Medicare Advantage |
$3,102.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1,481.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,496.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,146.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,495.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,752.32
|
| Rate for Payer: Ohio Health Group HMO |
$3,198.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$852.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$554.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,321.84
|
| Rate for Payer: PHCS Commercial |
$4,093.44
|
| Rate for Payer: United Healthcare All Payer |
$3,752.32
|
|
|
APP TOPICAL FLUORIDE VARNISH
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
HCPCS 99188
|
| Hospital Charge Code |
51000343
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$33.60 |
| Rate for Payer: Aetna Commercial |
$26.95
|
| Rate for Payer: Anthem Medicaid |
$12.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.30
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cigna Commercial |
$29.05
|
| Rate for Payer: First Health Commercial |
$33.25
|
| Rate for Payer: Humana Commercial |
$29.75
|
| Rate for Payer: Humana KY Medicaid |
$12.04
|
| Rate for Payer: Kentucky WC Medicaid |
$12.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.80
|
| Rate for Payer: Ohio Health Group HMO |
$26.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.85
|
| Rate for Payer: PHCS Commercial |
$33.60
|
| Rate for Payer: United Healthcare All Payer |
$30.80
|
|
|
APP TOPICAL FLUORIDE VARNISH
|
Professional
|
Both
|
$35.00
|
|
|
Service Code
|
HCPCS 99188
|
| Hospital Charge Code |
51000343
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Anthem Medicaid |
$18.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$35.00
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Humana Medicaid |
$18.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$13.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$19.12
|
| Rate for Payer: Molina Healthcare Passport |
$18.75
|
| Rate for Payer: Multiplan PHCS |
$21.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$24.50
|
| Rate for Payer: UHCCP Medicaid |
$12.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$18.94
|
|
|
APP TOPICAL FLUORIDE VARNISH
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS 99188
|
| Hospital Charge Code |
51000343
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$33.60 |
| Rate for Payer: Aetna Commercial |
$26.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.30
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cigna Commercial |
$29.05
|
| Rate for Payer: First Health Commercial |
$33.25
|
| Rate for Payer: Humana Commercial |
$29.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.80
|
| Rate for Payer: Ohio Health Group HMO |
$26.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.85
|
| Rate for Payer: PHCS Commercial |
$33.60
|
| Rate for Payer: United Healthcare All Payer |
$30.80
|
|
|
APP UNIPLANE EXT FIXATION SY(P
|
Professional
|
Both
|
$1,250.00
|
|
|
Service Code
|
HCPCS 20690
|
| Hospital Charge Code |
761P0351
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$215.55 |
| Max. Negotiated Rate |
$1,250.00 |
| Rate for Payer: Aetna Commercial |
$782.22
|
| Rate for Payer: Anthem Medicaid |
$215.55
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,250.00
|
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Cigna Commercial |
$411.39
|
| Rate for Payer: Healthspan PPO |
$708.53
|
| Rate for Payer: Humana Medicaid |
$215.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$717.13
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$219.86
|
| Rate for Payer: Molina Healthcare Passport |
$215.55
|
| Rate for Payer: Multiplan PHCS |
$750.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$875.00
|
| Rate for Payer: UHCCP Medicaid |
$437.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$217.71
|
|
|
APP UNIPLANE EXT FIXATION SYS
|
Facility
|
OP
|
$9,818.00
|
|
|
Service Code
|
HCPCS 20690
|
| Hospital Charge Code |
76100351
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,276.34 |
| Max. Negotiated Rate |
$9,425.28 |
| Rate for Payer: Aetna Commercial |
$7,559.86
|
| Rate for Payer: Anthem Medicaid |
$3,376.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,186.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,658.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,661.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,351.78
|
| Rate for Payer: Cash Price |
$4,909.00
|
| Rate for Payer: Cash Price |
$4,909.00
|
| Rate for Payer: Cigna Commercial |
$8,148.94
|
| Rate for Payer: First Health Commercial |
$9,327.10
|
| Rate for Payer: Humana Commercial |
$8,345.30
|
| Rate for Payer: Humana KY Medicaid |
$3,376.41
|
| Rate for Payer: Humana Medicare Advantage |
$6,186.50
|
| Rate for Payer: Kentucky WC Medicaid |
$3,410.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,050.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,245.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,423.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,444.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,639.84
|
| Rate for Payer: Ohio Health Group HMO |
$7,363.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,963.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,276.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,043.58
|
| Rate for Payer: PHCS Commercial |
$9,425.28
|
| Rate for Payer: United Healthcare All Payer |
$8,639.84
|
|
|
APP UNIPLANE EXT FIXATION SYS
|
Facility
|
IP
|
$9,818.00
|
|
|
Service Code
|
HCPCS 20690
|
| Hospital Charge Code |
76100351
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,276.34 |
| Max. Negotiated Rate |
$9,425.28 |
| Rate for Payer: Aetna Commercial |
$7,559.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,658.04
|
| Rate for Payer: Cash Price |
$4,909.00
|
| Rate for Payer: Cigna Commercial |
$8,148.94
|
| Rate for Payer: First Health Commercial |
$9,327.10
|
| Rate for Payer: Humana Commercial |
$8,345.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,050.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,245.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,945.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,639.84
|
| Rate for Payer: Ohio Health Group HMO |
$7,363.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,963.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,276.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,043.58
|
| Rate for Payer: PHCS Commercial |
$9,425.28
|
| Rate for Payer: United Healthcare All Payer |
$8,639.84
|
|
