|
OPEN DRAINAGE LIVER LESION
|
Professional
|
Both
|
$2,600.00
|
|
|
Service Code
|
HCPCS 47010
|
| Hospital Charge Code |
76101947
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$465.26 |
| Max. Negotiated Rate |
$2,600.00 |
| Rate for Payer: Aetna Commercial |
$1,698.39
|
| Rate for Payer: Anthem Medicaid |
$465.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,600.00
|
| Rate for Payer: Cash Price |
$1,300.00
|
| Rate for Payer: Cash Price |
$1,300.00
|
| Rate for Payer: Cigna Commercial |
$1,585.09
|
| Rate for Payer: Healthspan PPO |
$1,432.28
|
| Rate for Payer: Humana Medicaid |
$465.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,523.76
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$474.57
|
| Rate for Payer: Molina Healthcare Passport |
$465.26
|
| Rate for Payer: Multiplan PHCS |
$1,560.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,820.00
|
| Rate for Payer: UHCCP Medicaid |
$910.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$469.91
|
|
|
OPEN DRAINAGE LIVER LESION(P
|
Professional
|
Both
|
$2,600.00
|
|
|
Service Code
|
HCPCS 47010
|
| Hospital Charge Code |
761P1947
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$465.26 |
| Max. Negotiated Rate |
$2,600.00 |
| Rate for Payer: Aetna Commercial |
$1,698.39
|
| Rate for Payer: Anthem Medicaid |
$465.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,600.00
|
| Rate for Payer: Cash Price |
$1,300.00
|
| Rate for Payer: Cash Price |
$1,300.00
|
| Rate for Payer: Cigna Commercial |
$1,585.09
|
| Rate for Payer: Healthspan PPO |
$1,432.28
|
| Rate for Payer: Humana Medicaid |
$465.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,523.76
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$474.57
|
| Rate for Payer: Molina Healthcare Passport |
$465.26
|
| Rate for Payer: Multiplan PHCS |
$1,560.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,820.00
|
| Rate for Payer: UHCCP Medicaid |
$910.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$469.91
|
|
|
OPEN EXCISION PATELLAR OSSICLE
|
Facility
|
IP
|
$2,443.00
|
|
|
Service Code
|
HCPCS 27599
|
| Hospital Charge Code |
76102932
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$317.59 |
| Max. Negotiated Rate |
$2,345.28 |
| Rate for Payer: Aetna Commercial |
$1,881.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,905.54
|
| Rate for Payer: Cash Price |
$1,221.50
|
| Rate for Payer: Cigna Commercial |
$2,027.69
|
| Rate for Payer: First Health Commercial |
$2,320.85
|
| Rate for Payer: Humana Commercial |
$2,076.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,003.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,802.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$732.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,149.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,832.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$488.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$317.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$757.33
|
| Rate for Payer: PHCS Commercial |
$2,345.28
|
| Rate for Payer: United Healthcare All Payer |
$2,149.84
|
|
|
OPEN EXCISION PATELLAR OSSICLE
|
Facility
|
OP
|
$2,443.00
|
|
|
Service Code
|
HCPCS 27599
|
| Hospital Charge Code |
76102932
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$203.93 |
| Max. Negotiated Rate |
$2,345.28 |
| Rate for Payer: Aetna Commercial |
$1,881.11
|
| Rate for Payer: Anthem Medicaid |
$840.15
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$203.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,905.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$285.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$275.31
|
| Rate for Payer: Cash Price |
$1,221.50
|
| Rate for Payer: Cash Price |
$1,221.50
|
| Rate for Payer: Cigna Commercial |
$2,027.69
|
| Rate for Payer: First Health Commercial |
$2,320.85
|
| Rate for Payer: Humana Commercial |
$2,076.55
|
| Rate for Payer: Humana KY Medicaid |
$840.15
|
| Rate for Payer: Humana Medicare Advantage |
$203.93
|
| Rate for Payer: Kentucky WC Medicaid |
$848.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,003.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,802.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$244.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$857.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,149.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,832.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$488.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$317.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$757.33
|
| Rate for Payer: PHCS Commercial |
$2,345.28
|
| Rate for Payer: United Healthcare All Payer |
$2,149.84
|
|
|
OPEN EXCISION PATELLAR OSSICLE
|
Professional
|
Both
|
$2,443.00
|
|
|
Service Code
|
HCPCS 27599
|
| Hospital Charge Code |
76102932
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2,443.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$2,443.00
|
| Rate for Payer: Cash Price |
$1,221.50
|
| Rate for Payer: Cash Price |
$1,221.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$1,465.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,710.10
|
| Rate for Payer: UHCCP Medicaid |
$855.05
|
|
|
OPEN IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; SACRAL NERVE (TRANSFORAMINAL PLACEMENT)
|
Facility
|
OP
|
$8,279.85
|
|
|
Service Code
|
CPT 64581
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,914.18 |
| Max. Negotiated Rate |
$8,279.85 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,914.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,279.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,984.14
|
| Rate for Payer: Humana Medicare Advantage |
$5,914.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,097.02
|
|
|
OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INCLUDES OBTAINING GRAFT[S])
|
Facility
|
OP
|
$8,661.10
|
|
|
Service Code
|
CPT 28446
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,186.50 |
| Max. Negotiated Rate |
$8,661.10 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,186.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,661.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,351.78
|
| Rate for Payer: Humana Medicare Advantage |
$6,186.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,423.80
|
|
|
OPEN/PERQ PLACE STENT 1ST
|
Facility
|
OP
|
$5,375.00
|
|
|
Service Code
|
HCPCS 37236
|
| Hospital Charge Code |
76101560
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$698.75 |
| Max. Negotiated Rate |
$13,318.61 |
| Rate for Payer: Aetna Commercial |
$4,138.75
|
| Rate for Payer: Anthem Medicaid |
$1,848.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9,513.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,192.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13,318.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$12,842.94
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$4,461.25
|
| Rate for Payer: First Health Commercial |
$5,106.25
|
| Rate for Payer: Humana Commercial |
$4,568.75
|
| Rate for Payer: Humana KY Medicaid |
$1,848.46
|
| Rate for Payer: Humana Medicare Advantage |
$9,513.29
|
| Rate for Payer: Kentucky WC Medicaid |
$1,867.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,407.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,966.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,415.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,885.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,730.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,075.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$698.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,666.25
|
| Rate for Payer: PHCS Commercial |
$5,160.00
|
| Rate for Payer: United Healthcare All Payer |
$4,730.00
|
|
|
OPEN/PERQ PLACE STENT 1ST
|
Professional
|
Both
|
$5,375.00
|
|
|
Service Code
|
HCPCS 37236
|
| Hospital Charge Code |
76101560
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$365.33 |
| Max. Negotiated Rate |
$5,375.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$365.33
|
| Rate for Payer: Anthem Medicaid |
$377.71
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,375.00
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$852.94
|
| Rate for Payer: Healthspan PPO |
$3,428.17
|
| Rate for Payer: Humana Medicaid |
$377.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$614.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$385.26
|
| Rate for Payer: Molina Healthcare Passport |
$377.71
|
| Rate for Payer: Multiplan PHCS |
$3,225.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,762.50
|
| Rate for Payer: UHCCP Medicaid |
$383.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$381.49
|
|
|
OPEN/PERQ PLACE STENT 1ST
|
Facility
|
IP
|
$5,375.00
|
|
|
Service Code
|
HCPCS 37236
|
| Hospital Charge Code |
76101560
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$698.75 |
| Max. Negotiated Rate |
$5,160.00 |
| Rate for Payer: Aetna Commercial |
$4,138.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,192.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$4,461.25
|
| Rate for Payer: First Health Commercial |
$5,106.25
|
| Rate for Payer: Humana Commercial |
$4,568.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,407.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,966.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,612.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,730.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,075.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$698.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,666.25
|
| Rate for Payer: PHCS Commercial |
$5,160.00
|
| Rate for Payer: United Healthcare All Payer |
$4,730.00
|
|
|
OPEN/PERQ PLACE STENT 1ST(P
|
Professional
|
Both
|
$5,375.00
|
|
|
Service Code
|
HCPCS 37236
|
| Hospital Charge Code |
761P1560
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$365.33 |
| Max. Negotiated Rate |
$5,375.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$365.33
|
| Rate for Payer: Anthem Medicaid |
$377.71
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,375.00
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$852.94
|
| Rate for Payer: Healthspan PPO |
$3,428.17
|
| Rate for Payer: Humana Medicaid |
$377.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$614.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$385.26
|
| Rate for Payer: Molina Healthcare Passport |
$377.71
|
| Rate for Payer: Multiplan PHCS |
$3,225.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,762.50
|
| Rate for Payer: UHCCP Medicaid |
$383.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$381.49
|
|
|
OPEN/PERQ PLACE STENT EA ADD
|
Facility
|
OP
|
$535.00
|
|
|
Service Code
|
HCPCS 37239
|
| Hospital Charge Code |
76101563
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$69.55 |
| Max. Negotiated Rate |
$513.60 |
| Rate for Payer: Aetna Commercial |
$411.95
|
| Rate for Payer: Anthem Medicaid |
$183.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$417.30
|
| Rate for Payer: Cash Price |
$267.50
|
| Rate for Payer: Cigna Commercial |
$444.05
|
| Rate for Payer: First Health Commercial |
$508.25
|
| Rate for Payer: Humana Commercial |
$454.75
|
| Rate for Payer: Humana KY Medicaid |
$183.99
|
| Rate for Payer: Kentucky WC Medicaid |
$185.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$438.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$394.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$160.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$187.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$470.80
|
| Rate for Payer: Ohio Health Group HMO |
$401.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$107.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$165.85
|
| Rate for Payer: PHCS Commercial |
$513.60
|
| Rate for Payer: United Healthcare All Payer |
$470.80
|
|
|
OPEN/PERQ PLACE STENT EA ADD
|
Facility
|
OP
|
$420.00
|
|
|
Service Code
|
HCPCS 37237
|
| Hospital Charge Code |
76101561
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$403.20 |
| Rate for Payer: Aetna Commercial |
$323.40
|
| Rate for Payer: Anthem Medicaid |
$144.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$327.60
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cigna Commercial |
$348.60
|
| Rate for Payer: First Health Commercial |
$399.00
|
| Rate for Payer: Humana Commercial |
$357.00
|
| Rate for Payer: Humana KY Medicaid |
$144.44
|
| Rate for Payer: Kentucky WC Medicaid |
$145.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$344.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$309.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$126.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$147.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$369.60
|
| Rate for Payer: Ohio Health Group HMO |
$315.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$84.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$130.20
|
| Rate for Payer: PHCS Commercial |
$403.20
|
| Rate for Payer: United Healthcare All Payer |
$369.60
|
|
|
OPEN/PERQ PLACE STENT EA ADD
|
Professional
|
Both
|
$535.00
|
|
|
Service Code
|
HCPCS 37239
|
| Hospital Charge Code |
76101563
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$119.39 |
| Max. Negotiated Rate |
$2,473.56 |
| Rate for Payer: Molina Healthcare Passport |
$123.23
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$119.39
|
| Rate for Payer: Anthem Medicaid |
$123.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$535.00
|
| Rate for Payer: Cash Price |
$267.50
|
| Rate for Payer: Cash Price |
$267.50
|
| Rate for Payer: Cigna Commercial |
$278.38
|
| Rate for Payer: Healthspan PPO |
$2,473.56
|
| Rate for Payer: Humana Medicaid |
$123.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$200.69
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$125.69
|
| Rate for Payer: Multiplan PHCS |
$321.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$374.50
|
| Rate for Payer: UHCCP Medicaid |
$125.36
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$124.46
|
|
|
OPEN/PERQ PLACE STENT EA ADD
|
Facility
|
IP
|
$420.00
|
|
|
Service Code
|
HCPCS 37237
|
| Hospital Charge Code |
76101561
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$403.20 |
| Rate for Payer: Aetna Commercial |
$323.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$327.60
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cigna Commercial |
$348.60
|
| Rate for Payer: First Health Commercial |
$399.00
|
| Rate for Payer: Humana Commercial |
$357.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$344.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$309.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$126.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$369.60
|
| Rate for Payer: Ohio Health Group HMO |
$315.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$84.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$130.20
|
| Rate for Payer: PHCS Commercial |
$403.20
|
| Rate for Payer: United Healthcare All Payer |
$369.60
|
|
|
OPEN/PERQ PLACE STENT EA ADD
|
Facility
|
IP
|
$535.00
|
|
|
Service Code
|
HCPCS 37239
|
| Hospital Charge Code |
76101563
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$69.55 |
| Max. Negotiated Rate |
$513.60 |
| Rate for Payer: Aetna Commercial |
$411.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$417.30
|
| Rate for Payer: Cash Price |
$267.50
|
| Rate for Payer: Cigna Commercial |
$444.05
|
| Rate for Payer: First Health Commercial |
$508.25
|
| Rate for Payer: Humana Commercial |
$454.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$438.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$394.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$160.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$470.80
|
| Rate for Payer: Ohio Health Group HMO |
$401.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$107.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$165.85
|
| Rate for Payer: PHCS Commercial |
$513.60
|
| Rate for Payer: United Healthcare All Payer |
$470.80
|
|
|
OPEN/PERQ PLACE STENT EA ADD
|
Professional
|
Both
|
$420.00
|
|
|
Service Code
|
HCPCS 37237
|
| Hospital Charge Code |
76101561
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$171.04 |
| Max. Negotiated Rate |
$1,491.14 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$171.04
|
| Rate for Payer: Anthem Medicaid |
$176.55
|
| Rate for Payer: Buckeye Medicare Advantage |
$420.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cigna Commercial |
$398.84
|
| Rate for Payer: Healthspan PPO |
$1,491.14
|
| Rate for Payer: Humana Medicaid |
$176.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$287.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$180.08
|
| Rate for Payer: Molina Healthcare Passport |
$176.55
|
| Rate for Payer: Multiplan PHCS |
$252.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$294.00
|
| Rate for Payer: UHCCP Medicaid |
$179.59
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$178.32
|
|
|
OPEN/PERQ PLACE STENT EA AD(P
|
Professional
|
Both
|
$535.00
|
|
|
Service Code
|
HCPCS 37239
|
| Hospital Charge Code |
761P1563
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$119.39 |
| Max. Negotiated Rate |
$2,473.56 |
| Rate for Payer: Cash Price |
$267.50
|
| Rate for Payer: Cigna Commercial |
$278.38
|
| Rate for Payer: Healthspan PPO |
$2,473.56
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$119.39
|
| Rate for Payer: Anthem Medicaid |
$123.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$535.00
|
| Rate for Payer: Cash Price |
$267.50
|
| Rate for Payer: Humana Medicaid |
$123.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$200.69
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$125.69
|
| Rate for Payer: Molina Healthcare Passport |
$123.23
|
| Rate for Payer: Multiplan PHCS |
$321.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$374.50
|
| Rate for Payer: UHCCP Medicaid |
$125.36
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$124.46
|
|
|
OPEN/PERQ PLACE STENT EA AD(P
|
Professional
|
Both
|
$420.00
|
|
|
Service Code
|
HCPCS 37237
|
| Hospital Charge Code |
761P1561
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$171.04 |
| Max. Negotiated Rate |
$1,491.14 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$171.04
|
| Rate for Payer: Anthem Medicaid |
$176.55
|
| Rate for Payer: Buckeye Medicare Advantage |
$420.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cigna Commercial |
$398.84
|
| Rate for Payer: Healthspan PPO |
$1,491.14
|
| Rate for Payer: Humana Medicaid |
$176.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$287.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$180.08
|
| Rate for Payer: Molina Healthcare Passport |
$176.55
|
| Rate for Payer: Multiplan PHCS |
$252.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$294.00
|
| Rate for Payer: UHCCP Medicaid |
$179.59
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$178.32
|
|
|
OPEN/PERQ PLACE STENT SAME
|
Facility
|
OP
|
$800.00
|
|
|
Service Code
|
HCPCS 37238
|
| Hospital Charge Code |
76101562
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$104.00 |
| Max. Negotiated Rate |
$13,318.61 |
| Rate for Payer: Aetna Commercial |
$616.00
|
| Rate for Payer: Anthem Medicaid |
$275.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9,513.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13,318.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$12,842.94
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$664.00
|
| Rate for Payer: First Health Commercial |
$760.00
|
| Rate for Payer: Humana Commercial |
$680.00
|
| Rate for Payer: Humana KY Medicaid |
$275.12
|
| Rate for Payer: Humana Medicare Advantage |
$9,513.29
|
| Rate for Payer: Kentucky WC Medicaid |
$277.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$590.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,415.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$280.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.00
|
| Rate for Payer: Ohio Health Group HMO |
$600.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.00
|
| Rate for Payer: PHCS Commercial |
$768.00
|
| Rate for Payer: United Healthcare All Payer |
$704.00
|
|
|
OPEN/PERQ PLACE STENT SAME
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 37238
|
| Hospital Charge Code |
76101562
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$255.89 |
| Max. Negotiated Rate |
$4,977.64 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$255.89
|
| Rate for Payer: Anthem Medicaid |
$264.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$800.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$597.49
|
| Rate for Payer: Healthspan PPO |
$4,977.64
|
| Rate for Payer: Humana Medicaid |
$264.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$430.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$269.87
|
| Rate for Payer: Molina Healthcare Passport |
$264.58
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$560.00
|
| Rate for Payer: UHCCP Medicaid |
$268.68
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$267.23
|
|
|
OPEN/PERQ PLACE STENT SAME
|
Facility
|
IP
|
$800.00
|
|
|
Service Code
|
HCPCS 37238
|
| Hospital Charge Code |
76101562
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$104.00 |
| Max. Negotiated Rate |
$768.00 |
| Rate for Payer: Aetna Commercial |
$616.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$664.00
|
| Rate for Payer: First Health Commercial |
$760.00
|
| Rate for Payer: Humana Commercial |
$680.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$590.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.00
|
| Rate for Payer: Ohio Health Group HMO |
$600.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.00
|
| Rate for Payer: PHCS Commercial |
$768.00
|
| Rate for Payer: United Healthcare All Payer |
$704.00
|
|
|
OPEN/PERQ PLACE STENT SAME(P
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 37238
|
| Hospital Charge Code |
761P1562
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$255.89 |
| Max. Negotiated Rate |
$4,977.64 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$255.89
|
| Rate for Payer: Anthem Medicaid |
$264.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$800.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$597.49
|
| Rate for Payer: Healthspan PPO |
$4,977.64
|
| Rate for Payer: Humana Medicaid |
$264.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$430.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$269.87
|
| Rate for Payer: Molina Healthcare Passport |
$264.58
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$560.00
|
| Rate for Payer: UHCCP Medicaid |
$268.68
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$267.23
|
|
|
OPEN PROX HUM FX PROSTH RPLCMT
|
Facility
|
IP
|
$3,800.00
|
|
|
Service Code
|
HCPCS 23616
|
| Hospital Charge Code |
76100481
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$494.00 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$760.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$494.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,178.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
|
OPEN PROX HUM FX PROSTH RPLCMT
|
Facility
|
OP
|
$3,800.00
|
|
|
Service Code
|
HCPCS 23616
|
| Hospital Charge Code |
76100481
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$494.00 |
| Max. Negotiated Rate |
$22,561.84 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem Medicaid |
$1,306.82
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$16,115.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$22,561.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$21,756.06
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Humana KY Medicaid |
$1,306.82
|
| Rate for Payer: Humana Medicare Advantage |
$16,115.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1,320.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19,338.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,333.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$760.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$494.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,178.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
