|
OSTECTOMY - COMPLETE EXCISION
|
Facility
|
IP
|
$700.00
|
|
|
Service Code
|
HCPCS 28112
|
| Hospital Charge Code |
76100981
|
|
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
|
|
|
OSTECTOMY, COMPLETE EXCISION; OTHER METATARSAL HEAD (SECOND, THIRD OR FOURTH)
|
Facility
|
OP
|
$3,918.70
|
|
|
Service Code
|
CPT 28112
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,799.07 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
|
|
OSTECTOMY - COMPLETE EXCISIO(P
|
Professional
|
Both
|
$700.00
|
|
|
Service Code
|
HCPCS 28112
|
| Hospital Charge Code |
761P0981
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$159.19 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Commercial |
$483.21
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$159.19
|
| Rate for Payer: Anthem Medicaid |
$241.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$700.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$530.17
|
| Rate for Payer: Healthspan PPO |
$603.00
|
| Rate for Payer: Humana Medicaid |
$241.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$391.70
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$246.10
|
| Rate for Payer: Molina Healthcare Passport |
$241.27
|
| Rate for Payer: Multiplan PHCS |
$420.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$490.00
|
| Rate for Payer: UHCCP Medicaid |
$167.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$243.68
|
|
|
OSTECTOMY - COMPLETE EXCISIO(P
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 28111
|
| Hospital Charge Code |
761P0980
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$167.03 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Aetna Commercial |
$518.03
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$167.03
|
| Rate for Payer: Anthem Medicaid |
$287.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,000.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$569.76
|
| Rate for Payer: Healthspan PPO |
$638.90
|
| Rate for Payer: Humana Medicaid |
$287.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$417.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$292.87
|
| Rate for Payer: Molina Healthcare Passport |
$287.13
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$175.38
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$290.00
|
|
|
OSTECTOMY OF STERNUM, PARTIAL
|
Facility
|
OP
|
$2,600.00
|
|
|
Service Code
|
HCPCS 21620
|
| Hospital Charge Code |
76100401
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$338.00 |
| Max. Negotiated Rate |
$2,496.00 |
| Rate for Payer: Aetna Commercial |
$2,002.00
|
| Rate for Payer: Anthem Medicaid |
$894.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,028.00
|
| Rate for Payer: Cash Price |
$1,300.00
|
| Rate for Payer: Cigna Commercial |
$2,158.00
|
| Rate for Payer: First Health Commercial |
$2,470.00
|
| Rate for Payer: Humana Commercial |
$2,210.00
|
| Rate for Payer: Humana KY Medicaid |
$894.14
|
| Rate for Payer: Kentucky WC Medicaid |
$903.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,132.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,918.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$780.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$912.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,288.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,950.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$520.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$338.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$806.00
|
| Rate for Payer: PHCS Commercial |
$2,496.00
|
| Rate for Payer: United Healthcare All Payer |
$2,288.00
|
|
|
OSTECTOMY OF STERNUM, PARTIAL
|
Facility
|
IP
|
$2,600.00
|
|
|
Service Code
|
HCPCS 21620
|
| Hospital Charge Code |
76100401
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$338.00 |
| Max. Negotiated Rate |
$2,496.00 |
| Rate for Payer: Aetna Commercial |
$2,002.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,028.00
|
| Rate for Payer: Cash Price |
$1,300.00
|
| Rate for Payer: Cigna Commercial |
$2,158.00
|
| Rate for Payer: First Health Commercial |
$2,470.00
|
| Rate for Payer: Humana Commercial |
$2,210.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,132.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,918.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$780.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,288.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,950.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$520.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$338.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$806.00
|
| Rate for Payer: PHCS Commercial |
$2,496.00
|
| Rate for Payer: United Healthcare All Payer |
$2,288.00
|
|
|
OSTECTOMY OF STERNUM, PARTIAL
|
Professional
|
Both
|
$2,600.00
|
|
|
Service Code
|
HCPCS 21620
|
| Hospital Charge Code |
76100401
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$390.85 |
| Max. Negotiated Rate |
$2,600.00 |
| Rate for Payer: Aetna Commercial |
$762.49
|
| Rate for Payer: Anthem Medicaid |
$390.85
|
| 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 |
$847.89
|
| Rate for Payer: Healthspan PPO |
$690.65
|
| Rate for Payer: Humana Medicaid |
$390.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$660.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$398.67
|
| Rate for Payer: Molina Healthcare Passport |
$390.85
|
| 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 |
$394.76
|
|
|
OSTECTOMY OF STERNUM, PARTIA(P
|
Professional
|
Both
|
$2,600.00
|
|
|
Service Code
|
HCPCS 21620
|
| Hospital Charge Code |
761P0401
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$390.85 |
| Max. Negotiated Rate |
$2,600.00 |
| Rate for Payer: Aetna Commercial |
$762.49
|
| Rate for Payer: Anthem Medicaid |
$390.85
|
| 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 |
$847.89
|
| Rate for Payer: Healthspan PPO |
$690.65
|
| Rate for Payer: Humana Medicaid |
$390.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$660.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$398.67
|
| Rate for Payer: Molina Healthcare Passport |
$390.85
|
| 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 |
$394.76
|
|
|
OSTECTOMY - PARTIAL
|
Facility
|
OP
|
$750.00
|
|
|
Service Code
|
HCPCS 28288
|
| Hospital Charge Code |
76101001
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$97.50 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Aetna Commercial |
$577.50
|
| Rate for Payer: Anthem Medicaid |
$257.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$585.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$622.50
|
| Rate for Payer: First Health Commercial |
$712.50
|
| Rate for Payer: Humana Commercial |
$637.50
|
| Rate for Payer: Humana KY Medicaid |
$257.92
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Kentucky WC Medicaid |
$260.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$615.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$553.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$263.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$660.00
|
| Rate for Payer: Ohio Health Group HMO |
$562.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$150.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$232.50
|
| Rate for Payer: PHCS Commercial |
$720.00
|
| Rate for Payer: United Healthcare All Payer |
$660.00
|
|
|
OSTECTOMY - PARTIAL
|
Professional
|
Both
|
$750.00
|
|
|
Service Code
|
HCPCS 28288
|
| Hospital Charge Code |
76101001
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$220.48 |
| Max. Negotiated Rate |
$750.00 |
| Rate for Payer: Aetna Commercial |
$632.16
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$220.96
|
| Rate for Payer: Anthem Medicaid |
$220.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$750.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$693.65
|
| Rate for Payer: Healthspan PPO |
$721.43
|
| Rate for Payer: Humana Medicaid |
$220.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$533.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$224.89
|
| Rate for Payer: Molina Healthcare Passport |
$220.48
|
| Rate for Payer: Multiplan PHCS |
$450.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$525.00
|
| Rate for Payer: UHCCP Medicaid |
$232.01
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$222.68
|
|
|
OSTECTOMY - PARTIAL
|
Facility
|
IP
|
$750.00
|
|
|
Service Code
|
HCPCS 28288
|
| Hospital Charge Code |
76101001
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$97.50 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Aetna Commercial |
$577.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$585.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$622.50
|
| Rate for Payer: First Health Commercial |
$712.50
|
| Rate for Payer: Humana Commercial |
$637.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$615.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$553.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$225.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$660.00
|
| Rate for Payer: Ohio Health Group HMO |
$562.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$150.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$232.50
|
| Rate for Payer: PHCS Commercial |
$720.00
|
| Rate for Payer: United Healthcare All Payer |
$660.00
|
|
|
OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL HEAD (BUNIONETTE) (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$3,918.70
|
|
|
Service Code
|
CPT 28110
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,799.07 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
|
|
OSTECTOMY - PARTIAL(P
|
Professional
|
Both
|
$750.00
|
|
|
Service Code
|
HCPCS 28288
|
| Hospital Charge Code |
761P1001
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$220.48 |
| Max. Negotiated Rate |
$750.00 |
| Rate for Payer: Aetna Commercial |
$632.16
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$220.96
|
| Rate for Payer: Anthem Medicaid |
$220.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$750.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$693.65
|
| Rate for Payer: Healthspan PPO |
$721.43
|
| Rate for Payer: Humana Medicaid |
$220.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$533.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$224.89
|
| Rate for Payer: Molina Healthcare Passport |
$220.48
|
| Rate for Payer: Multiplan PHCS |
$450.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$525.00
|
| Rate for Payer: UHCCP Medicaid |
$232.01
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$222.68
|
|
|
OSTEOAUGER HARVESTER 8MM
|
Facility
|
OP
|
$4,177.50
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$543.08 |
| Max. Negotiated Rate |
$4,010.40 |
| Rate for Payer: Aetna Commercial |
$3,216.68
|
| Rate for Payer: Anthem Medicaid |
$1,436.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,258.45
|
| Rate for Payer: Cash Price |
$2,088.75
|
| Rate for Payer: Cigna Commercial |
$3,467.32
|
| Rate for Payer: First Health Commercial |
$3,968.62
|
| Rate for Payer: Humana Commercial |
$3,550.88
|
| Rate for Payer: Humana KY Medicaid |
$1,436.64
|
| Rate for Payer: Kentucky WC Medicaid |
$1,451.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,425.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,083.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,253.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,465.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,676.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,133.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$835.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$543.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,295.02
|
| Rate for Payer: PHCS Commercial |
$4,010.40
|
| Rate for Payer: United Healthcare All Payer |
$3,676.20
|
|
|
OSTEOAUGER HARVESTER 8MM
|
Facility
|
IP
|
$4,177.50
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$543.08 |
| Max. Negotiated Rate |
$4,010.40 |
| Rate for Payer: Aetna Commercial |
$3,216.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,258.45
|
| Rate for Payer: Cash Price |
$2,088.75
|
| Rate for Payer: Cigna Commercial |
$3,467.32
|
| Rate for Payer: First Health Commercial |
$3,968.62
|
| Rate for Payer: Humana Commercial |
$3,550.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,425.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,083.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,253.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,676.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,133.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$835.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$543.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,295.02
|
| Rate for Payer: PHCS Commercial |
$4,010.40
|
| Rate for Payer: United Healthcare All Payer |
$3,676.20
|
|
|
OSTEOCHON AUTOGRAFT TRANS 10MM
|
Facility
|
IP
|
$4,020.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$522.60 |
| Max. Negotiated Rate |
$3,859.20 |
| Rate for Payer: Aetna Commercial |
$3,095.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,135.60
|
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Cigna Commercial |
$3,336.60
|
| Rate for Payer: First Health Commercial |
$3,819.00
|
| Rate for Payer: Humana Commercial |
$3,417.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,296.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,966.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,206.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,537.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,015.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$804.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,246.20
|
| Rate for Payer: PHCS Commercial |
$3,859.20
|
| Rate for Payer: United Healthcare All Payer |
$3,537.60
|
|
|
OSTEOCHON AUTOGRAFT TRANS 10MM
|
Facility
|
OP
|
$4,020.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$522.60 |
| Max. Negotiated Rate |
$3,859.20 |
| Rate for Payer: Aetna Commercial |
$3,095.40
|
| Rate for Payer: Anthem Medicaid |
$1,382.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,135.60
|
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Cigna Commercial |
$3,336.60
|
| Rate for Payer: First Health Commercial |
$3,819.00
|
| Rate for Payer: Humana Commercial |
$3,417.00
|
| Rate for Payer: Humana KY Medicaid |
$1,382.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1,396.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,296.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,966.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,206.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,410.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,537.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,015.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$804.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,246.20
|
| Rate for Payer: PHCS Commercial |
$3,859.20
|
| Rate for Payer: United Healthcare All Payer |
$3,537.60
|
|
|
OSTEOCHON AUTOGRAFT TRANS 6MM
|
Facility
|
IP
|
$4,020.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$522.60 |
| Max. Negotiated Rate |
$3,859.20 |
| Rate for Payer: Aetna Commercial |
$3,095.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,135.60
|
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Cigna Commercial |
$3,336.60
|
| Rate for Payer: First Health Commercial |
$3,819.00
|
| Rate for Payer: Humana Commercial |
$3,417.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,296.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,966.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,206.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,537.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,015.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$804.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,246.20
|
| Rate for Payer: PHCS Commercial |
$3,859.20
|
| Rate for Payer: United Healthcare All Payer |
$3,537.60
|
|
|
OSTEOCHON AUTOGRAFT TRANS 6MM
|
Facility
|
OP
|
$4,020.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$522.60 |
| Max. Negotiated Rate |
$3,859.20 |
| Rate for Payer: Aetna Commercial |
$3,095.40
|
| Rate for Payer: Anthem Medicaid |
$1,382.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,135.60
|
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Cigna Commercial |
$3,336.60
|
| Rate for Payer: First Health Commercial |
$3,819.00
|
| Rate for Payer: Humana Commercial |
$3,417.00
|
| Rate for Payer: Humana KY Medicaid |
$1,382.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1,396.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,296.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,966.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,206.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,410.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,537.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,015.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$804.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,246.20
|
| Rate for Payer: PHCS Commercial |
$3,859.20
|
| Rate for Payer: United Healthcare All Payer |
$3,537.60
|
|
|
OSTEOCHON AUTOGRAFT TRANS 8MM
|
Facility
|
OP
|
$4,020.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$522.60 |
| Max. Negotiated Rate |
$3,859.20 |
| Rate for Payer: Aetna Commercial |
$3,095.40
|
| Rate for Payer: Anthem Medicaid |
$1,382.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,135.60
|
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Cigna Commercial |
$3,336.60
|
| Rate for Payer: First Health Commercial |
$3,819.00
|
| Rate for Payer: Humana Commercial |
$3,417.00
|
| Rate for Payer: Humana KY Medicaid |
$1,382.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1,396.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,296.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,966.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,206.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,410.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,537.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,015.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$804.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,246.20
|
| Rate for Payer: PHCS Commercial |
$3,859.20
|
| Rate for Payer: United Healthcare All Payer |
$3,537.60
|
|
|
OSTEOCHON AUTOGRAFT TRANS 8MM
|
Facility
|
IP
|
$4,020.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$522.60 |
| Max. Negotiated Rate |
$3,859.20 |
| Rate for Payer: Aetna Commercial |
$3,095.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,135.60
|
| Rate for Payer: Cash Price |
$2,010.00
|
| Rate for Payer: Cigna Commercial |
$3,336.60
|
| Rate for Payer: First Health Commercial |
$3,819.00
|
| Rate for Payer: Humana Commercial |
$3,417.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,296.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,966.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,206.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,537.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,015.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$804.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,246.20
|
| Rate for Payer: PHCS Commercial |
$3,859.20
|
| Rate for Payer: United Healthcare All Payer |
$3,537.60
|
|
|
OSTEOCHONDRAL ALLOGRAFT, KNEE
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 27415
|
| Hospital Charge Code |
76100836
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$390.00 |
| Max. Negotiated Rate |
$15,933.60 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem Medicaid |
$1,031.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$11,381.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$15,933.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$15,364.54
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Humana KY Medicaid |
$1,031.70
|
| Rate for Payer: Humana Medicare Advantage |
$11,381.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,042.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13,657.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,052.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$390.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$930.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
OSTEOCHONDRAL ALLOGRAFT, KNEE
|
Facility
|
IP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 27415
|
| Hospital Charge Code |
76100836
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$390.00 |
| Max. Negotiated Rate |
$2,880.00 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$900.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$390.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$930.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
OSTEOCHONDRAL ALLOGRAFT, KNEE
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 27415
|
| Hospital Charge Code |
76100836
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$980.98 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$2,113.72
|
| Rate for Payer: Anthem Medicaid |
$980.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,000.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,239.67
|
| Rate for Payer: Healthspan PPO |
$1,914.58
|
| Rate for Payer: Humana Medicaid |
$980.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,712.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,000.60
|
| Rate for Payer: Molina Healthcare Passport |
$980.98
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,100.00
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$990.79
|
|
|
OSTEOCHONDRAL ALLOGRAFT, KNE(P
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 27415
|
| Hospital Charge Code |
761P0836
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$980.98 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$2,113.72
|
| Rate for Payer: Anthem Medicaid |
$980.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,000.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,239.67
|
| Rate for Payer: Healthspan PPO |
$1,914.58
|
| Rate for Payer: Humana Medicaid |
$980.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,712.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,000.60
|
| Rate for Payer: Molina Healthcare Passport |
$980.98
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,100.00
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$990.79
|
|
