|
RECONSTRUCTION - CHEST WALL
|
Facility
|
OP
|
$3,700.00
|
|
|
Service Code
|
HCPCS 32820
|
| Hospital Charge Code |
76101233
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$481.00 |
| Max. Negotiated Rate |
$3,552.00 |
| Rate for Payer: Aetna Commercial |
$2,849.00
|
| Rate for Payer: Anthem Medicaid |
$1,272.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,886.00
|
| Rate for Payer: Cash Price |
$1,850.00
|
| Rate for Payer: Cigna Commercial |
$3,071.00
|
| Rate for Payer: First Health Commercial |
$3,515.00
|
| Rate for Payer: Humana Commercial |
$3,145.00
|
| Rate for Payer: Humana KY Medicaid |
$1,272.43
|
| Rate for Payer: Kentucky WC Medicaid |
$1,285.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,034.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,730.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,110.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,297.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,256.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,775.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$740.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$481.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,147.00
|
| Rate for Payer: PHCS Commercial |
$3,552.00
|
| Rate for Payer: United Healthcare All Payer |
$3,256.00
|
|
|
RECONSTRUCTION - CHEST WALL
|
Facility
|
IP
|
$3,700.00
|
|
|
Service Code
|
HCPCS 32820
|
| Hospital Charge Code |
76101233
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$481.00 |
| Max. Negotiated Rate |
$3,552.00 |
| Rate for Payer: Aetna Commercial |
$2,849.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,886.00
|
| Rate for Payer: Cash Price |
$1,850.00
|
| Rate for Payer: Cigna Commercial |
$3,071.00
|
| Rate for Payer: First Health Commercial |
$3,515.00
|
| Rate for Payer: Humana Commercial |
$3,145.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,034.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,730.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,110.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,256.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,775.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$740.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$481.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,147.00
|
| Rate for Payer: PHCS Commercial |
$3,552.00
|
| Rate for Payer: United Healthcare All Payer |
$3,256.00
|
|
|
RECONSTRUCTION - CHEST WALL(P
|
Professional
|
Both
|
$3,700.00
|
|
|
Service Code
|
HCPCS 32820
|
| Hospital Charge Code |
761P1233
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,169.03 |
| Max. Negotiated Rate |
$3,700.00 |
| Rate for Payer: Aetna Commercial |
$2,223.38
|
| Rate for Payer: Anthem Medicaid |
$1,169.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,700.00
|
| Rate for Payer: Cash Price |
$1,850.00
|
| Rate for Payer: Cash Price |
$1,850.00
|
| Rate for Payer: Cigna Commercial |
$2,168.52
|
| Rate for Payer: Healthspan PPO |
$1,735.95
|
| Rate for Payer: Humana Medicaid |
$1,169.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,853.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,192.41
|
| Rate for Payer: Molina Healthcare Passport |
$1,169.03
|
| Rate for Payer: Multiplan PHCS |
$2,220.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,590.00
|
| Rate for Payer: UHCCP Medicaid |
$1,295.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,180.72
|
|
|
RECONSTRUCTION OF DISLOCATING PATELLA; (EG, HAUSER TYPE PROCEDURE)
|
Facility
|
OP
|
$8,661.10
|
|
|
Service Code
|
CPT 27420
|
|
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
|
|
|
RECONSTRUCTION OF EXTERNAL AUDITORY CANAL (MEATOPLASTY) (EG, FOR STENOSIS DUE TO INJURY, INFECTION) (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$7,089.80
|
|
|
Service Code
|
CPT 69310
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,064.14 |
| Max. Negotiated Rate |
$7,089.80 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,064.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,089.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,836.59
|
| Rate for Payer: Humana Medicare Advantage |
$5,064.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,076.97
|
|
|
RECONSTRUCTION OF HIP SOCKE(P
|
Professional
|
Both
|
$3,670.00
|
|
|
Service Code
|
HCPCS 27122
|
| Hospital Charge Code |
761P0779
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$934.97 |
| Max. Negotiated Rate |
$3,670.00 |
| Rate for Payer: Aetna Commercial |
$1,648.89
|
| Rate for Payer: Anthem Medicaid |
$934.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,670.00
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$1,790.70
|
| Rate for Payer: Healthspan PPO |
$1,493.54
|
| Rate for Payer: Humana Medicaid |
$934.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,379.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$953.67
|
| Rate for Payer: Molina Healthcare Passport |
$934.97
|
| Rate for Payer: Multiplan PHCS |
$2,202.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,569.00
|
| Rate for Payer: UHCCP Medicaid |
$1,284.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$944.32
|
|
|
RECONSTRUCTION OF HIP SOCKET
|
Facility
|
IP
|
$3,670.00
|
|
|
Service Code
|
HCPCS 27122
|
| Hospital Charge Code |
76100779
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
RECONSTRUCTION OF HIP SOCKET
|
Facility
|
OP
|
$3,670.00
|
|
|
Service Code
|
HCPCS 27122
|
| Hospital Charge Code |
76100779
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem Medicaid |
$1,262.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Humana KY Medicaid |
$1,262.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,274.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,287.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
RECONSTRUCTION OF HIP SOCKET
|
Professional
|
Both
|
$3,670.00
|
|
|
Service Code
|
HCPCS 27122
|
| Hospital Charge Code |
76100779
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$934.97 |
| Max. Negotiated Rate |
$3,670.00 |
| Rate for Payer: Aetna Commercial |
$1,648.89
|
| Rate for Payer: Anthem Medicaid |
$934.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,670.00
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$1,790.70
|
| Rate for Payer: Healthspan PPO |
$1,493.54
|
| Rate for Payer: Humana Medicaid |
$934.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,379.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$953.67
|
| Rate for Payer: Molina Healthcare Passport |
$934.97
|
| Rate for Payer: Multiplan PHCS |
$2,202.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,569.00
|
| Rate for Payer: UHCCP Medicaid |
$1,284.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$944.32
|
|
|
RECONSTRUCTION OF STERNUM
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 21740
|
| Hospital Charge Code |
76100405
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$560.00 |
| Max. Negotiated Rate |
$1,736.42 |
| Rate for Payer: Aetna Commercial |
$1,624.13
|
| Rate for Payer: Anthem Medicaid |
$733.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,600.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,736.42
|
| Rate for Payer: Healthspan PPO |
$1,471.11
|
| Rate for Payer: Humana Medicaid |
$733.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,323.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$748.13
|
| Rate for Payer: Molina Healthcare Passport |
$733.46
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,120.00
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$740.79
|
|
|
RECONSTRUCTION OF STERNUM
|
Facility
|
OP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 21740
|
| Hospital Charge Code |
76100405
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$208.00 |
| Max. Negotiated Rate |
$1,536.00 |
| Rate for Payer: Aetna Commercial |
$1,232.00
|
| Rate for Payer: Anthem Medicaid |
$550.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,248.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,328.00
|
| Rate for Payer: First Health Commercial |
$1,520.00
|
| Rate for Payer: Humana Commercial |
$1,360.00
|
| Rate for Payer: Humana KY Medicaid |
$550.24
|
| Rate for Payer: Kentucky WC Medicaid |
$555.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,312.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,180.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$480.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$561.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,408.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$208.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$496.00
|
| Rate for Payer: PHCS Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare All Payer |
$1,408.00
|
|
|
RECONSTRUCTION OF STERNUM
|
Facility
|
IP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 21740
|
| Hospital Charge Code |
76100405
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$208.00 |
| Max. Negotiated Rate |
$1,536.00 |
| Rate for Payer: Aetna Commercial |
$1,232.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,248.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,328.00
|
| Rate for Payer: First Health Commercial |
$1,520.00
|
| Rate for Payer: Humana Commercial |
$1,360.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,312.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,180.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$480.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,408.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$208.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$496.00
|
| Rate for Payer: PHCS Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare All Payer |
$1,408.00
|
|
|
RECONSTRUCTION OF STERNUM(P
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 21740
|
| Hospital Charge Code |
761P0405
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$560.00 |
| Max. Negotiated Rate |
$1,736.42 |
| Rate for Payer: Aetna Commercial |
$1,624.13
|
| Rate for Payer: Anthem Medicaid |
$733.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,600.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,736.42
|
| Rate for Payer: Healthspan PPO |
$1,471.11
|
| Rate for Payer: Humana Medicaid |
$733.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,323.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$748.13
|
| Rate for Payer: Molina Healthcare Passport |
$733.46
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,120.00
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$740.79
|
|
|
RECONSTRUCTION OF URETHRA
|
Facility
|
OP
|
$995.00
|
|
|
Service Code
|
HCPCS 53410
|
| Hospital Charge Code |
76102806
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$129.35 |
| Max. Negotiated Rate |
$6,264.36 |
| Rate for Payer: Aetna Commercial |
$766.15
|
| Rate for Payer: Anthem Medicaid |
$342.18
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,474.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$776.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,264.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,040.63
|
| Rate for Payer: Cash Price |
$497.50
|
| Rate for Payer: Cash Price |
$497.50
|
| Rate for Payer: Cigna Commercial |
$825.85
|
| Rate for Payer: First Health Commercial |
$945.25
|
| Rate for Payer: Humana Commercial |
$845.75
|
| Rate for Payer: Humana KY Medicaid |
$342.18
|
| Rate for Payer: Humana Medicare Advantage |
$4,474.54
|
| Rate for Payer: Kentucky WC Medicaid |
$345.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$815.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$734.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,369.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$349.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$875.60
|
| Rate for Payer: Ohio Health Group HMO |
$746.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$199.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$129.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$308.45
|
| Rate for Payer: PHCS Commercial |
$955.20
|
| Rate for Payer: United Healthcare All Payer |
$875.60
|
|
|
RECONSTRUCTION OF URETHRA
|
Professional
|
Both
|
$995.00
|
|
|
Service Code
|
HCPCS 53410
|
| Hospital Charge Code |
76102806
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$348.25 |
| Max. Negotiated Rate |
$1,600.40 |
| Rate for Payer: Aetna Commercial |
$1,600.40
|
| Rate for Payer: Anthem Medicaid |
$707.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$995.00
|
| Rate for Payer: Cash Price |
$497.50
|
| Rate for Payer: Cash Price |
$497.50
|
| Rate for Payer: Cigna Commercial |
$1,425.80
|
| Rate for Payer: Healthspan PPO |
$1,279.67
|
| Rate for Payer: Humana Medicaid |
$707.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,336.02
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$721.62
|
| Rate for Payer: Molina Healthcare Passport |
$707.47
|
| Rate for Payer: Multiplan PHCS |
$597.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$696.50
|
| Rate for Payer: UHCCP Medicaid |
$348.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$714.54
|
|
|
RECONSTRUCTION OF URETHRA
|
Facility
|
IP
|
$1,125.00
|
|
|
Service Code
|
HCPCS 53415
|
| Hospital Charge Code |
76102856
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$146.25 |
| Max. Negotiated Rate |
$1,080.00 |
| Rate for Payer: Aetna Commercial |
$866.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$877.50
|
| Rate for Payer: Cash Price |
$562.50
|
| Rate for Payer: Cigna Commercial |
$933.75
|
| Rate for Payer: First Health Commercial |
$1,068.75
|
| Rate for Payer: Humana Commercial |
$956.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$922.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$830.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$337.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$990.00
|
| Rate for Payer: Ohio Health Group HMO |
$843.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$225.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$348.75
|
| Rate for Payer: PHCS Commercial |
$1,080.00
|
| Rate for Payer: United Healthcare All Payer |
$990.00
|
|
|
RECONSTRUCTION OF URETHRA
|
Professional
|
Both
|
$1,125.00
|
|
|
Service Code
|
HCPCS 53415
|
| Hospital Charge Code |
76102856
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$393.75 |
| Max. Negotiated Rate |
$1,848.03 |
| Rate for Payer: Aetna Commercial |
$1,848.03
|
| Rate for Payer: Anthem Medicaid |
$889.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,125.00
|
| Rate for Payer: Cash Price |
$562.50
|
| Rate for Payer: Cash Price |
$562.50
|
| Rate for Payer: Cigna Commercial |
$1,625.28
|
| Rate for Payer: Healthspan PPO |
$1,477.67
|
| Rate for Payer: Humana Medicaid |
$889.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,541.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$906.96
|
| Rate for Payer: Molina Healthcare Passport |
$889.18
|
| Rate for Payer: Multiplan PHCS |
$675.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$787.50
|
| Rate for Payer: UHCCP Medicaid |
$393.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$898.07
|
|
|
RECONSTRUCTION OF URETHRA
|
Facility
|
OP
|
$1,125.00
|
|
|
Service Code
|
HCPCS 53415
|
| Hospital Charge Code |
76102856
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$146.25 |
| Max. Negotiated Rate |
$1,080.00 |
| Rate for Payer: Aetna Commercial |
$866.25
|
| Rate for Payer: Anthem Medicaid |
$386.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$877.50
|
| Rate for Payer: Cash Price |
$562.50
|
| Rate for Payer: Cigna Commercial |
$933.75
|
| Rate for Payer: First Health Commercial |
$1,068.75
|
| Rate for Payer: Humana Commercial |
$956.25
|
| Rate for Payer: Humana KY Medicaid |
$386.89
|
| Rate for Payer: Kentucky WC Medicaid |
$390.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$922.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$830.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$337.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$394.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$990.00
|
| Rate for Payer: Ohio Health Group HMO |
$843.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$225.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$348.75
|
| Rate for Payer: PHCS Commercial |
$1,080.00
|
| Rate for Payer: United Healthcare All Payer |
$990.00
|
|
|
RECONSTRUCTION OF URETHRA
|
Facility
|
IP
|
$995.00
|
|
|
Service Code
|
HCPCS 53410
|
| Hospital Charge Code |
76102806
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$129.35 |
| Max. Negotiated Rate |
$955.20 |
| Rate for Payer: Aetna Commercial |
$766.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$776.10
|
| Rate for Payer: Cash Price |
$497.50
|
| Rate for Payer: Cigna Commercial |
$825.85
|
| Rate for Payer: First Health Commercial |
$945.25
|
| Rate for Payer: Humana Commercial |
$845.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$815.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$734.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$298.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$875.60
|
| Rate for Payer: Ohio Health Group HMO |
$746.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$199.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$129.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$308.45
|
| Rate for Payer: PHCS Commercial |
$955.20
|
| Rate for Payer: United Healthcare All Payer |
$875.60
|
|
|
RECONSTRUCT NAIL BED W GRAFT
|
Facility
|
OP
|
$5,475.00
|
|
|
Service Code
|
HCPCS 11762
|
| Hospital Charge Code |
76100102
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$711.75 |
| Max. Negotiated Rate |
$5,256.00 |
| Rate for Payer: Aetna Commercial |
$4,215.75
|
| Rate for Payer: Anthem Medicaid |
$1,882.85
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,270.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$2,737.50
|
| Rate for Payer: Cash Price |
$2,737.50
|
| Rate for Payer: Cigna Commercial |
$4,544.25
|
| Rate for Payer: First Health Commercial |
$5,201.25
|
| Rate for Payer: Humana Commercial |
$4,653.75
|
| Rate for Payer: Humana KY Medicaid |
$1,882.85
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,902.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,489.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,040.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,920.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,818.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,106.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,095.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$711.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,697.25
|
| Rate for Payer: PHCS Commercial |
$5,256.00
|
| Rate for Payer: United Healthcare All Payer |
$4,818.00
|
|
|
RECONSTRUCT NAIL BED W GRAFT
|
Facility
|
IP
|
$5,475.00
|
|
|
Service Code
|
HCPCS 11762
|
| Hospital Charge Code |
76100102
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$711.75 |
| Max. Negotiated Rate |
$5,256.00 |
| Rate for Payer: Aetna Commercial |
$4,215.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,270.50
|
| Rate for Payer: Cash Price |
$2,737.50
|
| Rate for Payer: Cigna Commercial |
$4,544.25
|
| Rate for Payer: First Health Commercial |
$5,201.25
|
| Rate for Payer: Humana Commercial |
$4,653.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,489.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,040.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,642.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,818.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,106.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,095.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$711.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,697.25
|
| Rate for Payer: PHCS Commercial |
$5,256.00
|
| Rate for Payer: United Healthcare All Payer |
$4,818.00
|
|
|
RECONSTRUCT NAIL BED W GRAFT
|
Professional
|
Both
|
$5,475.00
|
|
|
Service Code
|
HCPCS 11762
|
| Hospital Charge Code |
76100102
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$110.73 |
| Max. Negotiated Rate |
$5,475.00 |
| Rate for Payer: Aetna Commercial |
$292.63
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$110.73
|
| Rate for Payer: Anthem Medicaid |
$123.63
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,475.00
|
| Rate for Payer: Cash Price |
$2,737.50
|
| Rate for Payer: Cash Price |
$2,737.50
|
| Rate for Payer: Cigna Commercial |
$346.04
|
| Rate for Payer: Healthspan PPO |
$302.03
|
| Rate for Payer: Humana Medicaid |
$123.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$232.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$126.10
|
| Rate for Payer: Molina Healthcare Passport |
$123.63
|
| Rate for Payer: Multiplan PHCS |
$3,285.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,832.50
|
| Rate for Payer: UHCCP Medicaid |
$116.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$124.87
|
|
|
RECONSTRUCT NAIL BED W GRAFT(P
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 11762
|
| Hospital Charge Code |
761P0102
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$110.73 |
| Max. Negotiated Rate |
$800.00 |
| Rate for Payer: UHCCP Medicaid |
$116.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$124.87
|
| Rate for Payer: Aetna Commercial |
$292.63
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$110.73
|
| Rate for Payer: Anthem Medicaid |
$123.63
|
| 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 |
$346.04
|
| Rate for Payer: Healthspan PPO |
$302.03
|
| Rate for Payer: Humana Medicaid |
$123.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$232.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$126.10
|
| Rate for Payer: Molina Healthcare Passport |
$123.63
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$560.00
|
|
|
RECONSTRUCT NAIL BED W GRAFT(T
|
Facility
|
OP
|
$4,675.00
|
|
|
Service Code
|
HCPCS 11762
|
| Hospital Charge Code |
761T0102
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$607.75 |
| Max. Negotiated Rate |
$4,488.00 |
| Rate for Payer: Aetna Commercial |
$3,599.75
|
| Rate for Payer: Anthem Medicaid |
$1,607.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,646.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$2,337.50
|
| Rate for Payer: Cash Price |
$2,337.50
|
| Rate for Payer: Cigna Commercial |
$3,880.25
|
| Rate for Payer: First Health Commercial |
$4,441.25
|
| Rate for Payer: Humana Commercial |
$3,973.75
|
| Rate for Payer: Humana KY Medicaid |
$1,607.73
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,624.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,833.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,450.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,639.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,114.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,506.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$935.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$607.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,449.25
|
| Rate for Payer: PHCS Commercial |
$4,488.00
|
| Rate for Payer: United Healthcare All Payer |
$4,114.00
|
|
|
RECONSTRUCT NAIL BED W GRAFT(T
|
Facility
|
IP
|
$4,675.00
|
|
|
Service Code
|
HCPCS 11762
|
| Hospital Charge Code |
761T0102
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$607.75 |
| Max. Negotiated Rate |
$4,488.00 |
| Rate for Payer: Aetna Commercial |
$3,599.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,646.50
|
| Rate for Payer: Cash Price |
$2,337.50
|
| Rate for Payer: Cigna Commercial |
$3,880.25
|
| Rate for Payer: First Health Commercial |
$4,441.25
|
| Rate for Payer: Humana Commercial |
$3,973.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,833.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,450.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,402.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,114.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,506.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$935.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$607.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,449.25
|
| Rate for Payer: PHCS Commercial |
$4,488.00
|
| Rate for Payer: United Healthcare All Payer |
$4,114.00
|
|
