|
REPAIR COMPLEX 5CM OR LESS
|
Facility
|
OP
|
$1,133.00
|
|
|
Service Code
|
HCPCS 13133
|
| Hospital Charge Code |
45000073
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$147.29 |
| Max. Negotiated Rate |
$1,087.68 |
| Rate for Payer: Aetna Commercial |
$872.41
|
| Rate for Payer: Anthem Medicaid |
$389.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$883.74
|
| Rate for Payer: Cash Price |
$566.50
|
| Rate for Payer: Cigna Commercial |
$940.39
|
| Rate for Payer: First Health Commercial |
$1,076.35
|
| Rate for Payer: Humana Commercial |
$963.05
|
| Rate for Payer: Humana KY Medicaid |
$389.64
|
| Rate for Payer: Kentucky WC Medicaid |
$393.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$929.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$836.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$339.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$397.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$997.04
|
| Rate for Payer: Ohio Health Group HMO |
$849.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$226.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$147.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$351.23
|
| Rate for Payer: PHCS Commercial |
$1,087.68
|
| Rate for Payer: United Healthcare All Payer |
$997.04
|
|
|
REPAIR COMPLEX 5CM OR LESS
|
Facility
|
IP
|
$1,133.00
|
|
|
Service Code
|
HCPCS 13133
|
| Hospital Charge Code |
45000073
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$147.29 |
| Max. Negotiated Rate |
$1,087.68 |
| Rate for Payer: Aetna Commercial |
$872.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$883.74
|
| Rate for Payer: Cash Price |
$566.50
|
| Rate for Payer: Cigna Commercial |
$940.39
|
| Rate for Payer: First Health Commercial |
$1,076.35
|
| Rate for Payer: Humana Commercial |
$963.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$929.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$836.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$339.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$997.04
|
| Rate for Payer: Ohio Health Group HMO |
$849.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$226.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$147.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$351.23
|
| Rate for Payer: PHCS Commercial |
$1,087.68
|
| Rate for Payer: United Healthcare All Payer |
$997.04
|
|
|
REPAIR COMPLEX 5CM OR LESS(P
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 13133
|
| Hospital Charge Code |
761P0157
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$66.24 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Aetna Commercial |
$195.44
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$66.24
|
| Rate for Payer: Anthem Medicaid |
$96.50
|
| 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 |
$182.75
|
| Rate for Payer: Healthspan PPO |
$190.94
|
| Rate for Payer: Humana Medicaid |
$96.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$168.04
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$98.43
|
| Rate for Payer: Molina Healthcare Passport |
$96.50
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$69.55
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$97.46
|
|
|
REPAIR COMPLEX 5CM OR LESS(T
|
Facility
|
IP
|
$1,133.00
|
|
|
Service Code
|
HCPCS 13133
|
| Hospital Charge Code |
761T0157
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$147.29 |
| Max. Negotiated Rate |
$1,087.68 |
| Rate for Payer: Aetna Commercial |
$872.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$883.74
|
| Rate for Payer: Cash Price |
$566.50
|
| Rate for Payer: Cigna Commercial |
$940.39
|
| Rate for Payer: First Health Commercial |
$1,076.35
|
| Rate for Payer: Humana Commercial |
$963.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$929.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$836.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$339.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$997.04
|
| Rate for Payer: Ohio Health Group HMO |
$849.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$226.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$147.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$351.23
|
| Rate for Payer: PHCS Commercial |
$1,087.68
|
| Rate for Payer: United Healthcare All Payer |
$997.04
|
|
|
REPAIR COMPLEX 5CM OR LESS(T
|
Facility
|
OP
|
$1,133.00
|
|
|
Service Code
|
HCPCS 13133
|
| Hospital Charge Code |
761T0157
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$147.29 |
| Max. Negotiated Rate |
$1,087.68 |
| Rate for Payer: Aetna Commercial |
$872.41
|
| Rate for Payer: Anthem Medicaid |
$389.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$883.74
|
| Rate for Payer: Cash Price |
$566.50
|
| Rate for Payer: Cigna Commercial |
$940.39
|
| Rate for Payer: First Health Commercial |
$1,076.35
|
| Rate for Payer: Humana Commercial |
$963.05
|
| Rate for Payer: Humana KY Medicaid |
$389.64
|
| Rate for Payer: Kentucky WC Medicaid |
$393.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$929.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$836.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$339.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$397.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$997.04
|
| Rate for Payer: Ohio Health Group HMO |
$849.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$226.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$147.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$351.23
|
| Rate for Payer: PHCS Commercial |
$1,087.68
|
| Rate for Payer: United Healthcare All Payer |
$997.04
|
|
|
REPAIR - COMPLEX - EACH ADD. 5
|
Facility
|
OP
|
$1,148.00
|
|
|
Service Code
|
HCPCS 13122
|
| Hospital Charge Code |
45000071
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$149.24 |
| Max. Negotiated Rate |
$1,102.08 |
| Rate for Payer: Aetna Commercial |
$883.96
|
| Rate for Payer: Anthem Medicaid |
$394.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$895.44
|
| Rate for Payer: Cash Price |
$574.00
|
| Rate for Payer: Cigna Commercial |
$952.84
|
| Rate for Payer: First Health Commercial |
$1,090.60
|
| Rate for Payer: Humana Commercial |
$975.80
|
| Rate for Payer: Humana KY Medicaid |
$394.80
|
| Rate for Payer: Kentucky WC Medicaid |
$398.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$941.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$847.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$344.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$402.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,010.24
|
| Rate for Payer: Ohio Health Group HMO |
$861.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$229.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$149.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$355.88
|
| Rate for Payer: PHCS Commercial |
$1,102.08
|
| Rate for Payer: United Healthcare All Payer |
$1,010.24
|
|
|
REPAIR - COMPLEX - EACH ADD. 5
|
Facility
|
IP
|
$1,148.00
|
|
|
Service Code
|
HCPCS 13122
|
| Hospital Charge Code |
45000071
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$149.24 |
| Max. Negotiated Rate |
$1,102.08 |
| Rate for Payer: Aetna Commercial |
$883.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$895.44
|
| Rate for Payer: Cash Price |
$574.00
|
| Rate for Payer: Cigna Commercial |
$952.84
|
| Rate for Payer: First Health Commercial |
$1,090.60
|
| Rate for Payer: Humana Commercial |
$975.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$941.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$847.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$344.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,010.24
|
| Rate for Payer: Ohio Health Group HMO |
$861.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$229.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$149.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$355.88
|
| Rate for Payer: PHCS Commercial |
$1,102.08
|
| Rate for Payer: United Healthcare All Payer |
$1,010.24
|
|
|
REPAIR - COMPLEX - EACH ADD. 5
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 13122
|
| Hospital Charge Code |
761P0154
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$41.76 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Aetna Commercial |
$126.99
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$41.76
|
| Rate for Payer: Anthem Medicaid |
$65.12
|
| 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 |
$150.69
|
| Rate for Payer: Healthspan PPO |
$135.35
|
| Rate for Payer: Humana Medicaid |
$65.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$109.25
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$66.42
|
| Rate for Payer: Molina Healthcare Passport |
$65.12
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$43.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$65.77
|
|
|
REPAIR - COMPLEX - EACH ADD. 5
|
Facility
|
IP
|
$2,148.00
|
|
|
Service Code
|
HCPCS 13122
|
| Hospital Charge Code |
76100154
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$279.24 |
| Max. Negotiated Rate |
$2,062.08 |
| Rate for Payer: Aetna Commercial |
$1,653.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,675.44
|
| Rate for Payer: Cash Price |
$1,074.00
|
| Rate for Payer: Cigna Commercial |
$1,782.84
|
| Rate for Payer: First Health Commercial |
$2,040.60
|
| Rate for Payer: Humana Commercial |
$1,825.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,761.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,585.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$644.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,890.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,611.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$429.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$279.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$665.88
|
| Rate for Payer: PHCS Commercial |
$2,062.08
|
| Rate for Payer: United Healthcare All Payer |
$1,890.24
|
|
|
REPAIR - COMPLEX - EACH ADD. 5
|
Facility
|
OP
|
$1,148.00
|
|
|
Service Code
|
HCPCS 13122
|
| Hospital Charge Code |
761T0154
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$149.24 |
| Max. Negotiated Rate |
$1,102.08 |
| Rate for Payer: Aetna Commercial |
$883.96
|
| Rate for Payer: Anthem Medicaid |
$394.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$895.44
|
| Rate for Payer: Cash Price |
$574.00
|
| Rate for Payer: Cigna Commercial |
$952.84
|
| Rate for Payer: First Health Commercial |
$1,090.60
|
| Rate for Payer: Humana Commercial |
$975.80
|
| Rate for Payer: Humana KY Medicaid |
$394.80
|
| Rate for Payer: Kentucky WC Medicaid |
$398.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$941.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$847.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$344.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$402.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,010.24
|
| Rate for Payer: Ohio Health Group HMO |
$861.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$229.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$149.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$355.88
|
| Rate for Payer: PHCS Commercial |
$1,102.08
|
| Rate for Payer: United Healthcare All Payer |
$1,010.24
|
|
|
REPAIR - COMPLEX - EACH ADD. 5
|
Professional
|
Both
|
$2,148.00
|
|
|
Service Code
|
HCPCS 13122
|
| Hospital Charge Code |
76100154
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$41.76 |
| Max. Negotiated Rate |
$2,148.00 |
| Rate for Payer: Aetna Commercial |
$126.99
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$41.76
|
| Rate for Payer: Anthem Medicaid |
$65.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,148.00
|
| Rate for Payer: Cash Price |
$1,074.00
|
| Rate for Payer: Cash Price |
$1,074.00
|
| Rate for Payer: Cigna Commercial |
$150.69
|
| Rate for Payer: Healthspan PPO |
$135.35
|
| Rate for Payer: Humana Medicaid |
$65.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$109.25
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$66.42
|
| Rate for Payer: Molina Healthcare Passport |
$65.12
|
| Rate for Payer: Multiplan PHCS |
$1,288.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,503.60
|
| Rate for Payer: UHCCP Medicaid |
$43.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$65.77
|
|
|
REPAIR - COMPLEX - EACH ADD. 5
|
Facility
|
OP
|
$2,148.00
|
|
|
Service Code
|
HCPCS 13122
|
| Hospital Charge Code |
76100154
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$279.24 |
| Max. Negotiated Rate |
$2,062.08 |
| Rate for Payer: Aetna Commercial |
$1,653.96
|
| Rate for Payer: Anthem Medicaid |
$738.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,675.44
|
| Rate for Payer: Cash Price |
$1,074.00
|
| Rate for Payer: Cigna Commercial |
$1,782.84
|
| Rate for Payer: First Health Commercial |
$2,040.60
|
| Rate for Payer: Humana Commercial |
$1,825.80
|
| Rate for Payer: Humana KY Medicaid |
$738.70
|
| Rate for Payer: Kentucky WC Medicaid |
$746.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,761.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,585.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$644.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$753.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,890.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,611.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$429.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$279.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$665.88
|
| Rate for Payer: PHCS Commercial |
$2,062.08
|
| Rate for Payer: United Healthcare All Payer |
$1,890.24
|
|
|
REPAIR - COMPLEX - EACH ADD. 5
|
Facility
|
IP
|
$1,148.00
|
|
|
Service Code
|
HCPCS 13122
|
| Hospital Charge Code |
761T0154
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$149.24 |
| Max. Negotiated Rate |
$1,102.08 |
| Rate for Payer: Aetna Commercial |
$883.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$895.44
|
| Rate for Payer: Cash Price |
$574.00
|
| Rate for Payer: Cigna Commercial |
$952.84
|
| Rate for Payer: First Health Commercial |
$1,090.60
|
| Rate for Payer: Humana Commercial |
$975.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$941.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$847.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$344.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,010.24
|
| Rate for Payer: Ohio Health Group HMO |
$861.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$229.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$149.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$355.88
|
| Rate for Payer: PHCS Commercial |
$1,102.08
|
| Rate for Payer: United Healthcare All Payer |
$1,010.24
|
|
|
REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM
|
Facility
|
OP
|
$760.35
|
|
|
Service Code
|
CPT 13152
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$543.11 |
| Max. Negotiated Rate |
$760.35 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
|
|
REPAIR COMPLEX FACE 1.1-2.5 CM
|
Professional
|
Both
|
$2,191.00
|
|
|
Service Code
|
HCPCS 13151
|
| Hospital Charge Code |
76100158
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$140.68 |
| Max. Negotiated Rate |
$2,191.00 |
| Rate for Payer: Aetna Commercial |
$455.64
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$140.68
|
| Rate for Payer: Anthem Medicaid |
$170.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,191.00
|
| Rate for Payer: Cash Price |
$1,095.50
|
| Rate for Payer: Cash Price |
$1,095.50
|
| Rate for Payer: Cigna Commercial |
$529.49
|
| Rate for Payer: Healthspan PPO |
$453.34
|
| Rate for Payer: Humana Medicaid |
$170.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$397.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$173.88
|
| Rate for Payer: Molina Healthcare Passport |
$170.47
|
| Rate for Payer: Multiplan PHCS |
$1,314.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,533.70
|
| Rate for Payer: UHCCP Medicaid |
$147.71
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$172.17
|
|
|
REPAIR COMPLEX FACE 1.1-2.5 CM
|
Professional
|
Both
|
$550.00
|
|
|
Service Code
|
HCPCS 13151
|
| Hospital Charge Code |
761P0158
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$140.68 |
| Max. Negotiated Rate |
$550.00 |
| Rate for Payer: Aetna Commercial |
$455.64
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$140.68
|
| Rate for Payer: Anthem Medicaid |
$170.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$550.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$529.49
|
| Rate for Payer: Healthspan PPO |
$453.34
|
| Rate for Payer: Humana Medicaid |
$170.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$397.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$173.88
|
| Rate for Payer: Molina Healthcare Passport |
$170.47
|
| Rate for Payer: Multiplan PHCS |
$330.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$385.00
|
| Rate for Payer: UHCCP Medicaid |
$147.71
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$172.17
|
|
|
REPAIR COMPLEX FACE 1.1-2.5 CM
|
Facility
|
IP
|
$1,641.00
|
|
|
Service Code
|
HCPCS 13151
|
| Hospital Charge Code |
45000074
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$213.33 |
| Max. Negotiated Rate |
$1,575.36 |
| Rate for Payer: Aetna Commercial |
$1,263.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,279.98
|
| Rate for Payer: Cash Price |
$820.50
|
| Rate for Payer: Cigna Commercial |
$1,362.03
|
| Rate for Payer: First Health Commercial |
$1,558.95
|
| Rate for Payer: Humana Commercial |
$1,394.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,345.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,211.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$492.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,444.08
|
| Rate for Payer: Ohio Health Group HMO |
$1,230.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$328.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$213.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$508.71
|
| Rate for Payer: PHCS Commercial |
$1,575.36
|
| Rate for Payer: United Healthcare All Payer |
$1,444.08
|
|
|
REPAIR COMPLEX FACE 1.1-2.5 CM
|
Facility
|
OP
|
$1,641.00
|
|
|
Service Code
|
HCPCS 13151
|
| Hospital Charge Code |
45000074
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$213.33 |
| Max. Negotiated Rate |
$1,575.36 |
| Rate for Payer: Aetna Commercial |
$1,263.57
|
| Rate for Payer: Anthem Medicaid |
$564.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,279.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$820.50
|
| Rate for Payer: Cash Price |
$820.50
|
| Rate for Payer: Cigna Commercial |
$1,362.03
|
| Rate for Payer: First Health Commercial |
$1,558.95
|
| Rate for Payer: Humana Commercial |
$1,394.85
|
| Rate for Payer: Humana KY Medicaid |
$564.34
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$570.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,345.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,211.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$575.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,444.08
|
| Rate for Payer: Ohio Health Group HMO |
$1,230.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$328.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$213.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$508.71
|
| Rate for Payer: PHCS Commercial |
$1,575.36
|
| Rate for Payer: United Healthcare All Payer |
$1,444.08
|
|
|
REPAIR COMPLEX FACE 1.1-2.5 CM
|
Facility
|
OP
|
$1,641.00
|
|
|
Service Code
|
HCPCS 13151
|
| Hospital Charge Code |
761T0158
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$213.33 |
| Max. Negotiated Rate |
$1,575.36 |
| Rate for Payer: Aetna Commercial |
$1,263.57
|
| Rate for Payer: Anthem Medicaid |
$564.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,279.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$820.50
|
| Rate for Payer: Cash Price |
$820.50
|
| Rate for Payer: Cigna Commercial |
$1,362.03
|
| Rate for Payer: First Health Commercial |
$1,558.95
|
| Rate for Payer: Humana Commercial |
$1,394.85
|
| Rate for Payer: Humana KY Medicaid |
$564.34
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$570.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,345.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,211.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$575.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,444.08
|
| Rate for Payer: Ohio Health Group HMO |
$1,230.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$328.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$213.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$508.71
|
| Rate for Payer: PHCS Commercial |
$1,575.36
|
| Rate for Payer: United Healthcare All Payer |
$1,444.08
|
|
|
REPAIR COMPLEX FACE 1.1-2.5 CM
|
Facility
|
IP
|
$1,641.00
|
|
|
Service Code
|
HCPCS 13151
|
| Hospital Charge Code |
761T0158
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$213.33 |
| Max. Negotiated Rate |
$1,575.36 |
| Rate for Payer: Aetna Commercial |
$1,263.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,279.98
|
| Rate for Payer: Cash Price |
$820.50
|
| Rate for Payer: Cigna Commercial |
$1,362.03
|
| Rate for Payer: First Health Commercial |
$1,558.95
|
| Rate for Payer: Humana Commercial |
$1,394.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,345.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,211.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$492.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,444.08
|
| Rate for Payer: Ohio Health Group HMO |
$1,230.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$328.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$213.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$508.71
|
| Rate for Payer: PHCS Commercial |
$1,575.36
|
| Rate for Payer: United Healthcare All Payer |
$1,444.08
|
|
|
REPAIR COMPLEX FACE 1.1-2.5 CM
|
Facility
|
IP
|
$2,191.00
|
|
|
Service Code
|
HCPCS 13151
|
| Hospital Charge Code |
76100158
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$284.83 |
| Max. Negotiated Rate |
$2,103.36 |
| Rate for Payer: Aetna Commercial |
$1,687.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,708.98
|
| Rate for Payer: Cash Price |
$1,095.50
|
| Rate for Payer: Cigna Commercial |
$1,818.53
|
| Rate for Payer: First Health Commercial |
$2,081.45
|
| Rate for Payer: Humana Commercial |
$1,862.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,796.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,616.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$657.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,928.08
|
| Rate for Payer: Ohio Health Group HMO |
$1,643.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$438.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$284.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$679.21
|
| Rate for Payer: PHCS Commercial |
$2,103.36
|
| Rate for Payer: United Healthcare All Payer |
$1,928.08
|
|
|
REPAIR COMPLEX FACE 1.1-2.5 CM
|
Facility
|
OP
|
$2,191.00
|
|
|
Service Code
|
HCPCS 13151
|
| Hospital Charge Code |
76100158
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$284.83 |
| Max. Negotiated Rate |
$2,103.36 |
| Rate for Payer: Aetna Commercial |
$1,687.07
|
| Rate for Payer: Anthem Medicaid |
$753.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,708.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$1,095.50
|
| Rate for Payer: Cash Price |
$1,095.50
|
| Rate for Payer: Cigna Commercial |
$1,818.53
|
| Rate for Payer: First Health Commercial |
$2,081.45
|
| Rate for Payer: Humana Commercial |
$1,862.35
|
| Rate for Payer: Humana KY Medicaid |
$753.48
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$761.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,796.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,616.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$768.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,928.08
|
| Rate for Payer: Ohio Health Group HMO |
$1,643.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$438.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$284.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$679.21
|
| Rate for Payer: PHCS Commercial |
$2,103.36
|
| Rate for Payer: United Healthcare All Payer |
$1,928.08
|
|
|
REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM
|
Facility
|
OP
|
$482.75
|
|
|
Service Code
|
CPT 13131
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$344.82 |
| Max. Negotiated Rate |
$482.75 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
|
|
REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM
|
Facility
|
OP
|
$760.35
|
|
|
Service Code
|
CPT 13121
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$543.11 |
| Max. Negotiated Rate |
$760.35 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
|
|
REPAIR - COMPLEX - TRUNK - ADD
|
Facility
|
IP
|
$2,026.00
|
|
|
Service Code
|
HCPCS 13102
|
| Hospital Charge Code |
761T0151
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$263.38 |
| Max. Negotiated Rate |
$1,944.96 |
| Rate for Payer: Aetna Commercial |
$1,560.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,580.28
|
| Rate for Payer: Cash Price |
$1,013.00
|
| Rate for Payer: Cigna Commercial |
$1,681.58
|
| Rate for Payer: First Health Commercial |
$1,924.70
|
| Rate for Payer: Humana Commercial |
$1,722.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,661.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,495.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$607.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,782.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,519.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$405.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$263.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$628.06
|
| Rate for Payer: PHCS Commercial |
$1,944.96
|
| Rate for Payer: United Healthcare All Payer |
$1,782.88
|
|
