|
REPAIR LAC PALATE >2 CM/COMP
|
Professional
|
Both
|
$720.00
|
|
|
Service Code
|
HCPCS 42182
|
| Hospital Charge Code |
76101677
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$202.08 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Aetna Commercial |
$390.92
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$202.08
|
| Rate for Payer: Anthem Medicaid |
$213.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$720.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cigna Commercial |
$395.20
|
| Rate for Payer: Healthspan PPO |
$392.40
|
| Rate for Payer: Humana Medicaid |
$213.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$336.04
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$217.48
|
| Rate for Payer: Molina Healthcare Passport |
$213.22
|
| Rate for Payer: Multiplan PHCS |
$432.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$504.00
|
| Rate for Payer: UHCCP Medicaid |
$212.18
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$215.35
|
|
|
REPAIR LAC PALATE >2 CM/COMP(P
|
Professional
|
Both
|
$720.00
|
|
|
Service Code
|
HCPCS 42182
|
| Hospital Charge Code |
761P1677
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$202.08 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Aetna Commercial |
$390.92
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$202.08
|
| Rate for Payer: Anthem Medicaid |
$213.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$720.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cigna Commercial |
$395.20
|
| Rate for Payer: Healthspan PPO |
$392.40
|
| Rate for Payer: Humana Medicaid |
$213.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$336.04
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$217.48
|
| Rate for Payer: Molina Healthcare Passport |
$213.22
|
| Rate for Payer: Multiplan PHCS |
$432.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$504.00
|
| Rate for Payer: UHCCP Medicaid |
$212.18
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$215.35
|
|
|
REPAIR LARGE OMPHALOCELE
|
Professional
|
Both
|
$6,795.00
|
|
|
Service Code
|
HCPCS 49605
|
| Hospital Charge Code |
76102031
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$916.08 |
| Max. Negotiated Rate |
$7,252.08 |
| Rate for Payer: Aetna Commercial |
$7,252.08
|
| Rate for Payer: Anthem Medicaid |
$916.08
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,795.00
|
| Rate for Payer: Cash Price |
$3,397.50
|
| Rate for Payer: Cash Price |
$3,397.50
|
| Rate for Payer: Cigna Commercial |
$6,687.21
|
| Rate for Payer: Healthspan PPO |
$6,115.81
|
| Rate for Payer: Humana Medicaid |
$916.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$6,393.56
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$934.40
|
| Rate for Payer: Molina Healthcare Passport |
$916.08
|
| Rate for Payer: Multiplan PHCS |
$4,077.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,756.50
|
| Rate for Payer: UHCCP Medicaid |
$2,378.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$925.24
|
|
|
REPAIR LARGE OMPHALOCELE
|
Facility
|
OP
|
$6,795.00
|
|
|
Service Code
|
HCPCS 49605
|
| Hospital Charge Code |
76102031
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$883.35 |
| Max. Negotiated Rate |
$6,523.20 |
| Rate for Payer: Aetna Commercial |
$5,232.15
|
| Rate for Payer: Anthem Medicaid |
$2,336.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,300.10
|
| Rate for Payer: Cash Price |
$3,397.50
|
| Rate for Payer: Cigna Commercial |
$5,639.85
|
| Rate for Payer: First Health Commercial |
$6,455.25
|
| Rate for Payer: Humana Commercial |
$5,775.75
|
| Rate for Payer: Humana KY Medicaid |
$2,336.80
|
| Rate for Payer: Kentucky WC Medicaid |
$2,360.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,571.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,014.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,038.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,383.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,979.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,096.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,359.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$883.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,106.45
|
| Rate for Payer: PHCS Commercial |
$6,523.20
|
| Rate for Payer: United Healthcare All Payer |
$5,979.60
|
|
|
REPAIR LARGE OMPHALOCELE
|
Facility
|
IP
|
$6,795.00
|
|
|
Service Code
|
HCPCS 49605
|
| Hospital Charge Code |
76102031
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$883.35 |
| Max. Negotiated Rate |
$6,523.20 |
| Rate for Payer: Aetna Commercial |
$5,232.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,300.10
|
| Rate for Payer: Cash Price |
$3,397.50
|
| Rate for Payer: Cigna Commercial |
$5,639.85
|
| Rate for Payer: First Health Commercial |
$6,455.25
|
| Rate for Payer: Humana Commercial |
$5,775.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,571.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,014.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,038.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,979.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,096.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,359.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$883.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,106.45
|
| Rate for Payer: PHCS Commercial |
$6,523.20
|
| Rate for Payer: United Healthcare All Payer |
$5,979.60
|
|
|
REPAIR LARGE OMPHALOCELE(P
|
Professional
|
Both
|
$6,795.00
|
|
|
Service Code
|
HCPCS 49605
|
| Hospital Charge Code |
761P2031
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$916.08 |
| Max. Negotiated Rate |
$7,252.08 |
| Rate for Payer: Aetna Commercial |
$7,252.08
|
| Rate for Payer: Anthem Medicaid |
$916.08
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,795.00
|
| Rate for Payer: Cash Price |
$3,397.50
|
| Rate for Payer: Cash Price |
$3,397.50
|
| Rate for Payer: Cigna Commercial |
$6,687.21
|
| Rate for Payer: Healthspan PPO |
$6,115.81
|
| Rate for Payer: Humana Medicaid |
$916.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$6,393.56
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$934.40
|
| Rate for Payer: Molina Healthcare Passport |
$916.08
|
| Rate for Payer: Multiplan PHCS |
$4,077.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,756.50
|
| Rate for Payer: UHCCP Medicaid |
$2,378.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$925.24
|
|
|
REPAIR LATERAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE
|
Facility
|
OP
|
$3,918.70
|
|
|
Service Code
|
CPT 24343
|
|
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
|
|
|
REPAIR LEAD PACE-DEFIB ONE
|
Facility
|
OP
|
$1,040.00
|
|
|
Service Code
|
HCPCS 33218
|
| Hospital Charge Code |
76101252
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$135.20 |
| Max. Negotiated Rate |
$4,754.25 |
| Rate for Payer: Aetna Commercial |
$800.80
|
| Rate for Payer: Anthem Medicaid |
$357.66
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,395.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$811.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,754.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,584.45
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cigna Commercial |
$863.20
|
| Rate for Payer: First Health Commercial |
$988.00
|
| Rate for Payer: Humana Commercial |
$884.00
|
| Rate for Payer: Humana KY Medicaid |
$357.66
|
| Rate for Payer: Humana Medicare Advantage |
$3,395.89
|
| Rate for Payer: Kentucky WC Medicaid |
$361.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$852.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$767.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,075.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$364.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$915.20
|
| Rate for Payer: Ohio Health Group HMO |
$780.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$208.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$135.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$322.40
|
| Rate for Payer: PHCS Commercial |
$998.40
|
| Rate for Payer: United Healthcare All Payer |
$915.20
|
|
|
REPAIR LEAD PACE-DEFIB ONE
|
Professional
|
Both
|
$1,040.00
|
|
|
Service Code
|
HCPCS 33218
|
| Hospital Charge Code |
76101252
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$285.48 |
| Max. Negotiated Rate |
$1,040.00 |
| Rate for Payer: Aetna Commercial |
$670.11
|
| Rate for Payer: Anthem Medicaid |
$285.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,040.00
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cigna Commercial |
$633.52
|
| Rate for Payer: Healthspan PPO |
$658.85
|
| Rate for Payer: Humana Medicaid |
$285.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$553.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$291.19
|
| Rate for Payer: Molina Healthcare Passport |
$285.48
|
| Rate for Payer: Multiplan PHCS |
$624.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$728.00
|
| Rate for Payer: UHCCP Medicaid |
$364.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$288.33
|
|
|
REPAIR LEAD PACE-DEFIB ONE
|
Facility
|
IP
|
$1,040.00
|
|
|
Service Code
|
HCPCS 33218
|
| Hospital Charge Code |
76101252
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$135.20 |
| Max. Negotiated Rate |
$998.40 |
| Rate for Payer: Aetna Commercial |
$800.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$811.20
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cigna Commercial |
$863.20
|
| Rate for Payer: First Health Commercial |
$988.00
|
| Rate for Payer: Humana Commercial |
$884.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$852.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$767.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$312.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$915.20
|
| Rate for Payer: Ohio Health Group HMO |
$780.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$208.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$135.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$322.40
|
| Rate for Payer: PHCS Commercial |
$998.40
|
| Rate for Payer: United Healthcare All Payer |
$915.20
|
|
|
REPAIR LEAD PACE-DEFIB ONE(P
|
Professional
|
Both
|
$1,040.00
|
|
|
Service Code
|
HCPCS 33218
|
| Hospital Charge Code |
761P1252
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$285.48 |
| Max. Negotiated Rate |
$1,040.00 |
| Rate for Payer: Aetna Commercial |
$670.11
|
| Rate for Payer: Anthem Medicaid |
$285.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,040.00
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cigna Commercial |
$633.52
|
| Rate for Payer: Healthspan PPO |
$658.85
|
| Rate for Payer: Humana Medicaid |
$285.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$553.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$291.19
|
| Rate for Payer: Molina Healthcare Passport |
$285.48
|
| Rate for Payer: Multiplan PHCS |
$624.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$728.00
|
| Rate for Payer: UHCCP Medicaid |
$364.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$288.33
|
|
|
REPAIR LIP - FULL THICKNESS
|
Facility
|
OP
|
$660.00
|
|
|
Service Code
|
HCPCS 40650
|
| Hospital Charge Code |
45000246
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$85.80 |
| Max. Negotiated Rate |
$666.11 |
| Rate for Payer: Aetna Commercial |
$508.20
|
| Rate for Payer: Anthem Medicaid |
$226.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$475.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$514.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$666.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$642.32
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cigna Commercial |
$547.80
|
| Rate for Payer: First Health Commercial |
$627.00
|
| Rate for Payer: Humana Commercial |
$561.00
|
| Rate for Payer: Humana KY Medicaid |
$226.97
|
| Rate for Payer: Humana Medicare Advantage |
$475.79
|
| Rate for Payer: Kentucky WC Medicaid |
$229.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$541.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$487.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$570.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$231.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$580.80
|
| Rate for Payer: Ohio Health Group HMO |
$495.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$132.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$204.60
|
| Rate for Payer: PHCS Commercial |
$633.60
|
| Rate for Payer: United Healthcare All Payer |
$580.80
|
|
|
REPAIR LIP - FULL THICKNESS
|
Professional
|
Both
|
$2,196.50
|
|
|
Service Code
|
HCPCS 40650
|
| Hospital Charge Code |
76101628
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$222.05 |
| Max. Negotiated Rate |
$2,196.50 |
| Rate for Payer: Aetna Commercial |
$411.35
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$222.05
|
| Rate for Payer: Anthem Medicaid |
$238.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,196.50
|
| Rate for Payer: Cash Price |
$1,098.25
|
| Rate for Payer: Cash Price |
$1,098.25
|
| Rate for Payer: Cigna Commercial |
$407.68
|
| Rate for Payer: Healthspan PPO |
$479.14
|
| Rate for Payer: Humana Medicaid |
$238.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$370.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$242.86
|
| Rate for Payer: Molina Healthcare Passport |
$238.10
|
| Rate for Payer: Multiplan PHCS |
$1,317.90
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,537.55
|
| Rate for Payer: UHCCP Medicaid |
$233.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$240.48
|
|
|
REPAIR LIP - FULL THICKNESS
|
Facility
|
OP
|
$2,196.50
|
|
|
Service Code
|
HCPCS 40650
|
| Hospital Charge Code |
76101628
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$285.54 |
| Max. Negotiated Rate |
$2,108.64 |
| Rate for Payer: Aetna Commercial |
$1,691.30
|
| Rate for Payer: Anthem Medicaid |
$755.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$475.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,713.27
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$666.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$642.32
|
| Rate for Payer: Cash Price |
$1,098.25
|
| Rate for Payer: Cash Price |
$1,098.25
|
| Rate for Payer: Cigna Commercial |
$1,823.10
|
| Rate for Payer: First Health Commercial |
$2,086.68
|
| Rate for Payer: Humana Commercial |
$1,867.02
|
| Rate for Payer: Humana KY Medicaid |
$755.38
|
| Rate for Payer: Humana Medicare Advantage |
$475.79
|
| Rate for Payer: Kentucky WC Medicaid |
$763.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,801.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,621.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$570.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$770.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,932.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,647.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$439.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$285.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$680.92
|
| Rate for Payer: PHCS Commercial |
$2,108.64
|
| Rate for Payer: United Healthcare All Payer |
$1,932.92
|
|
|
REPAIR LIP - FULL THICKNESS
|
Facility
|
IP
|
$2,196.50
|
|
|
Service Code
|
HCPCS 40650
|
| Hospital Charge Code |
76101628
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$285.54 |
| Max. Negotiated Rate |
$2,108.64 |
| Rate for Payer: Aetna Commercial |
$1,691.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,713.27
|
| Rate for Payer: Cash Price |
$1,098.25
|
| Rate for Payer: Cigna Commercial |
$1,823.10
|
| Rate for Payer: First Health Commercial |
$2,086.68
|
| Rate for Payer: Humana Commercial |
$1,867.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,801.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,621.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$658.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,932.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,647.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$439.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$285.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$680.92
|
| Rate for Payer: PHCS Commercial |
$2,108.64
|
| Rate for Payer: United Healthcare All Payer |
$1,932.92
|
|
|
REPAIR LIP - FULL THICKNESS
|
Facility
|
IP
|
$660.00
|
|
|
Service Code
|
HCPCS 40650
|
| Hospital Charge Code |
45000246
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$85.80 |
| Max. Negotiated Rate |
$633.60 |
| Rate for Payer: Aetna Commercial |
$508.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$514.80
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cigna Commercial |
$547.80
|
| Rate for Payer: First Health Commercial |
$627.00
|
| Rate for Payer: Humana Commercial |
$561.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$541.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$487.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$198.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$580.80
|
| Rate for Payer: Ohio Health Group HMO |
$495.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$132.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$204.60
|
| Rate for Payer: PHCS Commercial |
$633.60
|
| Rate for Payer: United Healthcare All Payer |
$580.80
|
|
|
REPAIR LIP - FULL THICKNESS(P
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 40650
|
| Hospital Charge Code |
761P1628
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$222.05 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial |
$411.35
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$222.05
|
| Rate for Payer: Anthem Medicaid |
$238.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$600.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$407.68
|
| Rate for Payer: Healthspan PPO |
$479.14
|
| Rate for Payer: Humana Medicaid |
$238.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$370.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$242.86
|
| Rate for Payer: Molina Healthcare Passport |
$238.10
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$233.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$240.48
|
|
|
REPAIR LIP - FULL THICKNESS(T
|
Facility
|
OP
|
$1,596.50
|
|
|
Service Code
|
HCPCS 40650
|
| Hospital Charge Code |
761T1628
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$207.54 |
| Max. Negotiated Rate |
$1,532.64 |
| Rate for Payer: Aetna Commercial |
$1,229.30
|
| Rate for Payer: Anthem Medicaid |
$549.04
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$475.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,245.27
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$666.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$642.32
|
| Rate for Payer: Cash Price |
$798.25
|
| Rate for Payer: Cash Price |
$798.25
|
| Rate for Payer: Cigna Commercial |
$1,325.10
|
| Rate for Payer: First Health Commercial |
$1,516.68
|
| Rate for Payer: Humana Commercial |
$1,357.02
|
| Rate for Payer: Humana KY Medicaid |
$549.04
|
| Rate for Payer: Humana Medicare Advantage |
$475.79
|
| Rate for Payer: Kentucky WC Medicaid |
$554.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,309.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,178.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$570.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$560.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,404.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,197.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$319.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$207.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$494.92
|
| Rate for Payer: PHCS Commercial |
$1,532.64
|
| Rate for Payer: United Healthcare All Payer |
$1,404.92
|
|
|
REPAIR LIP - FULL THICKNESS(T
|
Facility
|
IP
|
$1,596.50
|
|
|
Service Code
|
HCPCS 40650
|
| Hospital Charge Code |
761T1628
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$207.54 |
| Max. Negotiated Rate |
$1,532.64 |
| Rate for Payer: Aetna Commercial |
$1,229.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,245.27
|
| Rate for Payer: Cash Price |
$798.25
|
| Rate for Payer: Cigna Commercial |
$1,325.10
|
| Rate for Payer: First Health Commercial |
$1,516.68
|
| Rate for Payer: Humana Commercial |
$1,357.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,309.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,178.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$478.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,404.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,197.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$319.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$207.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$494.92
|
| Rate for Payer: PHCS Commercial |
$1,532.64
|
| Rate for Payer: United Healthcare All Payer |
$1,404.92
|
|
|
REPAIR LIVER WOUND
|
Facility
|
OP
|
$6,175.00
|
|
|
Service Code
|
HCPCS 47361
|
| Hospital Charge Code |
76101952
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$802.75 |
| Max. Negotiated Rate |
$5,928.00 |
| Rate for Payer: Aetna Commercial |
$4,754.75
|
| Rate for Payer: Anthem Medicaid |
$2,123.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,816.50
|
| Rate for Payer: Cash Price |
$3,087.50
|
| Rate for Payer: Cigna Commercial |
$5,125.25
|
| Rate for Payer: First Health Commercial |
$5,866.25
|
| Rate for Payer: Humana Commercial |
$5,248.75
|
| Rate for Payer: Humana KY Medicaid |
$2,123.58
|
| Rate for Payer: Kentucky WC Medicaid |
$2,145.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,063.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,557.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,852.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,166.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,434.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,631.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,235.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$802.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,914.25
|
| Rate for Payer: PHCS Commercial |
$5,928.00
|
| Rate for Payer: United Healthcare All Payer |
$5,434.00
|
|
|
REPAIR LIVER WOUND
|
Facility
|
IP
|
$6,175.00
|
|
|
Service Code
|
HCPCS 47361
|
| Hospital Charge Code |
76101952
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$802.75 |
| Max. Negotiated Rate |
$5,928.00 |
| Rate for Payer: Aetna Commercial |
$4,754.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,816.50
|
| Rate for Payer: Cash Price |
$3,087.50
|
| Rate for Payer: Cigna Commercial |
$5,125.25
|
| Rate for Payer: First Health Commercial |
$5,866.25
|
| Rate for Payer: Humana Commercial |
$5,248.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,063.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,557.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,852.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,434.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,631.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,235.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$802.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,914.25
|
| Rate for Payer: PHCS Commercial |
$5,928.00
|
| Rate for Payer: United Healthcare All Payer |
$5,434.00
|
|
|
REPAIR LIVER WOUND
|
Facility
|
IP
|
$2,240.00
|
|
|
Service Code
|
HCPCS 47350
|
| Hospital Charge Code |
76101951
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$291.20 |
| Max. Negotiated Rate |
$2,150.40 |
| Rate for Payer: Aetna Commercial |
$1,724.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,747.20
|
| Rate for Payer: Cash Price |
$1,120.00
|
| Rate for Payer: Cigna Commercial |
$1,859.20
|
| Rate for Payer: First Health Commercial |
$2,128.00
|
| Rate for Payer: Humana Commercial |
$1,904.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,836.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,653.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$672.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,971.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$448.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$291.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$694.40
|
| Rate for Payer: PHCS Commercial |
$2,150.40
|
| Rate for Payer: United Healthcare All Payer |
$1,971.20
|
|
|
REPAIR LIVER WOUND
|
Facility
|
OP
|
$2,240.00
|
|
|
Service Code
|
HCPCS 47350
|
| Hospital Charge Code |
76101951
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$291.20 |
| Max. Negotiated Rate |
$2,150.40 |
| Rate for Payer: Aetna Commercial |
$1,724.80
|
| Rate for Payer: Anthem Medicaid |
$770.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,747.20
|
| Rate for Payer: Cash Price |
$1,120.00
|
| Rate for Payer: Cigna Commercial |
$1,859.20
|
| Rate for Payer: First Health Commercial |
$2,128.00
|
| Rate for Payer: Humana Commercial |
$1,904.00
|
| Rate for Payer: Humana KY Medicaid |
$770.34
|
| Rate for Payer: Kentucky WC Medicaid |
$778.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,836.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,653.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$672.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$785.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,971.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,680.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$448.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$291.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$694.40
|
| Rate for Payer: PHCS Commercial |
$2,150.40
|
| Rate for Payer: United Healthcare All Payer |
$1,971.20
|
|
|
REPAIR LIVER WOUND
|
Professional
|
Both
|
$2,240.00
|
|
|
Service Code
|
HCPCS 47350
|
| Hospital Charge Code |
76101951
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$567.59 |
| Max. Negotiated Rate |
$2,240.00 |
| Rate for Payer: Aetna Commercial |
$1,964.93
|
| Rate for Payer: Anthem Medicaid |
$567.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,240.00
|
| Rate for Payer: Cash Price |
$1,120.00
|
| Rate for Payer: Cash Price |
$1,120.00
|
| Rate for Payer: Cigna Commercial |
$1,823.19
|
| Rate for Payer: Healthspan PPO |
$1,657.06
|
| Rate for Payer: Humana Medicaid |
$567.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,744.74
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$578.94
|
| Rate for Payer: Molina Healthcare Passport |
$567.59
|
| Rate for Payer: Multiplan PHCS |
$1,344.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,568.00
|
| Rate for Payer: UHCCP Medicaid |
$784.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$573.27
|
|
|
REPAIR LIVER WOUND
|
Professional
|
Both
|
$6,175.00
|
|
|
Service Code
|
HCPCS 47361
|
| Hospital Charge Code |
76101952
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,297.15 |
| Max. Negotiated Rate |
$6,175.00 |
| Rate for Payer: Aetna Commercial |
$4,406.06
|
| Rate for Payer: Anthem Medicaid |
$1,297.15
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,175.00
|
| Rate for Payer: Cash Price |
$3,087.50
|
| Rate for Payer: Cash Price |
$3,087.50
|
| Rate for Payer: Cigna Commercial |
$4,116.29
|
| Rate for Payer: Healthspan PPO |
$3,715.70
|
| Rate for Payer: Humana Medicaid |
$1,297.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$3,865.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,323.09
|
| Rate for Payer: Molina Healthcare Passport |
$1,297.15
|
| Rate for Payer: Multiplan PHCS |
$3,705.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,322.50
|
| Rate for Payer: UHCCP Medicaid |
$2,161.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,310.12
|
|
