|
REPAIR TRUNK 2.6 TO 7.5 CM
|
Professional
|
Both
|
$3,151.00
|
|
|
Service Code
|
HCPCS 13101
|
| Hospital Charge Code |
76100150
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$125.45 |
| Max. Negotiated Rate |
$3,151.00 |
| Rate for Payer: Aetna Commercial |
$404.90
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$125.45
|
| Rate for Payer: Anthem Medicaid |
$146.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,151.00
|
| Rate for Payer: Cash Price |
$1,575.50
|
| Rate for Payer: Cash Price |
$1,575.50
|
| Rate for Payer: Cigna Commercial |
$498.30
|
| Rate for Payer: Healthspan PPO |
$437.58
|
| Rate for Payer: Humana Medicaid |
$146.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$356.17
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$149.49
|
| Rate for Payer: Molina Healthcare Passport |
$146.56
|
| Rate for Payer: Multiplan PHCS |
$1,890.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,205.70
|
| Rate for Payer: UHCCP Medicaid |
$131.72
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$148.03
|
|
|
REPAIR TRUNK 2.6 TO 7.5 CM(P
|
Professional
|
Both
|
$550.00
|
|
|
Service Code
|
HCPCS 13101
|
| Hospital Charge Code |
761P0150
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$125.45 |
| Max. Negotiated Rate |
$550.00 |
| Rate for Payer: Aetna Commercial |
$404.90
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$125.45
|
| Rate for Payer: Anthem Medicaid |
$146.56
|
| 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 |
$498.30
|
| Rate for Payer: Healthspan PPO |
$437.58
|
| Rate for Payer: Humana Medicaid |
$146.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$356.17
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$149.49
|
| Rate for Payer: Molina Healthcare Passport |
$146.56
|
| Rate for Payer: Multiplan PHCS |
$330.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$385.00
|
| Rate for Payer: UHCCP Medicaid |
$131.72
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$148.03
|
|
|
REPAIR TRUNK 2.6 TO 7.5 CM(T
|
Facility
|
IP
|
$2,601.00
|
|
|
Service Code
|
HCPCS 13101
|
| Hospital Charge Code |
761T0150
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$338.13 |
| Max. Negotiated Rate |
$2,496.96 |
| Rate for Payer: Aetna Commercial |
$2,002.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,028.78
|
| Rate for Payer: Cash Price |
$1,300.50
|
| Rate for Payer: Cigna Commercial |
$2,158.83
|
| Rate for Payer: First Health Commercial |
$2,470.95
|
| Rate for Payer: Humana Commercial |
$2,210.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,132.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,919.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$780.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,288.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,950.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$520.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$338.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$806.31
|
| Rate for Payer: PHCS Commercial |
$2,496.96
|
| Rate for Payer: United Healthcare All Payer |
$2,288.88
|
|
|
REPAIR TRUNK 2.6 TO 7.5 CM(T
|
Facility
|
OP
|
$2,601.00
|
|
|
Service Code
|
HCPCS 13101
|
| Hospital Charge Code |
761T0150
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$338.13 |
| Max. Negotiated Rate |
$2,496.96 |
| Rate for Payer: Aetna Commercial |
$2,002.77
|
| Rate for Payer: Anthem Medicaid |
$894.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,028.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$1,300.50
|
| Rate for Payer: Cash Price |
$1,300.50
|
| Rate for Payer: Cigna Commercial |
$2,158.83
|
| Rate for Payer: First Health Commercial |
$2,470.95
|
| Rate for Payer: Humana Commercial |
$2,210.85
|
| Rate for Payer: Humana KY Medicaid |
$894.48
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$903.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,132.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,919.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$912.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,288.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,950.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$520.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$338.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$806.31
|
| Rate for Payer: PHCS Commercial |
$2,496.96
|
| Rate for Payer: United Healthcare All Payer |
$2,288.88
|
|
|
REPAIR TUNNELED CV CATH
|
Facility
|
OP
|
$4,562.00
|
|
|
Service Code
|
HCPCS 36576
|
| Hospital Charge Code |
76101482
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$593.06 |
| Max. Negotiated Rate |
$4,379.52 |
| Rate for Payer: Aetna Commercial |
$3,512.74
|
| Rate for Payer: Anthem Medicaid |
$1,568.87
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,384.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,558.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,938.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,869.66
|
| Rate for Payer: Cash Price |
$2,281.00
|
| Rate for Payer: Cash Price |
$2,281.00
|
| Rate for Payer: Cigna Commercial |
$3,786.46
|
| Rate for Payer: First Health Commercial |
$4,333.90
|
| Rate for Payer: Humana Commercial |
$3,877.70
|
| Rate for Payer: Humana KY Medicaid |
$1,568.87
|
| Rate for Payer: Humana Medicare Advantage |
$1,384.93
|
| Rate for Payer: Kentucky WC Medicaid |
$1,584.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,740.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,366.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,661.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,600.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,014.56
|
| Rate for Payer: Ohio Health Group HMO |
$3,421.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$912.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$593.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,414.22
|
| Rate for Payer: PHCS Commercial |
$4,379.52
|
| Rate for Payer: United Healthcare All Payer |
$4,014.56
|
|
|
REPAIR TUNNELED CV CATH
|
Facility
|
IP
|
$4,562.00
|
|
|
Service Code
|
HCPCS 36576
|
| Hospital Charge Code |
76101482
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$593.06 |
| Max. Negotiated Rate |
$4,379.52 |
| Rate for Payer: Aetna Commercial |
$3,512.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,558.36
|
| Rate for Payer: Cash Price |
$2,281.00
|
| Rate for Payer: Cigna Commercial |
$3,786.46
|
| Rate for Payer: First Health Commercial |
$4,333.90
|
| Rate for Payer: Humana Commercial |
$3,877.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,740.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,366.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,368.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,014.56
|
| Rate for Payer: Ohio Health Group HMO |
$3,421.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$912.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$593.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,414.22
|
| Rate for Payer: PHCS Commercial |
$4,379.52
|
| Rate for Payer: United Healthcare All Payer |
$4,014.56
|
|
|
REPAIR TUNNELED CV CATH
|
Professional
|
Both
|
$4,562.00
|
|
|
Service Code
|
HCPCS 36576
|
| Hospital Charge Code |
76101482
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$94.13 |
| Max. Negotiated Rate |
$4,562.00 |
| Rate for Payer: Aetna Commercial |
$288.76
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$94.13
|
| Rate for Payer: Anthem Medicaid |
$152.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,562.00
|
| Rate for Payer: Cash Price |
$2,281.00
|
| Rate for Payer: Cash Price |
$2,281.00
|
| Rate for Payer: Cigna Commercial |
$278.44
|
| Rate for Payer: Healthspan PPO |
$422.18
|
| Rate for Payer: Humana Medicaid |
$152.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$250.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$155.07
|
| Rate for Payer: Molina Healthcare Passport |
$152.03
|
| Rate for Payer: Multiplan PHCS |
$2,737.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,193.40
|
| Rate for Payer: UHCCP Medicaid |
$98.84
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$153.55
|
|
|
REPAIR TUNNELED CV CATH(P
|
Professional
|
Both
|
$385.00
|
|
|
Service Code
|
HCPCS 36576
|
| Hospital Charge Code |
761P1482
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$94.13 |
| Max. Negotiated Rate |
$422.18 |
| Rate for Payer: Aetna Commercial |
$288.76
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$94.13
|
| Rate for Payer: Anthem Medicaid |
$152.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$385.00
|
| Rate for Payer: Cash Price |
$192.50
|
| Rate for Payer: Cash Price |
$192.50
|
| Rate for Payer: Cigna Commercial |
$278.44
|
| Rate for Payer: Healthspan PPO |
$422.18
|
| Rate for Payer: Humana Medicaid |
$152.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$250.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$155.07
|
| Rate for Payer: Molina Healthcare Passport |
$152.03
|
| Rate for Payer: Multiplan PHCS |
$231.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$269.50
|
| Rate for Payer: UHCCP Medicaid |
$98.84
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$153.55
|
|
|
REPAIR TUNNELED CV CATH(T
|
Facility
|
IP
|
$4,177.00
|
|
|
Service Code
|
HCPCS 36576
|
| Hospital Charge Code |
761T1482
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$543.01 |
| Max. Negotiated Rate |
$4,009.92 |
| Rate for Payer: Aetna Commercial |
$3,216.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,258.06
|
| Rate for Payer: Cash Price |
$2,088.50
|
| Rate for Payer: Cigna Commercial |
$3,466.91
|
| Rate for Payer: First Health Commercial |
$3,968.15
|
| Rate for Payer: Humana Commercial |
$3,550.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,425.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,082.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,253.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,675.76
|
| Rate for Payer: Ohio Health Group HMO |
$3,132.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$835.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$543.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,294.87
|
| Rate for Payer: PHCS Commercial |
$4,009.92
|
| Rate for Payer: United Healthcare All Payer |
$3,675.76
|
|
|
REPAIR TUNNELED CV CATH(T
|
Facility
|
OP
|
$4,177.00
|
|
|
Service Code
|
HCPCS 36576
|
| Hospital Charge Code |
761T1482
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$543.01 |
| Max. Negotiated Rate |
$4,009.92 |
| Rate for Payer: Aetna Commercial |
$3,216.29
|
| Rate for Payer: Anthem Medicaid |
$1,436.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,384.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,258.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,938.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,869.66
|
| Rate for Payer: Cash Price |
$2,088.50
|
| Rate for Payer: Cash Price |
$2,088.50
|
| Rate for Payer: Cigna Commercial |
$3,466.91
|
| Rate for Payer: First Health Commercial |
$3,968.15
|
| Rate for Payer: Humana Commercial |
$3,550.45
|
| Rate for Payer: Humana KY Medicaid |
$1,436.47
|
| Rate for Payer: Humana Medicare Advantage |
$1,384.93
|
| Rate for Payer: Kentucky WC Medicaid |
$1,451.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,425.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,082.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,661.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,465.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,675.76
|
| Rate for Payer: Ohio Health Group HMO |
$3,132.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$835.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$543.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,294.87
|
| Rate for Payer: PHCS Commercial |
$4,009.92
|
| Rate for Payer: United Healthcare All Payer |
$3,675.76
|
|
|
REPAIR WINDPIPE OPENING
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 31614
|
| Hospital Charge Code |
41000034
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$377.81 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: Aetna Commercial |
$1,117.32
|
| Rate for Payer: Anthem Medicaid |
$377.81
|
| 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 |
$990.99
|
| Rate for Payer: Healthspan PPO |
$872.37
|
| Rate for Payer: Humana Medicaid |
$377.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$949.72
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$385.37
|
| Rate for Payer: Molina Healthcare Passport |
$377.81
|
| 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 |
$381.59
|
|
|
REPAIR WINDPIPE OPENING(P
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 31614
|
| Hospital Charge Code |
410P0034
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$377.81 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: Aetna Commercial |
$1,117.32
|
| Rate for Payer: Anthem Medicaid |
$377.81
|
| 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 |
$990.99
|
| Rate for Payer: Healthspan PPO |
$872.37
|
| Rate for Payer: Humana Medicaid |
$377.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$949.72
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$385.37
|
| Rate for Payer: Molina Healthcare Passport |
$377.81
|
| 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 |
$381.59
|
|
|
REPAIR WOUND 7.6-12.5
|
Facility
|
IP
|
$499.00
|
|
|
Service Code
|
HCPCS 12034
|
| Hospital Charge Code |
45000057
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$64.87 |
| Max. Negotiated Rate |
$479.04 |
| Rate for Payer: Aetna Commercial |
$384.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$389.22
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cigna Commercial |
$414.17
|
| Rate for Payer: First Health Commercial |
$474.05
|
| Rate for Payer: Humana Commercial |
$424.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$409.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$368.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$149.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$439.12
|
| Rate for Payer: Ohio Health Group HMO |
$374.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$154.69
|
| Rate for Payer: PHCS Commercial |
$479.04
|
| Rate for Payer: United Healthcare All Payer |
$439.12
|
|
|
REPAIR WOUND 7.6-12.5
|
Facility
|
OP
|
$499.00
|
|
|
Service Code
|
HCPCS 12034
|
| Hospital Charge Code |
45000057
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$64.87 |
| Max. Negotiated Rate |
$482.75 |
| Rate for Payer: Aetna Commercial |
$384.23
|
| Rate for Payer: Anthem Medicaid |
$171.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$389.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cigna Commercial |
$414.17
|
| Rate for Payer: First Health Commercial |
$474.05
|
| Rate for Payer: Humana Commercial |
$424.15
|
| Rate for Payer: Humana KY Medicaid |
$171.61
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$173.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$409.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$368.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$175.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$439.12
|
| Rate for Payer: Ohio Health Group HMO |
$374.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$154.69
|
| Rate for Payer: PHCS Commercial |
$479.04
|
| Rate for Payer: United Healthcare All Payer |
$439.12
|
|
|
REPAIR WOUND 7.6-12.5
|
Facility
|
IP
|
$899.00
|
|
|
Service Code
|
HCPCS 12034
|
| Hospital Charge Code |
76100136
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$116.87 |
| Max. Negotiated Rate |
$863.04 |
| Rate for Payer: Aetna Commercial |
$692.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$701.22
|
| Rate for Payer: Cash Price |
$449.50
|
| Rate for Payer: Cigna Commercial |
$746.17
|
| Rate for Payer: First Health Commercial |
$854.05
|
| Rate for Payer: Humana Commercial |
$764.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$737.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$663.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$269.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$791.12
|
| Rate for Payer: Ohio Health Group HMO |
$674.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$179.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$116.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$278.69
|
| Rate for Payer: PHCS Commercial |
$863.04
|
| Rate for Payer: United Healthcare All Payer |
$791.12
|
|
|
REPAIR WOUND 7.6-12.5
|
Professional
|
Both
|
$899.00
|
|
|
Service Code
|
HCPCS 12034
|
| Hospital Charge Code |
76100136
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$103.82 |
| Max. Negotiated Rate |
$899.00 |
| Rate for Payer: Aetna Commercial |
$288.68
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$103.82
|
| Rate for Payer: Anthem Medicaid |
$127.29
|
| Rate for Payer: Buckeye Medicare Advantage |
$899.00
|
| Rate for Payer: Cash Price |
$449.50
|
| Rate for Payer: Cash Price |
$449.50
|
| Rate for Payer: Cigna Commercial |
$365.25
|
| Rate for Payer: Healthspan PPO |
$330.53
|
| Rate for Payer: Humana Medicaid |
$127.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$254.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$129.84
|
| Rate for Payer: Molina Healthcare Passport |
$127.29
|
| Rate for Payer: Multiplan PHCS |
$539.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$629.30
|
| Rate for Payer: UHCCP Medicaid |
$109.01
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$128.56
|
|
|
REPAIR WOUND 7.6-12.5
|
Facility
|
OP
|
$899.00
|
|
|
Service Code
|
HCPCS 12034
|
| Hospital Charge Code |
76100136
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$116.87 |
| Max. Negotiated Rate |
$863.04 |
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$449.50
|
| Rate for Payer: Cash Price |
$449.50
|
| Rate for Payer: Cigna Commercial |
$746.17
|
| Rate for Payer: First Health Commercial |
$854.05
|
| Rate for Payer: Humana Commercial |
$764.15
|
| Rate for Payer: Humana KY Medicaid |
$309.17
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$312.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$737.18
|
| Rate for Payer: Aetna Commercial |
$692.23
|
| Rate for Payer: Anthem Medicaid |
$309.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$701.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$663.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$315.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$791.12
|
| Rate for Payer: Ohio Health Group HMO |
$674.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$179.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$116.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$278.69
|
| Rate for Payer: PHCS Commercial |
$863.04
|
| Rate for Payer: United Healthcare All Payer |
$791.12
|
|
|
REPAIR WOUND 7.6-12.5(P
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 12034
|
| Hospital Charge Code |
761P0136
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$103.82 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna Commercial |
$288.68
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$103.82
|
| Rate for Payer: Anthem Medicaid |
$127.29
|
| Rate for Payer: Buckeye Medicare Advantage |
$400.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$365.25
|
| Rate for Payer: Healthspan PPO |
$330.53
|
| Rate for Payer: Humana Medicaid |
$127.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$254.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$129.84
|
| Rate for Payer: Molina Healthcare Passport |
$127.29
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$109.01
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$128.56
|
|
|
REPAIR WOUND 7.6-12.5(T
|
Facility
|
OP
|
$499.00
|
|
|
Service Code
|
HCPCS 12034
|
| Hospital Charge Code |
761T0136
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$64.87 |
| Max. Negotiated Rate |
$482.75 |
| Rate for Payer: Aetna Commercial |
$384.23
|
| Rate for Payer: Anthem Medicaid |
$171.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$389.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cigna Commercial |
$414.17
|
| Rate for Payer: First Health Commercial |
$474.05
|
| Rate for Payer: Humana Commercial |
$424.15
|
| Rate for Payer: Humana KY Medicaid |
$171.61
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$173.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$409.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$368.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$175.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$439.12
|
| Rate for Payer: Ohio Health Group HMO |
$374.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$154.69
|
| Rate for Payer: PHCS Commercial |
$479.04
|
| Rate for Payer: United Healthcare All Payer |
$439.12
|
|
|
REPAIR WOUND 7.6-12.5(T
|
Facility
|
IP
|
$499.00
|
|
|
Service Code
|
HCPCS 12034
|
| Hospital Charge Code |
761T0136
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$64.87 |
| Max. Negotiated Rate |
$479.04 |
| Rate for Payer: Aetna Commercial |
$384.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$389.22
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cigna Commercial |
$414.17
|
| Rate for Payer: First Health Commercial |
$474.05
|
| Rate for Payer: Humana Commercial |
$424.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$409.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$368.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$149.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$439.12
|
| Rate for Payer: Ohio Health Group HMO |
$374.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$154.69
|
| Rate for Payer: PHCS Commercial |
$479.04
|
| Rate for Payer: United Healthcare All Payer |
$439.12
|
|
|
REPAIR WRIST JOINTS
|
Facility
|
IP
|
$2,270.00
|
|
|
Service Code
|
HCPCS 25447
|
| Hospital Charge Code |
76100615
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$295.10 |
| Max. Negotiated Rate |
$2,179.20 |
| Rate for Payer: Aetna Commercial |
$1,747.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,770.60
|
| Rate for Payer: Cash Price |
$1,135.00
|
| Rate for Payer: Cigna Commercial |
$1,884.10
|
| Rate for Payer: First Health Commercial |
$2,156.50
|
| Rate for Payer: Humana Commercial |
$1,929.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,861.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,675.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$681.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,997.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,702.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$454.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$295.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$703.70
|
| Rate for Payer: PHCS Commercial |
$2,179.20
|
| Rate for Payer: United Healthcare All Payer |
$1,997.60
|
|
|
REPAIR WRIST JOINTS
|
Professional
|
Both
|
$2,270.00
|
|
|
Service Code
|
HCPCS 25447
|
| Hospital Charge Code |
76100615
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$586.06 |
| Max. Negotiated Rate |
$2,270.00 |
| Rate for Payer: Aetna Commercial |
$1,188.29
|
| Rate for Payer: Anthem Medicaid |
$586.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,270.00
|
| Rate for Payer: Cash Price |
$1,135.00
|
| Rate for Payer: Cash Price |
$1,135.00
|
| Rate for Payer: Cigna Commercial |
$1,289.15
|
| Rate for Payer: Healthspan PPO |
$1,076.34
|
| Rate for Payer: Humana Medicaid |
$586.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,015.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$597.78
|
| Rate for Payer: Molina Healthcare Passport |
$586.06
|
| Rate for Payer: Multiplan PHCS |
$1,362.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,589.00
|
| Rate for Payer: UHCCP Medicaid |
$794.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$591.92
|
|
|
REPAIR WRIST JOINTS
|
Facility
|
OP
|
$2,270.00
|
|
|
Service Code
|
HCPCS 25447
|
| Hospital Charge Code |
76100615
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$295.10 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Aetna Commercial |
$1,747.90
|
| Rate for Payer: Anthem Medicaid |
$780.65
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,770.60
|
| 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 |
$1,135.00
|
| Rate for Payer: Cash Price |
$1,135.00
|
| Rate for Payer: Cigna Commercial |
$1,884.10
|
| Rate for Payer: First Health Commercial |
$2,156.50
|
| Rate for Payer: Humana Commercial |
$1,929.50
|
| Rate for Payer: Humana KY Medicaid |
$780.65
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Kentucky WC Medicaid |
$788.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,861.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,675.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$796.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,997.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,702.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$454.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$295.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$703.70
|
| Rate for Payer: PHCS Commercial |
$2,179.20
|
| Rate for Payer: United Healthcare All Payer |
$1,997.60
|
|
|
REPAIR WRIST JOINTS(P
|
Professional
|
Both
|
$2,270.00
|
|
|
Service Code
|
HCPCS 25447
|
| Hospital Charge Code |
761P0615
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$586.06 |
| Max. Negotiated Rate |
$2,270.00 |
| Rate for Payer: Aetna Commercial |
$1,188.29
|
| Rate for Payer: Anthem Medicaid |
$586.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,270.00
|
| Rate for Payer: Cash Price |
$1,135.00
|
| Rate for Payer: Cash Price |
$1,135.00
|
| Rate for Payer: Cigna Commercial |
$1,289.15
|
| Rate for Payer: Healthspan PPO |
$1,076.34
|
| Rate for Payer: Humana Medicaid |
$586.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,015.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$597.78
|
| Rate for Payer: Molina Healthcare Passport |
$586.06
|
| Rate for Payer: Multiplan PHCS |
$1,362.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,589.00
|
| Rate for Payer: UHCCP Medicaid |
$794.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$591.92
|
|
|
REP CATH
|
Facility
|
OP
|
$1,787.00
|
|
|
Service Code
|
HCPCS 36575
|
| Hospital Charge Code |
76101481
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$232.31 |
| Max. Negotiated Rate |
$1,715.52 |
| Rate for Payer: Aetna Commercial |
$1,375.99
|
| Rate for Payer: Anthem Medicaid |
$614.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,393.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.37
|
| Rate for Payer: Cash Price |
$893.50
|
| Rate for Payer: Cash Price |
$893.50
|
| Rate for Payer: Cigna Commercial |
$1,483.21
|
| Rate for Payer: First Health Commercial |
$1,697.65
|
| Rate for Payer: Humana Commercial |
$1,518.95
|
| Rate for Payer: Humana KY Medicaid |
$614.55
|
| Rate for Payer: Humana Medicare Advantage |
$543.24
|
| Rate for Payer: Kentucky WC Medicaid |
$620.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,465.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,318.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$626.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,572.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,340.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$357.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$232.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$553.97
|
| Rate for Payer: PHCS Commercial |
$1,715.52
|
| Rate for Payer: United Healthcare All Payer |
$1,572.56
|
|
