|
REPAIR BROW PTOSIS
|
Facility
|
IP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 67900
|
| Hospital Charge Code |
76102393
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$480.00 |
| Max. Negotiated Rate |
$1,536.00 |
| Rate for Payer: Aetna Commercial |
$1,232.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,248.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,328.00
|
| Rate for Payer: First Health Commercial |
$1,520.00
|
| Rate for Payer: Humana Commercial |
$1,360.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,312.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,180.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$480.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,408.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,392.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,104.00
|
| Rate for Payer: PHCS Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare All Payer |
$1,408.00
|
|
|
REPAIR BROW PTOSIS
|
Facility
|
OP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 67900
|
| Hospital Charge Code |
76102393
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$550.24 |
| Max. Negotiated Rate |
$3,017.85 |
| Rate for Payer: Aetna Commercial |
$1,232.00
|
| Rate for Payer: Anthem Medicaid |
$550.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,155.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,248.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,017.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,910.07
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,328.00
|
| Rate for Payer: First Health Commercial |
$1,520.00
|
| Rate for Payer: Humana Commercial |
$1,360.00
|
| Rate for Payer: Humana KY Medicaid |
$550.24
|
| Rate for Payer: Humana Medicare Advantage |
$2,155.61
|
| Rate for Payer: Kentucky WC Medicaid |
$555.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,312.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,180.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,586.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$561.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,408.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,392.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,104.00
|
| Rate for Payer: PHCS Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare All Payer |
$1,408.00
|
|
|
REPAIR BROW PTOSIS(P
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 67900
|
| Hospital Charge Code |
761P2393
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$239.47 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$676.07
|
| Rate for Payer: Ambetter Exchange |
$465.53
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$253.32
|
| Rate for Payer: Anthem Medicaid |
$239.47
|
| Rate for Payer: Buckeye Individual/Medicaid |
$465.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$465.53
|
| Rate for Payer: CareSource Just4Me Medicare |
$558.64
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$659.84
|
| Rate for Payer: Healthspan PPO |
$741.67
|
| Rate for Payer: Humana Medicaid |
$239.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$642.51
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$465.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$465.53
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$244.26
|
| Rate for Payer: Molina Healthcare Passport |
$239.47
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$605.19
|
| Rate for Payer: UHCCP Medicaid |
$265.99
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$241.86
|
| Rate for Payer: Wellcare Medicare Advantage |
$465.53
|
|
|
REPAIR CARDIAC WOUND W/O BYPAS
|
Professional
|
Both
|
$3,100.00
|
|
|
Service Code
|
HCPCS 33300
|
| Hospital Charge Code |
761P1282
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$923.41 |
| Max. Negotiated Rate |
$3,847.18 |
| Rate for Payer: Aetna Commercial |
$3,847.18
|
| Rate for Payer: Ambetter Exchange |
$2,298.45
|
| Rate for Payer: Anthem Medicaid |
$923.41
|
| Rate for Payer: Buckeye Individual/Medicaid |
$2,298.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,298.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,758.14
|
| Rate for Payer: Cash Price |
$1,550.00
|
| Rate for Payer: Cash Price |
$1,550.00
|
| Rate for Payer: Cigna Commercial |
$3,403.66
|
| Rate for Payer: Healthspan PPO |
$3,782.53
|
| Rate for Payer: Humana Medicaid |
$923.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$3,404.90
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$2,298.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,298.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$941.88
|
| Rate for Payer: Molina Healthcare Passport |
$923.41
|
| Rate for Payer: Multiplan PHCS |
$1,860.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,987.99
|
| Rate for Payer: UHCCP Medicaid |
$1,085.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$932.64
|
| Rate for Payer: Wellcare Medicare Advantage |
$2,298.45
|
|
|
REPAIR CARDIAC WOUND W/O BYPAS
|
Facility
|
IP
|
$3,100.00
|
|
|
Service Code
|
HCPCS 33300
|
| Hospital Charge Code |
76101282
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$930.00 |
| Max. Negotiated Rate |
$2,976.00 |
| Rate for Payer: Aetna Commercial |
$2,387.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,418.00
|
| Rate for Payer: Cash Price |
$1,550.00
|
| Rate for Payer: Cigna Commercial |
$2,573.00
|
| Rate for Payer: First Health Commercial |
$2,945.00
|
| Rate for Payer: Humana Commercial |
$2,635.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,542.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,287.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$930.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,728.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,325.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,697.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,139.00
|
| Rate for Payer: PHCS Commercial |
$2,976.00
|
| Rate for Payer: United Healthcare All Payer |
$2,728.00
|
|
|
REPAIR CARDIAC WOUND W/O BYPAS
|
Facility
|
OP
|
$3,100.00
|
|
|
Service Code
|
HCPCS 33300
|
| Hospital Charge Code |
76101282
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$930.00 |
| Max. Negotiated Rate |
$2,976.00 |
| Rate for Payer: Aetna Commercial |
$2,387.00
|
| Rate for Payer: Anthem Medicaid |
$1,066.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,418.00
|
| Rate for Payer: Cash Price |
$1,550.00
|
| Rate for Payer: Cigna Commercial |
$2,573.00
|
| Rate for Payer: First Health Commercial |
$2,945.00
|
| Rate for Payer: Humana Commercial |
$2,635.00
|
| Rate for Payer: Humana KY Medicaid |
$1,066.09
|
| Rate for Payer: Kentucky WC Medicaid |
$1,076.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,542.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,287.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$930.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,087.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,728.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,325.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,697.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,139.00
|
| Rate for Payer: PHCS Commercial |
$2,976.00
|
| Rate for Payer: United Healthcare All Payer |
$2,728.00
|
|
|
REPAIR CARDIAC WOUND W/O BYPAS
|
Professional
|
Both
|
$3,100.00
|
|
|
Service Code
|
HCPCS 33300
|
| Hospital Charge Code |
76101282
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$923.41 |
| Max. Negotiated Rate |
$3,847.18 |
| Rate for Payer: Aetna Commercial |
$3,847.18
|
| Rate for Payer: Ambetter Exchange |
$2,298.45
|
| Rate for Payer: Anthem Medicaid |
$923.41
|
| Rate for Payer: Buckeye Individual/Medicaid |
$2,298.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,298.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,758.14
|
| Rate for Payer: Cash Price |
$1,550.00
|
| Rate for Payer: Cash Price |
$1,550.00
|
| Rate for Payer: Cigna Commercial |
$3,403.66
|
| Rate for Payer: Healthspan PPO |
$3,782.53
|
| Rate for Payer: Humana Medicaid |
$923.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$3,404.90
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$2,298.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,298.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$941.88
|
| Rate for Payer: Molina Healthcare Passport |
$923.41
|
| Rate for Payer: Multiplan PHCS |
$1,860.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,987.99
|
| Rate for Payer: UHCCP Medicaid |
$1,085.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$932.64
|
| Rate for Payer: Wellcare Medicare Advantage |
$2,298.45
|
|
|
REPAIR - COMPLEX 1.1 TO 2.5 C
|
Facility
|
IP
|
$1,785.00
|
|
|
Service Code
|
HCPCS 13131
|
| Hospital Charge Code |
76100155
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$535.50 |
| Max. Negotiated Rate |
$1,713.60 |
| Rate for Payer: Aetna Commercial |
$1,374.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,392.30
|
| Rate for Payer: Cash Price |
$892.50
|
| Rate for Payer: Cigna Commercial |
$1,481.55
|
| Rate for Payer: First Health Commercial |
$1,695.75
|
| Rate for Payer: Humana Commercial |
$1,517.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,463.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,317.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,570.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,338.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,428.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,552.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,231.65
|
| Rate for Payer: PHCS Commercial |
$1,713.60
|
| Rate for Payer: United Healthcare All Payer |
$1,570.80
|
|
|
REPAIR - COMPLEX 1.1 TO 2.5 C
|
Professional
|
Both
|
$1,785.00
|
|
|
Service Code
|
HCPCS 13131
|
| Hospital Charge Code |
76100155
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$122.16 |
| Max. Negotiated Rate |
$1,071.00 |
| Rate for Payer: Aetna Commercial |
$393.10
|
| Rate for Payer: Ambetter Exchange |
$227.16
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$122.16
|
| Rate for Payer: Anthem Medicaid |
$168.44
|
| Rate for Payer: Buckeye Individual/Medicaid |
$227.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$227.16
|
| Rate for Payer: CareSource Just4Me Medicare |
$272.59
|
| Rate for Payer: Cash Price |
$892.50
|
| Rate for Payer: Cash Price |
$892.50
|
| Rate for Payer: Cigna Commercial |
$466.46
|
| Rate for Payer: Healthspan PPO |
$398.63
|
| Rate for Payer: Humana Medicaid |
$168.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$345.15
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$227.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$227.16
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$171.81
|
| Rate for Payer: Molina Healthcare Passport |
$168.44
|
| Rate for Payer: Multiplan PHCS |
$1,071.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$295.31
|
| Rate for Payer: UHCCP Medicaid |
$128.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$170.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$227.16
|
|
|
REPAIR - COMPLEX 1.1 TO 2.5 C
|
Facility
|
OP
|
$1,335.00
|
|
|
Service Code
|
HCPCS 13131
|
| Hospital Charge Code |
45000072
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$369.16 |
| Max. Negotiated Rate |
$1,281.60 |
| Rate for Payer: Aetna Commercial |
$1,027.95
|
| Rate for Payer: Anthem Medicaid |
$459.11
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,041.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$667.50
|
| Rate for Payer: Cash Price |
$667.50
|
| Rate for Payer: Cigna Commercial |
$1,108.05
|
| Rate for Payer: First Health Commercial |
$1,268.25
|
| Rate for Payer: Humana Commercial |
$1,134.75
|
| Rate for Payer: Humana KY Medicaid |
$459.11
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$463.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,094.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$985.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$468.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,174.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,001.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,068.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,161.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$921.15
|
| Rate for Payer: PHCS Commercial |
$1,281.60
|
| Rate for Payer: United Healthcare All Payer |
$1,174.80
|
|
|
REPAIR - COMPLEX 1.1 TO 2.5 C
|
Facility
|
OP
|
$1,785.00
|
|
|
Service Code
|
HCPCS 13131
|
| Hospital Charge Code |
76100155
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$369.16 |
| Max. Negotiated Rate |
$1,713.60 |
| Rate for Payer: Aetna Commercial |
$1,374.45
|
| Rate for Payer: Anthem Medicaid |
$613.86
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,392.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$892.50
|
| Rate for Payer: Cash Price |
$892.50
|
| Rate for Payer: Cigna Commercial |
$1,481.55
|
| Rate for Payer: First Health Commercial |
$1,695.75
|
| Rate for Payer: Humana Commercial |
$1,517.25
|
| Rate for Payer: Humana KY Medicaid |
$613.86
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$620.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,463.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,317.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$626.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,570.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,338.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,428.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,552.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,231.65
|
| Rate for Payer: PHCS Commercial |
$1,713.60
|
| Rate for Payer: United Healthcare All Payer |
$1,570.80
|
|
|
REPAIR - COMPLEX 1.1 TO 2.5 C
|
Facility
|
IP
|
$1,335.00
|
|
|
Service Code
|
HCPCS 13131
|
| Hospital Charge Code |
45000072
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$400.50 |
| Max. Negotiated Rate |
$1,281.60 |
| Rate for Payer: Aetna Commercial |
$1,027.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,041.30
|
| Rate for Payer: Cash Price |
$667.50
|
| Rate for Payer: Cigna Commercial |
$1,108.05
|
| Rate for Payer: First Health Commercial |
$1,268.25
|
| Rate for Payer: Humana Commercial |
$1,134.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,094.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$985.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$400.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,174.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,001.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,068.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,161.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$921.15
|
| Rate for Payer: PHCS Commercial |
$1,281.60
|
| Rate for Payer: United Healthcare All Payer |
$1,174.80
|
|
|
REPAIR - COMPLEX 1.1 TO 2.5 (P
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 13131
|
| Hospital Charge Code |
761P0155
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$122.16 |
| Max. Negotiated Rate |
$466.46 |
| Rate for Payer: Aetna Commercial |
$393.10
|
| Rate for Payer: Ambetter Exchange |
$227.16
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$122.16
|
| Rate for Payer: Anthem Medicaid |
$168.44
|
| Rate for Payer: Buckeye Individual/Medicaid |
$227.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$227.16
|
| Rate for Payer: CareSource Just4Me Medicare |
$272.59
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$466.46
|
| Rate for Payer: Healthspan PPO |
$398.63
|
| Rate for Payer: Humana Medicaid |
$168.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$345.15
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$227.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$227.16
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$171.81
|
| Rate for Payer: Molina Healthcare Passport |
$168.44
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$295.31
|
| Rate for Payer: UHCCP Medicaid |
$128.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$170.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$227.16
|
|
|
REPAIR - COMPLEX 1.1 TO 2.5 (T
|
Facility
|
OP
|
$1,335.00
|
|
|
Service Code
|
HCPCS 13131
|
| Hospital Charge Code |
761T0155
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$369.16 |
| Max. Negotiated Rate |
$1,281.60 |
| Rate for Payer: Aetna Commercial |
$1,027.95
|
| Rate for Payer: Anthem Medicaid |
$459.11
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,041.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$667.50
|
| Rate for Payer: Cash Price |
$667.50
|
| Rate for Payer: Cigna Commercial |
$1,108.05
|
| Rate for Payer: First Health Commercial |
$1,268.25
|
| Rate for Payer: Humana Commercial |
$1,134.75
|
| Rate for Payer: Humana KY Medicaid |
$459.11
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$463.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,094.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$985.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$468.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,174.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,001.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,068.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,161.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$921.15
|
| Rate for Payer: PHCS Commercial |
$1,281.60
|
| Rate for Payer: United Healthcare All Payer |
$1,174.80
|
|
|
REPAIR - COMPLEX 1.1 TO 2.5 (T
|
Facility
|
IP
|
$1,335.00
|
|
|
Service Code
|
HCPCS 13131
|
| Hospital Charge Code |
761T0155
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$400.50 |
| Max. Negotiated Rate |
$1,281.60 |
| Rate for Payer: Aetna Commercial |
$1,027.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,041.30
|
| Rate for Payer: Cash Price |
$667.50
|
| Rate for Payer: Cigna Commercial |
$1,108.05
|
| Rate for Payer: First Health Commercial |
$1,268.25
|
| Rate for Payer: Humana Commercial |
$1,134.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,094.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$985.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$400.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,174.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,001.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,068.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,161.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$921.15
|
| Rate for Payer: PHCS Commercial |
$1,281.60
|
| Rate for Payer: United Healthcare All Payer |
$1,174.80
|
|
|
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 |
$339.90 |
| 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 |
$906.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$985.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$781.77
|
| Rate for Payer: PHCS Commercial |
$1,087.68
|
| Rate for Payer: United Healthcare All Payer |
$997.04
|
|
|
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 |
$339.90 |
| 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 |
$906.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$985.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$781.77
|
| Rate for Payer: PHCS Commercial |
$1,087.68
|
| Rate for Payer: United Healthcare All Payer |
$997.04
|
|
|
REPAIR COMPLEX 5CM OR LESS
|
Professional
|
Both
|
$2,133.00
|
|
|
Service Code
|
HCPCS 13133
|
| Hospital Charge Code |
76100157
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$66.24 |
| Max. Negotiated Rate |
$1,279.80 |
| Rate for Payer: Aetna Commercial |
$195.44
|
| Rate for Payer: Ambetter Exchange |
$117.32
|
| 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 Individual/Medicaid |
$117.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$117.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$140.78
|
| Rate for Payer: Cash Price |
$1,066.50
|
| Rate for Payer: Cash Price |
$1,066.50
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$117.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$98.43
|
| Rate for Payer: Molina Healthcare Passport |
$96.50
|
| Rate for Payer: Multiplan PHCS |
$1,279.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$152.52
|
| Rate for Payer: UHCCP Medicaid |
$69.55
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$97.47
|
| Rate for Payer: Wellcare Medicare Advantage |
$117.32
|
|
|
REPAIR COMPLEX 5CM OR LESS
|
Facility
|
IP
|
$2,133.00
|
|
|
Service Code
|
HCPCS 13133
|
| Hospital Charge Code |
76100157
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$639.90 |
| Max. Negotiated Rate |
$2,047.68 |
| Rate for Payer: Aetna Commercial |
$1,642.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,663.74
|
| Rate for Payer: Cash Price |
$1,066.50
|
| Rate for Payer: Cigna Commercial |
$1,770.39
|
| Rate for Payer: First Health Commercial |
$2,026.35
|
| Rate for Payer: Humana Commercial |
$1,813.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,749.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,574.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$639.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,877.04
|
| Rate for Payer: Ohio Health Group HMO |
$1,599.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,706.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,855.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,471.77
|
| Rate for Payer: PHCS Commercial |
$2,047.68
|
| Rate for Payer: United Healthcare All Payer |
$1,877.04
|
|
|
REPAIR COMPLEX 5CM OR LESS
|
Facility
|
OP
|
$2,133.00
|
|
|
Service Code
|
HCPCS 13133
|
| Hospital Charge Code |
76100157
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$639.90 |
| Max. Negotiated Rate |
$2,047.68 |
| Rate for Payer: Aetna Commercial |
$1,642.41
|
| Rate for Payer: Anthem Medicaid |
$733.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,663.74
|
| Rate for Payer: Cash Price |
$1,066.50
|
| Rate for Payer: Cigna Commercial |
$1,770.39
|
| Rate for Payer: First Health Commercial |
$2,026.35
|
| Rate for Payer: Humana Commercial |
$1,813.05
|
| Rate for Payer: Humana KY Medicaid |
$733.54
|
| Rate for Payer: Kentucky WC Medicaid |
$741.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,749.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,574.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$639.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$748.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,877.04
|
| Rate for Payer: Ohio Health Group HMO |
$1,599.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,706.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,855.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,471.77
|
| Rate for Payer: PHCS Commercial |
$2,047.68
|
| Rate for Payer: United Healthcare All Payer |
$1,877.04
|
|
|
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 |
$600.00 |
| Rate for Payer: Aetna Commercial |
$195.44
|
| Rate for Payer: Ambetter Exchange |
$117.32
|
| 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 Individual/Medicaid |
$117.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$117.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$140.78
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$117.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.32
|
| 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 |
$152.52
|
| Rate for Payer: UHCCP Medicaid |
$69.55
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$97.47
|
| Rate for Payer: Wellcare Medicare Advantage |
$117.32
|
|
|
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 |
$339.90 |
| 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 |
$906.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$985.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$781.77
|
| Rate for Payer: PHCS Commercial |
$1,087.68
|
| Rate for Payer: United Healthcare All Payer |
$997.04
|
|
|
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 |
$339.90 |
| 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 |
$906.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$985.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$781.77
|
| Rate for Payer: PHCS Commercial |
$1,087.68
|
| Rate for Payer: United Healthcare All Payer |
$997.04
|
|
|
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 |
$644.40 |
| 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 |
$1,718.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,868.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,482.12
|
| 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 |
45000071
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$344.40 |
| 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 |
$918.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$998.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$792.12
|
| Rate for Payer: PHCS Commercial |
$1,102.08
|
| Rate for Payer: United Healthcare All Payer |
$1,010.24
|
|
