|
REPAIR - COMPLEX - EACH ADD. 5
|
Facility
|
IP
|
$2,148.00
|
|
|
Service Code
|
HCPCS 13122
|
| Hospital Charge Code |
76100154
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$644.40 |
| Max. Negotiated Rate |
$2,062.08 |
| Rate for Payer: Aetna Commercial |
$1,653.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,675.44
|
| Rate for Payer: Cash Price |
$1,074.00
|
| Rate for Payer: Cigna Commercial |
$1,782.84
|
| Rate for Payer: First Health Commercial |
$2,040.60
|
| Rate for Payer: Humana Commercial |
$1,825.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,761.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,585.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$644.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,890.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,611.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$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
|
Professional
|
Both
|
$2,148.00
|
|
|
Service Code
|
HCPCS 13122
|
| Hospital Charge Code |
76100154
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$41.76 |
| Max. Negotiated Rate |
$1,288.80 |
| Rate for Payer: Aetna Commercial |
$126.99
|
| Rate for Payer: Ambetter Exchange |
$77.17
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$41.76
|
| Rate for Payer: Anthem Medicaid |
$65.12
|
| Rate for Payer: Buckeye Individual/Medicaid |
$77.17
|
| Rate for Payer: Buckeye Medicare Advantage |
$77.17
|
| Rate for Payer: CareSource Just4Me Medicare |
$92.60
|
| Rate for Payer: Cash Price |
$1,074.00
|
| Rate for Payer: Cash Price |
$1,074.00
|
| Rate for Payer: Cigna Commercial |
$150.69
|
| Rate for Payer: Healthspan PPO |
$135.35
|
| Rate for Payer: Humana Medicaid |
$65.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$109.25
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$77.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$77.17
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$66.42
|
| Rate for Payer: Molina Healthcare Passport |
$65.12
|
| Rate for Payer: Multiplan PHCS |
$1,288.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$100.32
|
| Rate for Payer: UHCCP Medicaid |
$43.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$65.77
|
| Rate for Payer: Wellcare Medicare Advantage |
$77.17
|
|
|
REPAIR - COMPLEX - EACH ADD. 5
|
Facility
|
IP
|
$1,148.00
|
|
|
Service Code
|
HCPCS 13122
|
| Hospital Charge Code |
761T0154
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$344.40 |
| Max. Negotiated Rate |
$1,102.08 |
| Rate for Payer: Aetna Commercial |
$883.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$895.44
|
| Rate for Payer: Cash Price |
$574.00
|
| Rate for Payer: Cigna Commercial |
$952.84
|
| Rate for Payer: First Health Commercial |
$1,090.60
|
| Rate for Payer: Humana Commercial |
$975.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$941.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$847.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$344.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,010.24
|
| Rate for Payer: Ohio Health Group HMO |
$861.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$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
|
|
|
REPAIR - COMPLEX - EACH ADD. 5
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 13122
|
| Hospital Charge Code |
761P0154
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$41.76 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial |
$126.99
|
| Rate for Payer: Ambetter Exchange |
$77.17
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$41.76
|
| Rate for Payer: Anthem Medicaid |
$65.12
|
| Rate for Payer: Buckeye Individual/Medicaid |
$77.17
|
| Rate for Payer: Buckeye Medicare Advantage |
$77.17
|
| Rate for Payer: CareSource Just4Me Medicare |
$92.60
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$150.69
|
| Rate for Payer: Healthspan PPO |
$135.35
|
| Rate for Payer: Humana Medicaid |
$65.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$109.25
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$77.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$77.17
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$66.42
|
| Rate for Payer: Molina Healthcare Passport |
$65.12
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$100.32
|
| Rate for Payer: UHCCP Medicaid |
$43.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$65.77
|
| Rate for Payer: Wellcare Medicare Advantage |
$77.17
|
|
|
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 |
761T0154
|
|
Hospital Revenue Code
|
761
|
| 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
|
|
|
REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM
|
Facility
|
OP
|
$791.84
|
|
|
Service Code
|
CPT 13152
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$565.60 |
| Max. Negotiated Rate |
$791.84 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
|
|
REPAIR COMPLEX FACE 1.1-2.5 CM
|
Facility
|
OP
|
$1,698.00
|
|
|
Service Code
|
HCPCS 13151
|
| Hospital Charge Code |
45000074
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$565.60 |
| Max. Negotiated Rate |
$1,630.08 |
| Rate for Payer: Aetna Commercial |
$1,307.46
|
| Rate for Payer: Anthem Medicaid |
$583.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,324.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$849.00
|
| Rate for Payer: Cash Price |
$849.00
|
| Rate for Payer: Cigna Commercial |
$1,409.34
|
| Rate for Payer: First Health Commercial |
$1,613.10
|
| Rate for Payer: Humana Commercial |
$1,443.30
|
| Rate for Payer: Humana KY Medicaid |
$583.94
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$589.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,392.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,253.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$595.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,494.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,273.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,358.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,477.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,171.62
|
| Rate for Payer: PHCS Commercial |
$1,630.08
|
| Rate for Payer: United Healthcare All Payer |
$1,494.24
|
|
|
REPAIR COMPLEX FACE 1.1-2.5 CM
|
Professional
|
Both
|
$2,248.00
|
|
|
Service Code
|
HCPCS 13151
|
| Hospital Charge Code |
76100158
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$140.68 |
| Max. Negotiated Rate |
$1,348.80 |
| Rate for Payer: Aetna Commercial |
$455.64
|
| Rate for Payer: Ambetter Exchange |
$260.72
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$140.68
|
| Rate for Payer: Anthem Medicaid |
$203.33
|
| Rate for Payer: Buckeye Individual/Medicaid |
$260.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$260.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$312.86
|
| Rate for Payer: Cash Price |
$1,124.00
|
| Rate for Payer: Cash Price |
$1,124.00
|
| Rate for Payer: Cigna Commercial |
$529.49
|
| Rate for Payer: Healthspan PPO |
$453.34
|
| Rate for Payer: Humana Medicaid |
$203.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$397.66
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$260.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$260.72
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$207.40
|
| Rate for Payer: Molina Healthcare Passport |
$203.33
|
| Rate for Payer: Multiplan PHCS |
$1,348.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$338.94
|
| Rate for Payer: UHCCP Medicaid |
$147.71
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$205.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$260.72
|
|
|
REPAIR COMPLEX FACE 1.1-2.5 CM
|
Facility
|
IP
|
$2,248.00
|
|
|
Service Code
|
HCPCS 13151
|
| Hospital Charge Code |
76100158
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$674.40 |
| Max. Negotiated Rate |
$2,158.08 |
| Rate for Payer: Aetna Commercial |
$1,730.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,753.44
|
| Rate for Payer: Cash Price |
$1,124.00
|
| Rate for Payer: Cigna Commercial |
$1,865.84
|
| Rate for Payer: First Health Commercial |
$2,135.60
|
| Rate for Payer: Humana Commercial |
$1,910.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,843.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,659.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$674.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,978.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,686.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,798.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,955.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,551.12
|
| Rate for Payer: PHCS Commercial |
$2,158.08
|
| Rate for Payer: United Healthcare All Payer |
$1,978.24
|
|
|
REPAIR COMPLEX FACE 1.1-2.5 CM
|
Professional
|
Both
|
$550.00
|
|
|
Service Code
|
HCPCS 13151
|
| Hospital Charge Code |
761P0158
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$140.68 |
| Max. Negotiated Rate |
$529.49 |
| Rate for Payer: Aetna Commercial |
$455.64
|
| Rate for Payer: Ambetter Exchange |
$260.72
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$140.68
|
| Rate for Payer: Anthem Medicaid |
$203.33
|
| Rate for Payer: Buckeye Individual/Medicaid |
$260.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$260.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$312.86
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$529.49
|
| Rate for Payer: Healthspan PPO |
$453.34
|
| Rate for Payer: Humana Medicaid |
$203.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$397.66
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$260.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$260.72
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$207.40
|
| Rate for Payer: Molina Healthcare Passport |
$203.33
|
| Rate for Payer: Multiplan PHCS |
$330.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$338.94
|
| Rate for Payer: UHCCP Medicaid |
$147.71
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$205.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$260.72
|
|
|
REPAIR COMPLEX FACE 1.1-2.5 CM
|
Facility
|
IP
|
$1,698.00
|
|
|
Service Code
|
HCPCS 13151
|
| Hospital Charge Code |
45000074
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$509.40 |
| Max. Negotiated Rate |
$1,630.08 |
| Rate for Payer: Aetna Commercial |
$1,307.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,324.44
|
| Rate for Payer: Cash Price |
$849.00
|
| Rate for Payer: Cigna Commercial |
$1,409.34
|
| Rate for Payer: First Health Commercial |
$1,613.10
|
| Rate for Payer: Humana Commercial |
$1,443.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,392.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,253.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$509.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,494.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,273.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,358.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,477.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,171.62
|
| Rate for Payer: PHCS Commercial |
$1,630.08
|
| Rate for Payer: United Healthcare All Payer |
$1,494.24
|
|
|
REPAIR COMPLEX FACE 1.1-2.5 CM
|
Facility
|
IP
|
$1,698.00
|
|
|
Service Code
|
HCPCS 13151
|
| Hospital Charge Code |
761T0158
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$509.40 |
| Max. Negotiated Rate |
$1,630.08 |
| Rate for Payer: Aetna Commercial |
$1,307.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,324.44
|
| Rate for Payer: Cash Price |
$849.00
|
| Rate for Payer: Cigna Commercial |
$1,409.34
|
| Rate for Payer: First Health Commercial |
$1,613.10
|
| Rate for Payer: Humana Commercial |
$1,443.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,392.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,253.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$509.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,494.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,273.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,358.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,477.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,171.62
|
| Rate for Payer: PHCS Commercial |
$1,630.08
|
| Rate for Payer: United Healthcare All Payer |
$1,494.24
|
|
|
REPAIR COMPLEX FACE 1.1-2.5 CM
|
Facility
|
OP
|
$1,698.00
|
|
|
Service Code
|
HCPCS 13151
|
| Hospital Charge Code |
761T0158
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$565.60 |
| Max. Negotiated Rate |
$1,630.08 |
| Rate for Payer: Aetna Commercial |
$1,307.46
|
| Rate for Payer: Anthem Medicaid |
$583.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,324.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$849.00
|
| Rate for Payer: Cash Price |
$849.00
|
| Rate for Payer: Cigna Commercial |
$1,409.34
|
| Rate for Payer: First Health Commercial |
$1,613.10
|
| Rate for Payer: Humana Commercial |
$1,443.30
|
| Rate for Payer: Humana KY Medicaid |
$583.94
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$589.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,392.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,253.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$595.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,494.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,273.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,358.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,477.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,171.62
|
| Rate for Payer: PHCS Commercial |
$1,630.08
|
| Rate for Payer: United Healthcare All Payer |
$1,494.24
|
|
|
REPAIR COMPLEX FACE 1.1-2.5 CM
|
Facility
|
OP
|
$2,248.00
|
|
|
Service Code
|
HCPCS 13151
|
| Hospital Charge Code |
76100158
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$565.60 |
| Max. Negotiated Rate |
$2,158.08 |
| Rate for Payer: Aetna Commercial |
$1,730.96
|
| Rate for Payer: Anthem Medicaid |
$773.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,753.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$1,124.00
|
| Rate for Payer: Cash Price |
$1,124.00
|
| Rate for Payer: Cigna Commercial |
$1,865.84
|
| Rate for Payer: First Health Commercial |
$2,135.60
|
| Rate for Payer: Humana Commercial |
$1,910.80
|
| Rate for Payer: Humana KY Medicaid |
$773.09
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$780.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,843.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,659.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$788.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,978.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,686.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,798.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,955.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,551.12
|
| Rate for Payer: PHCS Commercial |
$2,158.08
|
| Rate for Payer: United Healthcare All Payer |
$1,978.24
|
|
|
REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM
|
Facility
|
OP
|
$516.82
|
|
|
Service Code
|
CPT 13131
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$369.16 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
|
|
REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM
|
Facility
|
OP
|
$791.84
|
|
|
Service Code
|
CPT 13121
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$565.60 |
| Max. Negotiated Rate |
$791.84 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
|
|
REPAIR - COMPLEX - TRUNK - ADD
|
Professional
|
Both
|
$2,226.00
|
|
|
Service Code
|
HCPCS 13102
|
| Hospital Charge Code |
76100151
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$36.69 |
| Max. Negotiated Rate |
$1,335.60 |
| Rate for Payer: Aetna Commercial |
$110.81
|
| Rate for Payer: Ambetter Exchange |
$67.42
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$36.69
|
| Rate for Payer: Anthem Medicaid |
$56.01
|
| Rate for Payer: Buckeye Individual/Medicaid |
$67.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$67.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$80.90
|
| Rate for Payer: Cash Price |
$1,113.00
|
| Rate for Payer: Cash Price |
$1,113.00
|
| Rate for Payer: Cigna Commercial |
$136.22
|
| Rate for Payer: Healthspan PPO |
$120.70
|
| Rate for Payer: Humana Medicaid |
$56.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$95.54
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$67.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$67.42
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$57.13
|
| Rate for Payer: Molina Healthcare Passport |
$56.01
|
| Rate for Payer: Multiplan PHCS |
$1,335.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.65
|
| Rate for Payer: UHCCP Medicaid |
$38.52
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$56.57
|
| Rate for Payer: Wellcare Medicare Advantage |
$67.42
|
|
|
REPAIR - COMPLEX - TRUNK - ADD
|
Facility
|
OP
|
$2,226.00
|
|
|
Service Code
|
HCPCS 13102
|
| Hospital Charge Code |
76100151
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$667.80 |
| Max. Negotiated Rate |
$2,136.96 |
| Rate for Payer: Aetna Commercial |
$1,714.02
|
| Rate for Payer: Anthem Medicaid |
$765.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,736.28
|
| Rate for Payer: Cash Price |
$1,113.00
|
| Rate for Payer: Cigna Commercial |
$1,847.58
|
| Rate for Payer: First Health Commercial |
$2,114.70
|
| Rate for Payer: Humana Commercial |
$1,892.10
|
| Rate for Payer: Humana KY Medicaid |
$765.52
|
| Rate for Payer: Kentucky WC Medicaid |
$773.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,825.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,642.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$667.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$780.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,958.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,669.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,780.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,936.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,535.94
|
| Rate for Payer: PHCS Commercial |
$2,136.96
|
| Rate for Payer: United Healthcare All Payer |
$1,958.88
|
|
|
REPAIR - COMPLEX - TRUNK - ADD
|
Facility
|
IP
|
$2,226.00
|
|
|
Service Code
|
HCPCS 13102
|
| Hospital Charge Code |
76100151
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$667.80 |
| Max. Negotiated Rate |
$2,136.96 |
| Rate for Payer: Aetna Commercial |
$1,714.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,736.28
|
| Rate for Payer: Cash Price |
$1,113.00
|
| Rate for Payer: Cigna Commercial |
$1,847.58
|
| Rate for Payer: First Health Commercial |
$2,114.70
|
| Rate for Payer: Humana Commercial |
$1,892.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,825.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,642.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$667.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,958.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,669.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,780.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,936.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,535.94
|
| Rate for Payer: PHCS Commercial |
$2,136.96
|
| Rate for Payer: United Healthcare All Payer |
$1,958.88
|
|
|
REPAIR - COMPLEX - TRUNK - ADD
|
Facility
|
OP
|
$2,026.00
|
|
|
Service Code
|
HCPCS 13102
|
| Hospital Charge Code |
761T0151
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$607.80 |
| Max. Negotiated Rate |
$1,944.96 |
| Rate for Payer: Aetna Commercial |
$1,560.02
|
| Rate for Payer: Anthem Medicaid |
$696.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,580.28
|
| Rate for Payer: Cash Price |
$1,013.00
|
| Rate for Payer: Cigna Commercial |
$1,681.58
|
| Rate for Payer: First Health Commercial |
$1,924.70
|
| Rate for Payer: Humana Commercial |
$1,722.10
|
| Rate for Payer: Humana KY Medicaid |
$696.74
|
| Rate for Payer: Kentucky WC Medicaid |
$703.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,661.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,495.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$607.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$710.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,782.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,519.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,620.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,762.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,397.94
|
| Rate for Payer: PHCS Commercial |
$1,944.96
|
| Rate for Payer: United Healthcare All Payer |
$1,782.88
|
|
|
REPAIR - COMPLEX - TRUNK - ADD
|
Facility
|
IP
|
$2,026.00
|
|
|
Service Code
|
HCPCS 13102
|
| Hospital Charge Code |
761T0151
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$607.80 |
| Max. Negotiated Rate |
$1,944.96 |
| Rate for Payer: Aetna Commercial |
$1,560.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,580.28
|
| Rate for Payer: Cash Price |
$1,013.00
|
| Rate for Payer: Cigna Commercial |
$1,681.58
|
| Rate for Payer: First Health Commercial |
$1,924.70
|
| Rate for Payer: Humana Commercial |
$1,722.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,661.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,495.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$607.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,782.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,519.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,620.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,762.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,397.94
|
| Rate for Payer: PHCS Commercial |
$1,944.96
|
| Rate for Payer: United Healthcare All Payer |
$1,782.88
|
|
|
REPAIR - COMPLEX - TRUNK - ADD
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 13102
|
| Hospital Charge Code |
761P0151
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$36.69 |
| Max. Negotiated Rate |
$136.22 |
| Rate for Payer: Aetna Commercial |
$110.81
|
| Rate for Payer: Ambetter Exchange |
$67.42
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$36.69
|
| Rate for Payer: Anthem Medicaid |
$56.01
|
| Rate for Payer: Buckeye Individual/Medicaid |
$67.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$67.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$80.90
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$136.22
|
| Rate for Payer: Healthspan PPO |
$120.70
|
| Rate for Payer: Humana Medicaid |
$56.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$95.54
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$67.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$67.42
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$57.13
|
| Rate for Payer: Molina Healthcare Passport |
$56.01
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.65
|
| Rate for Payer: UHCCP Medicaid |
$38.52
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$56.57
|
| Rate for Payer: Wellcare Medicare Advantage |
$67.42
|
|
|
REPAIR DEFECT OF ARM ARTERY
|
Professional
|
Both
|
$1,190.00
|
|
|
Service Code
|
HCPCS 35045
|
| Hospital Charge Code |
76102712
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$416.50 |
| Max. Negotiated Rate |
$1,705.30 |
| Rate for Payer: Aetna Commercial |
$1,705.30
|
| Rate for Payer: Ambetter Exchange |
$908.51
|
| Rate for Payer: Anthem Medicaid |
$684.85
|
| Rate for Payer: Buckeye Individual/Medicaid |
$908.51
|
| Rate for Payer: Buckeye Medicare Advantage |
$908.51
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,090.21
|
| Rate for Payer: Cash Price |
$595.00
|
| Rate for Payer: Cash Price |
$595.00
|
| Rate for Payer: Cigna Commercial |
$1,621.83
|
| Rate for Payer: Healthspan PPO |
$1,676.64
|
| Rate for Payer: Humana Medicaid |
$684.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,330.79
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$908.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$908.51
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$698.55
|
| Rate for Payer: Molina Healthcare Passport |
$684.85
|
| Rate for Payer: Multiplan PHCS |
$714.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,181.06
|
| Rate for Payer: UHCCP Medicaid |
$416.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$691.70
|
| Rate for Payer: Wellcare Medicare Advantage |
$908.51
|
|
|
REPAIR DEFECT OF ARTERY
|
Facility
|
OP
|
$2,600.00
|
|
|
Service Code
|
HCPCS 35011
|
| Hospital Charge Code |
76101356
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$894.14 |
| Max. Negotiated Rate |
$6,992.66 |
| Rate for Payer: Aetna Commercial |
$2,002.00
|
| Rate for Payer: Anthem Medicaid |
$894.14
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,994.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,028.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,992.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,742.93
|
| Rate for Payer: Cash Price |
$1,300.00
|
| Rate for Payer: Cash Price |
$1,300.00
|
| Rate for Payer: Cigna Commercial |
$2,158.00
|
| Rate for Payer: First Health Commercial |
$2,470.00
|
| Rate for Payer: Humana Commercial |
$2,210.00
|
| Rate for Payer: Humana KY Medicaid |
$894.14
|
| Rate for Payer: Humana Medicare Advantage |
$4,994.76
|
| Rate for Payer: Kentucky WC Medicaid |
$903.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,132.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,918.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,993.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$912.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,288.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,950.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,080.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,262.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,794.00
|
| Rate for Payer: PHCS Commercial |
$2,496.00
|
| Rate for Payer: United Healthcare All Payer |
$2,288.00
|
|
