|
REPAIR INTERM. NECK - HAND -
|
Facility
|
OP
|
$881.00
|
|
|
Service Code
|
HCPCS 12041
|
| Hospital Charge Code |
76100138
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$302.98 |
| Max. Negotiated Rate |
$845.76 |
| Rate for Payer: Aetna Commercial |
$678.37
|
| Rate for Payer: Anthem Medicaid |
$302.98
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$687.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$440.50
|
| Rate for Payer: Cash Price |
$440.50
|
| Rate for Payer: Cigna Commercial |
$731.23
|
| Rate for Payer: First Health Commercial |
$836.95
|
| Rate for Payer: Humana Commercial |
$748.85
|
| Rate for Payer: Humana KY Medicaid |
$302.98
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$306.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$722.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$650.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$309.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$775.28
|
| Rate for Payer: Ohio Health Group HMO |
$660.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$704.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$766.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$607.89
|
| Rate for Payer: PHCS Commercial |
$845.76
|
| Rate for Payer: United Healthcare All Payer |
$775.28
|
|
|
REPAIR INTERM. NECK - HAND -
|
Facility
|
OP
|
$531.00
|
|
|
Service Code
|
HCPCS 12041
|
| Hospital Charge Code |
45000061
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$182.61 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Aetna Commercial |
$408.87
|
| Rate for Payer: Anthem Medicaid |
$182.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cigna Commercial |
$440.73
|
| Rate for Payer: First Health Commercial |
$504.45
|
| Rate for Payer: Humana Commercial |
$451.35
|
| Rate for Payer: Humana KY Medicaid |
$182.61
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$184.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$435.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$186.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$467.28
|
| Rate for Payer: Ohio Health Group HMO |
$398.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$366.39
|
| Rate for Payer: PHCS Commercial |
$509.76
|
| Rate for Payer: United Healthcare All Payer |
$467.28
|
|
|
REPAIR INTERM. NECK - HAND -
|
Facility
|
IP
|
$881.00
|
|
|
Service Code
|
HCPCS 12041
|
| Hospital Charge Code |
76100138
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$264.30 |
| Max. Negotiated Rate |
$845.76 |
| Rate for Payer: Aetna Commercial |
$678.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$687.18
|
| Rate for Payer: Cash Price |
$440.50
|
| Rate for Payer: Cigna Commercial |
$731.23
|
| Rate for Payer: First Health Commercial |
$836.95
|
| Rate for Payer: Humana Commercial |
$748.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$722.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$650.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$264.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$775.28
|
| Rate for Payer: Ohio Health Group HMO |
$660.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$704.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$766.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$607.89
|
| Rate for Payer: PHCS Commercial |
$845.76
|
| Rate for Payer: United Healthcare All Payer |
$775.28
|
|
|
REPAIR INTERM. NECK - HAND -
|
Facility
|
IP
|
$531.00
|
|
|
Service Code
|
HCPCS 12041
|
| Hospital Charge Code |
45000061
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$159.30 |
| Max. Negotiated Rate |
$509.76 |
| Rate for Payer: Aetna Commercial |
$408.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.18
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cigna Commercial |
$440.73
|
| Rate for Payer: First Health Commercial |
$504.45
|
| Rate for Payer: Humana Commercial |
$451.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$435.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$467.28
|
| Rate for Payer: Ohio Health Group HMO |
$398.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$366.39
|
| Rate for Payer: PHCS Commercial |
$509.76
|
| Rate for Payer: United Healthcare All Payer |
$467.28
|
|
|
REPAIR INTERM. NECK - HAND -(P
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
HCPCS 12041
|
| Hospital Charge Code |
761P0138
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$72.85 |
| Max. Negotiated Rate |
$295.96 |
| Rate for Payer: Aetna Commercial |
$239.82
|
| Rate for Payer: Ambetter Exchange |
$136.77
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$72.85
|
| Rate for Payer: Anthem Medicaid |
$92.55
|
| Rate for Payer: Buckeye Individual/Medicaid |
$136.77
|
| Rate for Payer: Buckeye Medicare Advantage |
$136.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$164.12
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna Commercial |
$295.96
|
| Rate for Payer: Healthspan PPO |
$272.20
|
| Rate for Payer: Humana Medicaid |
$92.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$213.17
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$136.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$136.77
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$94.40
|
| Rate for Payer: Molina Healthcare Passport |
$92.55
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$177.80
|
| Rate for Payer: UHCCP Medicaid |
$76.49
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$93.48
|
| Rate for Payer: Wellcare Medicare Advantage |
$136.77
|
|
|
REPAIR INTERM. NECK - HAND -(T
|
Facility
|
IP
|
$531.00
|
|
|
Service Code
|
HCPCS 12041
|
| Hospital Charge Code |
761T0138
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$159.30 |
| Max. Negotiated Rate |
$509.76 |
| Rate for Payer: Aetna Commercial |
$408.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.18
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cigna Commercial |
$440.73
|
| Rate for Payer: First Health Commercial |
$504.45
|
| Rate for Payer: Humana Commercial |
$451.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$435.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$467.28
|
| Rate for Payer: Ohio Health Group HMO |
$398.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$366.39
|
| Rate for Payer: PHCS Commercial |
$509.76
|
| Rate for Payer: United Healthcare All Payer |
$467.28
|
|
|
REPAIR INTERM. NECK - HAND -(T
|
Facility
|
OP
|
$531.00
|
|
|
Service Code
|
HCPCS 12041
|
| Hospital Charge Code |
761T0138
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$182.61 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Aetna Commercial |
$408.87
|
| Rate for Payer: Anthem Medicaid |
$182.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cigna Commercial |
$440.73
|
| Rate for Payer: First Health Commercial |
$504.45
|
| Rate for Payer: Humana Commercial |
$451.35
|
| Rate for Payer: Humana KY Medicaid |
$182.61
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$184.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$435.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$186.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$467.28
|
| Rate for Payer: Ohio Health Group HMO |
$398.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$366.39
|
| Rate for Payer: PHCS Commercial |
$509.76
|
| Rate for Payer: United Healthcare All Payer |
$467.28
|
|
|
REPAIR - LACERATION OF DIAPH(P
|
Professional
|
Both
|
$2,500.00
|
|
|
Service Code
|
HCPCS 39501
|
| Hospital Charge Code |
761P1621
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$692.01 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Aetna Commercial |
$1,258.26
|
| Rate for Payer: Ambetter Exchange |
$808.19
|
| Rate for Payer: Anthem Medicaid |
$692.01
|
| Rate for Payer: Buckeye Individual/Medicaid |
$808.19
|
| Rate for Payer: Buckeye Medicare Advantage |
$808.19
|
| Rate for Payer: CareSource Just4Me Medicare |
$969.83
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$1,289.99
|
| Rate for Payer: Healthspan PPO |
$1,006.09
|
| Rate for Payer: Humana Medicaid |
$692.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,096.93
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$808.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$808.19
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$705.85
|
| Rate for Payer: Molina Healthcare Passport |
$692.01
|
| Rate for Payer: Multiplan PHCS |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,050.65
|
| Rate for Payer: UHCCP Medicaid |
$875.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$698.93
|
| Rate for Payer: Wellcare Medicare Advantage |
$808.19
|
|
|
REPAIR - LACERATION OF DIAPHR
|
Facility
|
IP
|
$2,500.00
|
|
|
Service Code
|
HCPCS 39501
|
| Hospital Charge Code |
76101621
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$750.00 |
| Max. Negotiated Rate |
$2,400.00 |
| Rate for Payer: Aetna Commercial |
$1,925.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,950.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$2,075.00
|
| Rate for Payer: First Health Commercial |
$2,375.00
|
| Rate for Payer: Humana Commercial |
$2,125.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,050.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,845.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$750.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,200.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,875.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,175.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,725.00
|
| Rate for Payer: PHCS Commercial |
$2,400.00
|
| Rate for Payer: United Healthcare All Payer |
$2,200.00
|
|
|
REPAIR - LACERATION OF DIAPHR
|
Professional
|
Both
|
$2,500.00
|
|
|
Service Code
|
HCPCS 39501
|
| Hospital Charge Code |
76101621
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$692.01 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Aetna Commercial |
$1,258.26
|
| Rate for Payer: Ambetter Exchange |
$808.19
|
| Rate for Payer: Anthem Medicaid |
$692.01
|
| Rate for Payer: Buckeye Individual/Medicaid |
$808.19
|
| Rate for Payer: Buckeye Medicare Advantage |
$808.19
|
| Rate for Payer: CareSource Just4Me Medicare |
$969.83
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$1,289.99
|
| Rate for Payer: Healthspan PPO |
$1,006.09
|
| Rate for Payer: Humana Medicaid |
$692.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,096.93
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$808.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$808.19
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$705.85
|
| Rate for Payer: Molina Healthcare Passport |
$692.01
|
| Rate for Payer: Multiplan PHCS |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,050.65
|
| Rate for Payer: UHCCP Medicaid |
$875.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$698.93
|
| Rate for Payer: Wellcare Medicare Advantage |
$808.19
|
|
|
REPAIR - LACERATION OF DIAPHR
|
Facility
|
OP
|
$2,500.00
|
|
|
Service Code
|
HCPCS 39501
|
| Hospital Charge Code |
76101621
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$750.00 |
| Max. Negotiated Rate |
$2,400.00 |
| Rate for Payer: Aetna Commercial |
$1,925.00
|
| Rate for Payer: Anthem Medicaid |
$859.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,950.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$2,075.00
|
| Rate for Payer: First Health Commercial |
$2,375.00
|
| Rate for Payer: Humana Commercial |
$2,125.00
|
| Rate for Payer: Humana KY Medicaid |
$859.75
|
| Rate for Payer: Kentucky WC Medicaid |
$868.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,050.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,845.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$750.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$877.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,200.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,875.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,175.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,725.00
|
| Rate for Payer: PHCS Commercial |
$2,400.00
|
| Rate for Payer: United Healthcare All Payer |
$2,200.00
|
|
|
REPAIR LAC OF PALATE UP TO 2CM
|
Facility
|
OP
|
$660.00
|
|
|
Service Code
|
HCPCS 42180
|
| Hospital Charge Code |
45000258
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$226.97 |
| Max. Negotiated Rate |
$658.76 |
| Rate for Payer: Aetna Commercial |
$508.20
|
| Rate for Payer: Anthem Medicaid |
$226.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$470.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$514.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$658.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$635.23
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cigna Commercial |
$547.80
|
| Rate for Payer: First Health Commercial |
$627.00
|
| Rate for Payer: Humana Commercial |
$561.00
|
| Rate for Payer: Humana KY Medicaid |
$226.97
|
| Rate for Payer: Humana Medicare Advantage |
$470.54
|
| Rate for Payer: Kentucky WC Medicaid |
$229.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$541.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$487.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$231.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$580.80
|
| Rate for Payer: Ohio Health Group HMO |
$495.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$528.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$574.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$455.40
|
| Rate for Payer: PHCS Commercial |
$633.60
|
| Rate for Payer: United Healthcare All Payer |
$580.80
|
|
|
REPAIR LAC OF PALATE UP TO 2CM
|
Facility
|
IP
|
$660.00
|
|
|
Service Code
|
HCPCS 42180
|
| Hospital Charge Code |
45000258
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$198.00 |
| Max. Negotiated Rate |
$633.60 |
| Rate for Payer: Aetna Commercial |
$508.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$514.80
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cigna Commercial |
$547.80
|
| Rate for Payer: First Health Commercial |
$627.00
|
| Rate for Payer: Humana Commercial |
$561.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$541.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$487.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$198.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$580.80
|
| Rate for Payer: Ohio Health Group HMO |
$495.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$528.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$574.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$455.40
|
| Rate for Payer: PHCS Commercial |
$633.60
|
| Rate for Payer: United Healthcare All Payer |
$580.80
|
|
|
REPAIR LAC OF PALATE UP TO 2CM
|
Facility
|
IP
|
$633.00
|
|
|
Service Code
|
HCPCS 42180
|
| Hospital Charge Code |
76101676
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$189.90 |
| Max. Negotiated Rate |
$607.68 |
| Rate for Payer: Aetna Commercial |
$487.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$493.74
|
| Rate for Payer: Cash Price |
$316.50
|
| Rate for Payer: Cigna Commercial |
$525.39
|
| Rate for Payer: First Health Commercial |
$601.35
|
| Rate for Payer: Humana Commercial |
$538.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$519.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$467.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$189.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$557.04
|
| Rate for Payer: Ohio Health Group HMO |
$474.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$506.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$550.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$436.77
|
| Rate for Payer: PHCS Commercial |
$607.68
|
| Rate for Payer: United Healthcare All Payer |
$557.04
|
|
|
REPAIR LAC OF PALATE UP TO 2CM
|
Facility
|
OP
|
$633.00
|
|
|
Service Code
|
HCPCS 42180
|
| Hospital Charge Code |
76101676
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$217.69 |
| Max. Negotiated Rate |
$658.76 |
| Rate for Payer: Aetna Commercial |
$487.41
|
| Rate for Payer: Anthem Medicaid |
$217.69
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$470.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$493.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$658.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$635.23
|
| Rate for Payer: Cash Price |
$316.50
|
| Rate for Payer: Cash Price |
$316.50
|
| Rate for Payer: Cigna Commercial |
$525.39
|
| Rate for Payer: First Health Commercial |
$601.35
|
| Rate for Payer: Humana Commercial |
$538.05
|
| Rate for Payer: Humana KY Medicaid |
$217.69
|
| Rate for Payer: Humana Medicare Advantage |
$470.54
|
| Rate for Payer: Kentucky WC Medicaid |
$219.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$519.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$467.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$222.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$557.04
|
| Rate for Payer: Ohio Health Group HMO |
$474.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$506.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$550.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$436.77
|
| Rate for Payer: PHCS Commercial |
$607.68
|
| Rate for Payer: United Healthcare All Payer |
$557.04
|
|
|
REPAIR LAC PALATE >2 CM/COMP
|
Professional
|
Both
|
$720.00
|
|
|
Service Code
|
HCPCS 42182
|
| Hospital Charge Code |
76101677
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$202.08 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna Commercial |
$390.92
|
| Rate for Payer: Ambetter Exchange |
$243.79
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$202.08
|
| Rate for Payer: Anthem Medicaid |
$213.22
|
| Rate for Payer: Buckeye Individual/Medicaid |
$243.79
|
| Rate for Payer: Buckeye Medicare Advantage |
$243.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$292.55
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cigna Commercial |
$395.20
|
| Rate for Payer: Healthspan PPO |
$392.40
|
| Rate for Payer: Humana Medicaid |
$213.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$336.04
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$243.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$243.79
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$217.48
|
| Rate for Payer: Molina Healthcare Passport |
$213.22
|
| Rate for Payer: Multiplan PHCS |
$432.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$316.93
|
| Rate for Payer: UHCCP Medicaid |
$212.18
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$215.35
|
| Rate for Payer: Wellcare Medicare Advantage |
$243.79
|
|
|
REPAIR LAC PALATE >2 CM/COMP
|
Facility
|
IP
|
$7,243.00
|
|
|
Service Code
|
HCPCS 42182
|
| Hospital Charge Code |
45000259
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,172.90 |
| Max. Negotiated Rate |
$6,953.28 |
| Rate for Payer: Aetna Commercial |
$5,577.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,649.54
|
| Rate for Payer: Cash Price |
$3,621.50
|
| Rate for Payer: Cigna Commercial |
$6,011.69
|
| Rate for Payer: First Health Commercial |
$6,880.85
|
| Rate for Payer: Humana Commercial |
$6,156.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,939.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,345.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,172.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,373.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,432.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,794.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,301.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,997.67
|
| Rate for Payer: PHCS Commercial |
$6,953.28
|
| Rate for Payer: United Healthcare All Payer |
$6,373.84
|
|
|
REPAIR LAC PALATE >2 CM/COMP
|
Facility
|
OP
|
$720.00
|
|
|
Service Code
|
HCPCS 42182
|
| Hospital Charge Code |
76101677
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$247.61 |
| Max. Negotiated Rate |
$7,652.33 |
| Rate for Payer: Aetna Commercial |
$554.40
|
| Rate for Payer: Anthem Medicaid |
$247.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,465.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$561.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,652.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,379.03
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cigna Commercial |
$597.60
|
| Rate for Payer: First Health Commercial |
$684.00
|
| Rate for Payer: Humana Commercial |
$612.00
|
| Rate for Payer: Humana KY Medicaid |
$247.61
|
| Rate for Payer: Humana Medicare Advantage |
$5,465.95
|
| Rate for Payer: Kentucky WC Medicaid |
$250.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$590.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$531.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,559.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$252.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$633.60
|
| Rate for Payer: Ohio Health Group HMO |
$540.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$576.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$626.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$496.80
|
| Rate for Payer: PHCS Commercial |
$691.20
|
| Rate for Payer: United Healthcare All Payer |
$633.60
|
|
|
REPAIR LAC PALATE >2 CM/COMP
|
Facility
|
IP
|
$720.00
|
|
|
Service Code
|
HCPCS 42182
|
| Hospital Charge Code |
76101677
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$216.00 |
| Max. Negotiated Rate |
$691.20 |
| Rate for Payer: Aetna Commercial |
$554.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$561.60
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cigna Commercial |
$597.60
|
| Rate for Payer: First Health Commercial |
$684.00
|
| Rate for Payer: Humana Commercial |
$612.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$590.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$531.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$216.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$633.60
|
| Rate for Payer: Ohio Health Group HMO |
$540.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$576.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$626.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$496.80
|
| Rate for Payer: PHCS Commercial |
$691.20
|
| Rate for Payer: United Healthcare All Payer |
$633.60
|
|
|
REPAIR LAC PALATE >2 CM/COMP
|
Facility
|
OP
|
$7,243.00
|
|
|
Service Code
|
HCPCS 42182
|
| Hospital Charge Code |
45000259
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,490.87 |
| Max. Negotiated Rate |
$7,652.33 |
| Rate for Payer: Aetna Commercial |
$5,577.11
|
| Rate for Payer: Anthem Medicaid |
$2,490.87
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,465.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,649.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,652.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,379.03
|
| Rate for Payer: Cash Price |
$3,621.50
|
| Rate for Payer: Cash Price |
$3,621.50
|
| Rate for Payer: Cigna Commercial |
$6,011.69
|
| Rate for Payer: First Health Commercial |
$6,880.85
|
| Rate for Payer: Humana Commercial |
$6,156.55
|
| Rate for Payer: Humana KY Medicaid |
$2,490.87
|
| Rate for Payer: Humana Medicare Advantage |
$5,465.95
|
| Rate for Payer: Kentucky WC Medicaid |
$2,516.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,939.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,345.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,559.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,540.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,373.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,432.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,794.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,301.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,997.67
|
| Rate for Payer: PHCS Commercial |
$6,953.28
|
| Rate for Payer: United Healthcare All Payer |
$6,373.84
|
|
|
REPAIR LAC PALATE >2 CM/COMP(P
|
Professional
|
Both
|
$720.00
|
|
|
Service Code
|
HCPCS 42182
|
| Hospital Charge Code |
761P1677
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$202.08 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna Commercial |
$390.92
|
| Rate for Payer: Ambetter Exchange |
$243.79
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$202.08
|
| Rate for Payer: Anthem Medicaid |
$213.22
|
| Rate for Payer: Buckeye Individual/Medicaid |
$243.79
|
| Rate for Payer: Buckeye Medicare Advantage |
$243.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$292.55
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cigna Commercial |
$395.20
|
| Rate for Payer: Healthspan PPO |
$392.40
|
| Rate for Payer: Humana Medicaid |
$213.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$336.04
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$243.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$243.79
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$217.48
|
| Rate for Payer: Molina Healthcare Passport |
$213.22
|
| Rate for Payer: Multiplan PHCS |
$432.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$316.93
|
| Rate for Payer: UHCCP Medicaid |
$212.18
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$215.35
|
| Rate for Payer: Wellcare Medicare Advantage |
$243.79
|
|
|
REPAIR LARGE OMPHALOCELE
|
Professional
|
Both
|
$6,795.00
|
|
|
Service Code
|
HCPCS 49605
|
| Hospital Charge Code |
76102031
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$916.08 |
| Max. Negotiated Rate |
$7,252.08 |
| Rate for Payer: Aetna Commercial |
$7,252.08
|
| Rate for Payer: Ambetter Exchange |
$4,679.46
|
| Rate for Payer: Anthem Medicaid |
$916.08
|
| Rate for Payer: Buckeye Individual/Medicaid |
$4,679.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,679.46
|
| Rate for Payer: CareSource Just4Me Medicare |
$5,615.35
|
| Rate for Payer: Cash Price |
$3,397.50
|
| Rate for Payer: Cash Price |
$3,397.50
|
| Rate for Payer: Cigna Commercial |
$6,687.21
|
| Rate for Payer: Healthspan PPO |
$6,115.81
|
| Rate for Payer: Humana Medicaid |
$916.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$6,393.56
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$4,679.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,679.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$934.40
|
| Rate for Payer: Molina Healthcare Passport |
$916.08
|
| Rate for Payer: Multiplan PHCS |
$4,077.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$6,083.30
|
| Rate for Payer: UHCCP Medicaid |
$2,378.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$925.24
|
| Rate for Payer: Wellcare Medicare Advantage |
$4,679.46
|
|
|
REPAIR LARGE OMPHALOCELE
|
Facility
|
OP
|
$6,795.00
|
|
|
Service Code
|
HCPCS 49605
|
| Hospital Charge Code |
76102031
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,038.50 |
| Max. Negotiated Rate |
$6,523.20 |
| Rate for Payer: Aetna Commercial |
$5,232.15
|
| Rate for Payer: Anthem Medicaid |
$2,336.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,300.10
|
| Rate for Payer: Cash Price |
$3,397.50
|
| Rate for Payer: Cigna Commercial |
$5,639.85
|
| Rate for Payer: First Health Commercial |
$6,455.25
|
| Rate for Payer: Humana Commercial |
$5,775.75
|
| Rate for Payer: Humana KY Medicaid |
$2,336.80
|
| Rate for Payer: Kentucky WC Medicaid |
$2,360.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,571.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,014.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,038.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,383.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,979.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,096.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,436.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,911.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,688.55
|
| Rate for Payer: PHCS Commercial |
$6,523.20
|
| Rate for Payer: United Healthcare All Payer |
$5,979.60
|
|
|
REPAIR LARGE OMPHALOCELE
|
Facility
|
IP
|
$6,795.00
|
|
|
Service Code
|
HCPCS 49605
|
| Hospital Charge Code |
76102031
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,038.50 |
| Max. Negotiated Rate |
$6,523.20 |
| Rate for Payer: Aetna Commercial |
$5,232.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,300.10
|
| Rate for Payer: Cash Price |
$3,397.50
|
| Rate for Payer: Cigna Commercial |
$5,639.85
|
| Rate for Payer: First Health Commercial |
$6,455.25
|
| Rate for Payer: Humana Commercial |
$5,775.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,571.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,014.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,038.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,979.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,096.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,436.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,911.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,688.55
|
| Rate for Payer: PHCS Commercial |
$6,523.20
|
| Rate for Payer: United Healthcare All Payer |
$5,979.60
|
|
|
REPAIR LARGE OMPHALOCELE(P
|
Professional
|
Both
|
$6,795.00
|
|
|
Service Code
|
HCPCS 49605
|
| Hospital Charge Code |
761P2031
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$916.08 |
| Max. Negotiated Rate |
$7,252.08 |
| Rate for Payer: Aetna Commercial |
$7,252.08
|
| Rate for Payer: Ambetter Exchange |
$4,679.46
|
| Rate for Payer: Anthem Medicaid |
$916.08
|
| Rate for Payer: Buckeye Individual/Medicaid |
$4,679.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,679.46
|
| Rate for Payer: CareSource Just4Me Medicare |
$5,615.35
|
| Rate for Payer: Cash Price |
$3,397.50
|
| Rate for Payer: Cash Price |
$3,397.50
|
| Rate for Payer: Cigna Commercial |
$6,687.21
|
| Rate for Payer: Healthspan PPO |
$6,115.81
|
| Rate for Payer: Humana Medicaid |
$916.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$6,393.56
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$4,679.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,679.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$934.40
|
| Rate for Payer: Molina Healthcare Passport |
$916.08
|
| Rate for Payer: Multiplan PHCS |
$4,077.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$6,083.30
|
| Rate for Payer: UHCCP Medicaid |
$2,378.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$925.24
|
| Rate for Payer: Wellcare Medicare Advantage |
$4,679.46
|
|
