|
REPAIR SUPERFICI 2.5CM OR LESS
|
Facility
|
IP
|
$333.00
|
|
|
Service Code
|
HCPCS 12001
|
| Hospital Charge Code |
45000042
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$99.90 |
| Max. Negotiated Rate |
$319.68 |
| Rate for Payer: Aetna Commercial |
$256.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$259.74
|
| Rate for Payer: Cash Price |
$166.50
|
| Rate for Payer: Cigna Commercial |
$276.39
|
| Rate for Payer: First Health Commercial |
$316.35
|
| Rate for Payer: Humana Commercial |
$283.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$273.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$245.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$99.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$293.04
|
| Rate for Payer: Ohio Health Group HMO |
$249.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$266.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$289.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$229.77
|
| Rate for Payer: PHCS Commercial |
$319.68
|
| Rate for Payer: United Healthcare All Payer |
$293.04
|
|
|
REPAIR SUPERFICI 2.5CM OR LESS
|
Facility
|
OP
|
$533.00
|
|
|
Service Code
|
HCPCS 12001
|
| Hospital Charge Code |
76100120
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$183.30 |
| Max. Negotiated Rate |
$511.68 |
| Rate for Payer: Aetna Commercial |
$410.41
|
| Rate for Payer: Anthem Medicaid |
$183.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$415.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$266.50
|
| Rate for Payer: Cash Price |
$266.50
|
| Rate for Payer: Cigna Commercial |
$442.39
|
| Rate for Payer: First Health Commercial |
$506.35
|
| Rate for Payer: Humana Commercial |
$453.05
|
| Rate for Payer: Humana KY Medicaid |
$183.30
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$185.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$437.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$393.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$186.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$469.04
|
| Rate for Payer: Ohio Health Group HMO |
$399.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$426.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$463.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$367.77
|
| Rate for Payer: PHCS Commercial |
$511.68
|
| Rate for Payer: United Healthcare All Payer |
$469.04
|
|
|
REPAIR SUPERFICI 2.5CM OR LESS
|
Facility
|
IP
|
$533.00
|
|
|
Service Code
|
HCPCS 12001
|
| Hospital Charge Code |
76100120
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$159.90 |
| Max. Negotiated Rate |
$511.68 |
| Rate for Payer: Aetna Commercial |
$410.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$415.74
|
| Rate for Payer: Cash Price |
$266.50
|
| Rate for Payer: Cigna Commercial |
$442.39
|
| Rate for Payer: First Health Commercial |
$506.35
|
| Rate for Payer: Humana Commercial |
$453.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$437.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$393.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$469.04
|
| Rate for Payer: Ohio Health Group HMO |
$399.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$426.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$463.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$367.77
|
| Rate for Payer: PHCS Commercial |
$511.68
|
| Rate for Payer: United Healthcare All Payer |
$469.04
|
|
|
REPAIR SUPERFICI 2.5CM OR LESS
|
Professional
|
Both
|
$533.00
|
|
|
Service Code
|
HCPCS 12001
|
| Hospital Charge Code |
76100120
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.86 |
| Max. Negotiated Rate |
$319.80 |
| Rate for Payer: Aetna Commercial |
$149.58
|
| Rate for Payer: Ambetter Exchange |
$42.54
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$30.86
|
| Rate for Payer: Anthem Medicaid |
$64.92
|
| Rate for Payer: Buckeye Individual/Medicaid |
$42.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$42.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$51.05
|
| Rate for Payer: Cash Price |
$266.50
|
| Rate for Payer: Cash Price |
$266.50
|
| Rate for Payer: Cigna Commercial |
$141.92
|
| Rate for Payer: Healthspan PPO |
$163.69
|
| Rate for Payer: Humana Medicaid |
$64.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$68.99
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$42.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$66.22
|
| Rate for Payer: Molina Healthcare Passport |
$64.92
|
| Rate for Payer: Multiplan PHCS |
$319.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$55.30
|
| Rate for Payer: UHCCP Medicaid |
$32.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$65.57
|
| Rate for Payer: Wellcare Medicare Advantage |
$42.54
|
|
|
REPAIR SUPERFICI 2.5CM OR LESS
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 12001
|
| Hospital Charge Code |
761P0120
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.86 |
| Max. Negotiated Rate |
$163.69 |
| Rate for Payer: Aetna Commercial |
$149.58
|
| Rate for Payer: Ambetter Exchange |
$42.54
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$30.86
|
| Rate for Payer: Anthem Medicaid |
$64.92
|
| Rate for Payer: Buckeye Individual/Medicaid |
$42.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$42.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$51.05
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$141.92
|
| Rate for Payer: Healthspan PPO |
$163.69
|
| Rate for Payer: Humana Medicaid |
$64.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$68.99
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$42.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$66.22
|
| Rate for Payer: Molina Healthcare Passport |
$64.92
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$55.30
|
| Rate for Payer: UHCCP Medicaid |
$32.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$65.57
|
| Rate for Payer: Wellcare Medicare Advantage |
$42.54
|
|
|
REPAIR SUPERFICI 2.5CM OR LESS
|
Facility
|
OP
|
$333.00
|
|
|
Service Code
|
HCPCS 12001
|
| Hospital Charge Code |
45000042
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$114.52 |
| Max. Negotiated Rate |
$319.68 |
| Rate for Payer: Aetna Commercial |
$256.41
|
| Rate for Payer: Anthem Medicaid |
$114.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$259.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$166.50
|
| Rate for Payer: Cash Price |
$166.50
|
| Rate for Payer: Cigna Commercial |
$276.39
|
| Rate for Payer: First Health Commercial |
$316.35
|
| Rate for Payer: Humana Commercial |
$283.05
|
| Rate for Payer: Humana KY Medicaid |
$114.52
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$115.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$273.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$245.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$116.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$293.04
|
| Rate for Payer: Ohio Health Group HMO |
$249.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$266.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$289.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$229.77
|
| Rate for Payer: PHCS Commercial |
$319.68
|
| Rate for Payer: United Healthcare All Payer |
$293.04
|
|
|
REPAIR SUPERFICIAL 2.6-7.5 CM
|
Professional
|
Both
|
$663.00
|
|
|
Service Code
|
HCPCS 12002
|
| Hospital Charge Code |
76100121
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$39.09 |
| Max. Negotiated Rate |
$397.80 |
| Rate for Payer: Aetna Commercial |
$166.13
|
| Rate for Payer: Ambetter Exchange |
$56.01
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$39.09
|
| Rate for Payer: Anthem Medicaid |
$76.00
|
| Rate for Payer: Buckeye Individual/Medicaid |
$56.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$56.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$67.21
|
| Rate for Payer: Cash Price |
$331.50
|
| Rate for Payer: Cash Price |
$331.50
|
| Rate for Payer: Cigna Commercial |
$158.48
|
| Rate for Payer: Healthspan PPO |
$174.77
|
| Rate for Payer: Humana Medicaid |
$76.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$88.80
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$56.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$77.52
|
| Rate for Payer: Molina Healthcare Passport |
$76.00
|
| Rate for Payer: Multiplan PHCS |
$397.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$72.81
|
| Rate for Payer: UHCCP Medicaid |
$41.04
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$76.76
|
| Rate for Payer: Wellcare Medicare Advantage |
$56.01
|
|
|
REPAIR SUPERFICIAL 2.6-7.5 CM
|
Facility
|
OP
|
$413.00
|
|
|
Service Code
|
HCPCS 12002
|
| Hospital Charge Code |
45000043
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$142.03 |
| Max. Negotiated Rate |
$396.48 |
| Rate for Payer: Aetna Commercial |
$318.01
|
| Rate for Payer: Anthem Medicaid |
$142.03
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$322.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$206.50
|
| Rate for Payer: Cash Price |
$206.50
|
| Rate for Payer: Cigna Commercial |
$342.79
|
| Rate for Payer: First Health Commercial |
$392.35
|
| Rate for Payer: Humana Commercial |
$351.05
|
| Rate for Payer: Humana KY Medicaid |
$142.03
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$143.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$338.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$304.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$144.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$363.44
|
| Rate for Payer: Ohio Health Group HMO |
$309.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$330.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$359.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$284.97
|
| Rate for Payer: PHCS Commercial |
$396.48
|
| Rate for Payer: United Healthcare All Payer |
$363.44
|
|
|
REPAIR SUPERFICIAL 2.6-7.5 CM
|
Facility
|
OP
|
$663.00
|
|
|
Service Code
|
HCPCS 12002
|
| Hospital Charge Code |
76100121
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$183.59 |
| Max. Negotiated Rate |
$636.48 |
| Rate for Payer: Aetna Commercial |
$510.51
|
| Rate for Payer: Anthem Medicaid |
$228.01
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$517.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$331.50
|
| Rate for Payer: Cash Price |
$331.50
|
| Rate for Payer: Cigna Commercial |
$550.29
|
| Rate for Payer: First Health Commercial |
$629.85
|
| Rate for Payer: Humana Commercial |
$563.55
|
| Rate for Payer: Humana KY Medicaid |
$228.01
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$230.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$543.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$489.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$232.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$583.44
|
| Rate for Payer: Ohio Health Group HMO |
$497.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$530.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$576.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$457.47
|
| Rate for Payer: PHCS Commercial |
$636.48
|
| Rate for Payer: United Healthcare All Payer |
$583.44
|
|
|
REPAIR SUPERFICIAL 2.6-7.5 CM
|
Facility
|
IP
|
$413.00
|
|
|
Service Code
|
HCPCS 12002
|
| Hospital Charge Code |
45000043
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$123.90 |
| Max. Negotiated Rate |
$396.48 |
| Rate for Payer: Aetna Commercial |
$318.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$322.14
|
| Rate for Payer: Cash Price |
$206.50
|
| Rate for Payer: Cigna Commercial |
$342.79
|
| Rate for Payer: First Health Commercial |
$392.35
|
| Rate for Payer: Humana Commercial |
$351.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$338.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$304.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$123.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$363.44
|
| Rate for Payer: Ohio Health Group HMO |
$309.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$330.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$359.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$284.97
|
| Rate for Payer: PHCS Commercial |
$396.48
|
| Rate for Payer: United Healthcare All Payer |
$363.44
|
|
|
REPAIR SUPERFICIAL 2.6-7.5 CM
|
Facility
|
IP
|
$663.00
|
|
|
Service Code
|
HCPCS 12002
|
| Hospital Charge Code |
76100121
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$198.90 |
| Max. Negotiated Rate |
$636.48 |
| Rate for Payer: Aetna Commercial |
$510.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$517.14
|
| Rate for Payer: Cash Price |
$331.50
|
| Rate for Payer: Cigna Commercial |
$550.29
|
| Rate for Payer: First Health Commercial |
$629.85
|
| Rate for Payer: Humana Commercial |
$563.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$543.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$489.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$198.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$583.44
|
| Rate for Payer: Ohio Health Group HMO |
$497.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$530.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$576.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$457.47
|
| Rate for Payer: PHCS Commercial |
$636.48
|
| Rate for Payer: United Healthcare All Payer |
$583.44
|
|
|
REPAIR SUPERFICIAL 2.6-7.5 C(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 12002
|
| Hospital Charge Code |
761P0121
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$39.09 |
| Max. Negotiated Rate |
$174.77 |
| Rate for Payer: Aetna Commercial |
$166.13
|
| Rate for Payer: Ambetter Exchange |
$56.01
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$39.09
|
| Rate for Payer: Anthem Medicaid |
$76.00
|
| Rate for Payer: Buckeye Individual/Medicaid |
$56.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$56.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$67.21
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$158.48
|
| Rate for Payer: Healthspan PPO |
$174.77
|
| Rate for Payer: Humana Medicaid |
$76.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$88.80
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$56.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$77.52
|
| Rate for Payer: Molina Healthcare Passport |
$76.00
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$72.81
|
| Rate for Payer: UHCCP Medicaid |
$41.04
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$76.76
|
| Rate for Payer: Wellcare Medicare Advantage |
$56.01
|
|
|
REPAIR SUPERFICIAL 2.6-7.5 C(T
|
Facility
|
IP
|
$413.00
|
|
|
Service Code
|
HCPCS 12002
|
| Hospital Charge Code |
761T0121
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$123.90 |
| Max. Negotiated Rate |
$396.48 |
| Rate for Payer: Aetna Commercial |
$318.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$322.14
|
| Rate for Payer: Cash Price |
$206.50
|
| Rate for Payer: Cigna Commercial |
$342.79
|
| Rate for Payer: First Health Commercial |
$392.35
|
| Rate for Payer: Humana Commercial |
$351.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$338.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$304.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$123.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$363.44
|
| Rate for Payer: Ohio Health Group HMO |
$309.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$330.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$359.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$284.97
|
| Rate for Payer: PHCS Commercial |
$396.48
|
| Rate for Payer: United Healthcare All Payer |
$363.44
|
|
|
REPAIR SUPERFICIAL 2.6-7.5 C(T
|
Facility
|
OP
|
$413.00
|
|
|
Service Code
|
HCPCS 12002
|
| Hospital Charge Code |
761T0121
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$142.03 |
| Max. Negotiated Rate |
$396.48 |
| Rate for Payer: Aetna Commercial |
$318.01
|
| Rate for Payer: Anthem Medicaid |
$142.03
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$322.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$206.50
|
| Rate for Payer: Cash Price |
$206.50
|
| Rate for Payer: Cigna Commercial |
$342.79
|
| Rate for Payer: First Health Commercial |
$392.35
|
| Rate for Payer: Humana Commercial |
$351.05
|
| Rate for Payer: Humana KY Medicaid |
$142.03
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$143.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$338.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$304.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$144.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$363.44
|
| Rate for Payer: Ohio Health Group HMO |
$309.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$330.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$359.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$284.97
|
| Rate for Payer: PHCS Commercial |
$396.48
|
| Rate for Payer: United Healthcare All Payer |
$363.44
|
|
|
REPAIR TCAT MITRAL VALVE
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 33418
|
| Hospital Charge Code |
76101288
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$900.00 |
| Max. Negotiated Rate |
$2,880.00 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem Medicaid |
$1,031.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Humana KY Medicaid |
$1,031.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1,042.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$900.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,052.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,610.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,070.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
REPAIR TCAT MITRAL VALVE
|
Facility
|
IP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 33418
|
| Hospital Charge Code |
76101288
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$900.00 |
| Max. Negotiated Rate |
$2,880.00 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$900.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,610.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,070.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
REPAIR TCAT MITRAL VALVE
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 33418
|
| Hospital Charge Code |
76101288
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$3,406.39 |
| Rate for Payer: Ambetter Exchange |
$1,681.45
|
| Rate for Payer: Anthem Medicaid |
$1,503.43
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,681.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,681.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,017.74
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$3,406.39
|
| Rate for Payer: Humana Medicaid |
$1,503.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,487.21
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,681.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,681.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,533.50
|
| Rate for Payer: Molina Healthcare Passport |
$1,503.43
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,185.89
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,518.46
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,681.45
|
|
|
REPAIR TCAT MITRAL VALVE(P
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 33418
|
| Hospital Charge Code |
761P1288
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$3,406.39 |
| Rate for Payer: Ambetter Exchange |
$1,681.45
|
| Rate for Payer: Anthem Medicaid |
$1,503.43
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,681.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,681.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,017.74
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$3,406.39
|
| Rate for Payer: Humana Medicaid |
$1,503.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,487.21
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,681.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,681.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,533.50
|
| Rate for Payer: Molina Healthcare Passport |
$1,503.43
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,185.89
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,518.46
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,681.45
|
|
|
REPAIR, TENDON, EXTENSOR, FOOT; PRIMARY OR SECONDARY, EACH TENDON
|
Facility
|
OP
|
$4,197.13
|
|
|
Service Code
|
CPT 28208
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,997.95 |
| Max. Negotiated Rate |
$4,197.13 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,997.95
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| Rate for Payer: Humana Medicare Advantage |
$2,997.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,597.54
|
|
|
REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR MUSCLE, PRIMARY OR SECONDARY (EXCLUDES ROTATOR CUFF)
|
Facility
|
OP
|
$9,240.92
|
|
|
Service Code
|
CPT 24341
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,600.66 |
| Max. Negotiated Rate |
$9,240.92 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,600.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9,240.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,910.89
|
| Rate for Payer: Humana Medicare Advantage |
$6,600.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,920.79
|
|
|
REPAIR TESTIS INJURY
|
Professional
|
Both
|
$990.00
|
|
|
Service Code
|
HCPCS 54670
|
| Hospital Charge Code |
76102977
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$303.60 |
| Max. Negotiated Rate |
$654.67 |
| Rate for Payer: Aetna Commercial |
$654.67
|
| Rate for Payer: Ambetter Exchange |
$387.74
|
| Rate for Payer: Anthem Medicaid |
$303.60
|
| Rate for Payer: Buckeye Individual/Medicaid |
$387.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$387.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.29
|
| Rate for Payer: Cash Price |
$495.00
|
| Rate for Payer: Cash Price |
$495.00
|
| Rate for Payer: Cigna Commercial |
$588.98
|
| Rate for Payer: Healthspan PPO |
$633.89
|
| Rate for Payer: Humana Medicaid |
$303.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$548.98
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$387.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$387.74
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$309.67
|
| Rate for Payer: Molina Healthcare Passport |
$303.60
|
| Rate for Payer: Multiplan PHCS |
$594.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$504.06
|
| Rate for Payer: UHCCP Medicaid |
$346.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$306.64
|
| Rate for Payer: Wellcare Medicare Advantage |
$387.74
|
|
|
REPAIR TOE DISLOCATION
|
Professional
|
Both
|
$850.00
|
|
|
Service Code
|
HCPCS 28645
|
| Hospital Charge Code |
76102677
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$212.34 |
| Max. Negotiated Rate |
$777.16 |
| Rate for Payer: Aetna Commercial |
$691.01
|
| Rate for Payer: Ambetter Exchange |
$462.62
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$247.26
|
| Rate for Payer: Anthem Medicaid |
$212.34
|
| Rate for Payer: Buckeye Individual/Medicaid |
$462.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$462.62
|
| Rate for Payer: CareSource Just4Me Medicare |
$555.14
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$496.01
|
| Rate for Payer: Healthspan PPO |
$777.16
|
| Rate for Payer: Humana Medicaid |
$212.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$586.56
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$462.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$216.59
|
| Rate for Payer: Molina Healthcare Passport |
$212.34
|
| Rate for Payer: Multiplan PHCS |
$510.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$601.41
|
| Rate for Payer: UHCCP Medicaid |
$259.62
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$214.46
|
| Rate for Payer: Wellcare Medicare Advantage |
$462.62
|
|
|
REPAIR TRUNK 2.6 TO 7.5 CM
|
Facility
|
OP
|
$3,151.00
|
|
|
Service Code
|
HCPCS 13101
|
| Hospital Charge Code |
76100150
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$565.60 |
| Max. Negotiated Rate |
$3,024.96 |
| Rate for Payer: Aetna Commercial |
$2,426.27
|
| Rate for Payer: Anthem Medicaid |
$1,083.63
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,457.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$1,575.50
|
| Rate for Payer: Cash Price |
$1,575.50
|
| Rate for Payer: Cigna Commercial |
$2,615.33
|
| Rate for Payer: First Health Commercial |
$2,993.45
|
| Rate for Payer: Humana Commercial |
$2,678.35
|
| Rate for Payer: Humana KY Medicaid |
$1,083.63
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1,094.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,583.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,325.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,105.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,772.88
|
| Rate for Payer: Ohio Health Group HMO |
$2,363.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,520.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,741.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,174.19
|
| Rate for Payer: PHCS Commercial |
$3,024.96
|
| Rate for Payer: United Healthcare All Payer |
$2,772.88
|
|
|
REPAIR TRUNK 2.6 TO 7.5 CM
|
Professional
|
Both
|
$3,151.00
|
|
|
Service Code
|
HCPCS 13101
|
| Hospital Charge Code |
76100150
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$125.45 |
| Max. Negotiated Rate |
$1,890.60 |
| Rate for Payer: Aetna Commercial |
$404.90
|
| Rate for Payer: Ambetter Exchange |
$229.83
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$125.45
|
| Rate for Payer: Anthem Medicaid |
$174.45
|
| Rate for Payer: Buckeye Individual/Medicaid |
$229.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$229.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$275.80
|
| Rate for Payer: Cash Price |
$1,575.50
|
| Rate for Payer: Cash Price |
$1,575.50
|
| Rate for Payer: Cigna Commercial |
$498.30
|
| Rate for Payer: Healthspan PPO |
$437.58
|
| Rate for Payer: Humana Medicaid |
$174.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$356.17
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$229.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$229.83
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$177.94
|
| Rate for Payer: Molina Healthcare Passport |
$174.45
|
| Rate for Payer: Multiplan PHCS |
$1,890.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$298.78
|
| Rate for Payer: UHCCP Medicaid |
$131.72
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$176.19
|
| Rate for Payer: Wellcare Medicare Advantage |
$229.83
|
|
|
REPAIR TRUNK 2.6 TO 7.5 CM
|
Facility
|
IP
|
$3,151.00
|
|
|
Service Code
|
HCPCS 13101
|
| Hospital Charge Code |
76100150
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$945.30 |
| Max. Negotiated Rate |
$3,024.96 |
| Rate for Payer: Aetna Commercial |
$2,426.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,457.78
|
| Rate for Payer: Cash Price |
$1,575.50
|
| Rate for Payer: Cigna Commercial |
$2,615.33
|
| Rate for Payer: First Health Commercial |
$2,993.45
|
| Rate for Payer: Humana Commercial |
$2,678.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,583.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,325.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$945.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,772.88
|
| Rate for Payer: Ohio Health Group HMO |
$2,363.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,520.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,741.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,174.19
|
| Rate for Payer: PHCS Commercial |
$3,024.96
|
| Rate for Payer: United Healthcare All Payer |
$2,772.88
|
|
