|
REVISION OF TIPS(P
|
Professional
|
Both
|
$585.00
|
|
|
Service Code
|
HCPCS 37183
|
| Hospital Charge Code |
761P1524
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$243.96 |
| Max. Negotiated Rate |
$672.44 |
| Rate for Payer: Aetna Commercial |
$672.44
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$243.96
|
| Rate for Payer: Anthem Medicaid |
$321.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$585.00
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Cigna Commercial |
$610.50
|
| Rate for Payer: Healthspan PPO |
$537.68
|
| Rate for Payer: Humana Medicaid |
$321.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$520.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$328.02
|
| Rate for Payer: Molina Healthcare Passport |
$321.59
|
| Rate for Payer: Multiplan PHCS |
$351.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$409.50
|
| Rate for Payer: UHCCP Medicaid |
$256.16
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$324.81
|
|
|
REVISION OF TRACH/BRONCH STENT
|
Professional
|
Both
|
$502.00
|
|
|
Service Code
|
HCPCS 31638
|
| Hospital Charge Code |
410P0048
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$175.70 |
| Max. Negotiated Rate |
$502.00 |
| Rate for Payer: Aetna Commercial |
$419.50
|
| Rate for Payer: Anthem Medicaid |
$200.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$502.00
|
| Rate for Payer: Cash Price |
$251.00
|
| Rate for Payer: Cash Price |
$251.00
|
| Rate for Payer: Cigna Commercial |
$384.55
|
| Rate for Payer: Healthspan PPO |
$327.54
|
| Rate for Payer: Humana Medicaid |
$200.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$334.20
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$204.76
|
| Rate for Payer: Molina Healthcare Passport |
$200.75
|
| Rate for Payer: Multiplan PHCS |
$301.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$351.40
|
| Rate for Payer: UHCCP Medicaid |
$175.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$202.76
|
|
|
REVISION OF TRACH/BRONCH STENT
|
Professional
|
Both
|
$502.00
|
|
|
Service Code
|
HCPCS 31638
|
| Hospital Charge Code |
41000048
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$175.70 |
| Max. Negotiated Rate |
$502.00 |
| Rate for Payer: Aetna Commercial |
$419.50
|
| Rate for Payer: Anthem Medicaid |
$200.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$502.00
|
| Rate for Payer: Cash Price |
$251.00
|
| Rate for Payer: Cash Price |
$251.00
|
| Rate for Payer: Cigna Commercial |
$384.55
|
| Rate for Payer: Healthspan PPO |
$327.54
|
| Rate for Payer: Humana Medicaid |
$200.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$334.20
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$204.76
|
| Rate for Payer: Molina Healthcare Passport |
$200.75
|
| Rate for Payer: Multiplan PHCS |
$301.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$351.40
|
| Rate for Payer: UHCCP Medicaid |
$175.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$202.76
|
|
|
REVISION OF URETHRA
|
Facility
|
IP
|
$975.00
|
|
|
Service Code
|
HCPCS 53450
|
| Hospital Charge Code |
76102935
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$126.75 |
| Max. Negotiated Rate |
$936.00 |
| Rate for Payer: Aetna Commercial |
$750.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$760.50
|
| Rate for Payer: Cash Price |
$487.50
|
| Rate for Payer: Cigna Commercial |
$809.25
|
| Rate for Payer: First Health Commercial |
$926.25
|
| Rate for Payer: Humana Commercial |
$828.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$799.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$719.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$292.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$858.00
|
| Rate for Payer: Ohio Health Group HMO |
$731.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$195.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$126.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$302.25
|
| Rate for Payer: PHCS Commercial |
$936.00
|
| Rate for Payer: United Healthcare All Payer |
$858.00
|
|
|
REVISION OF URETHRA
|
Professional
|
Both
|
$975.00
|
|
|
Service Code
|
HCPCS 53450
|
| Hospital Charge Code |
76102935
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$247.90 |
| Max. Negotiated Rate |
$975.00 |
| Rate for Payer: Aetna Commercial |
$659.20
|
| Rate for Payer: Anthem Medicaid |
$247.90
|
| Rate for Payer: Buckeye Medicare Advantage |
$975.00
|
| Rate for Payer: Cash Price |
$487.50
|
| Rate for Payer: Cash Price |
$487.50
|
| Rate for Payer: Cigna Commercial |
$581.55
|
| Rate for Payer: Healthspan PPO |
$527.09
|
| Rate for Payer: Humana Medicaid |
$247.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$554.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$252.86
|
| Rate for Payer: Molina Healthcare Passport |
$247.90
|
| Rate for Payer: Multiplan PHCS |
$585.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$682.50
|
| Rate for Payer: UHCCP Medicaid |
$341.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$250.38
|
|
|
REVISION OF URETHRA
|
Facility
|
OP
|
$975.00
|
|
|
Service Code
|
HCPCS 53450
|
| Hospital Charge Code |
76102935
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$126.75 |
| Max. Negotiated Rate |
$4,220.54 |
| Rate for Payer: Aetna Commercial |
$750.75
|
| Rate for Payer: Anthem Medicaid |
$335.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,014.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$760.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,220.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,069.80
|
| Rate for Payer: Cash Price |
$487.50
|
| Rate for Payer: Cash Price |
$487.50
|
| Rate for Payer: Cigna Commercial |
$809.25
|
| Rate for Payer: First Health Commercial |
$926.25
|
| Rate for Payer: Humana Commercial |
$828.75
|
| Rate for Payer: Humana KY Medicaid |
$335.30
|
| Rate for Payer: Humana Medicare Advantage |
$3,014.67
|
| Rate for Payer: Kentucky WC Medicaid |
$338.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$799.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$719.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,617.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$342.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$858.00
|
| Rate for Payer: Ohio Health Group HMO |
$731.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$195.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$126.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$302.25
|
| Rate for Payer: PHCS Commercial |
$936.00
|
| Rate for Payer: United Healthcare All Payer |
$858.00
|
|
|
REVISION - OPEN - ARTERIOVEN
|
Facility
|
IP
|
$1,017.00
|
|
|
Service Code
|
HCPCS 36833
|
| Hospital Charge Code |
76101512
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$132.21 |
| Max. Negotiated Rate |
$976.32 |
| Rate for Payer: Aetna Commercial |
$783.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$793.26
|
| Rate for Payer: Cash Price |
$508.50
|
| Rate for Payer: Cigna Commercial |
$844.11
|
| Rate for Payer: First Health Commercial |
$966.15
|
| Rate for Payer: Humana Commercial |
$864.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$833.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$750.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$305.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$894.96
|
| Rate for Payer: Ohio Health Group HMO |
$762.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$203.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$132.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$315.27
|
| Rate for Payer: PHCS Commercial |
$976.32
|
| Rate for Payer: United Healthcare All Payer |
$894.96
|
|
|
REVISION - OPEN - ARTERIOVEN
|
Facility
|
OP
|
$1,017.00
|
|
|
Service Code
|
HCPCS 36833
|
| Hospital Charge Code |
76101512
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$132.21 |
| Max. Negotiated Rate |
$6,652.97 |
| Rate for Payer: Aetna Commercial |
$783.09
|
| Rate for Payer: Anthem Medicaid |
$349.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,752.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$793.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,652.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,415.36
|
| Rate for Payer: Cash Price |
$508.50
|
| Rate for Payer: Cash Price |
$508.50
|
| Rate for Payer: Cigna Commercial |
$844.11
|
| Rate for Payer: First Health Commercial |
$966.15
|
| Rate for Payer: Humana Commercial |
$864.45
|
| Rate for Payer: Humana KY Medicaid |
$349.75
|
| Rate for Payer: Humana Medicare Advantage |
$4,752.12
|
| Rate for Payer: Kentucky WC Medicaid |
$353.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$833.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$750.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,702.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$356.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$894.96
|
| Rate for Payer: Ohio Health Group HMO |
$762.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$203.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$132.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$315.27
|
| Rate for Payer: PHCS Commercial |
$976.32
|
| Rate for Payer: United Healthcare All Payer |
$894.96
|
|
|
REVISION - OPEN - ARTERIOVEN
|
Professional
|
Both
|
$1,017.00
|
|
|
Service Code
|
HCPCS 36833
|
| Hospital Charge Code |
76101512
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$355.95 |
| Max. Negotiated Rate |
$1,050.84 |
| Rate for Payer: Aetna Commercial |
$1,050.84
|
| Rate for Payer: Anthem Medicaid |
$492.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,017.00
|
| Rate for Payer: Cash Price |
$508.50
|
| Rate for Payer: Cash Price |
$508.50
|
| Rate for Payer: Cigna Commercial |
$1,001.71
|
| Rate for Payer: Healthspan PPO |
$840.24
|
| Rate for Payer: Humana Medicaid |
$492.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$880.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$501.86
|
| Rate for Payer: Molina Healthcare Passport |
$492.02
|
| Rate for Payer: Multiplan PHCS |
$610.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$711.90
|
| Rate for Payer: UHCCP Medicaid |
$355.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$496.94
|
|
|
REVISION - OPEN - ARTERIOVEN
|
Facility
|
IP
|
$1,350.00
|
|
|
Service Code
|
HCPCS 36832
|
| Hospital Charge Code |
76101511
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$175.50 |
| Max. Negotiated Rate |
$1,296.00 |
| Rate for Payer: Aetna Commercial |
$1,039.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,053.00
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cigna Commercial |
$1,120.50
|
| Rate for Payer: First Health Commercial |
$1,282.50
|
| Rate for Payer: Humana Commercial |
$1,147.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,107.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$996.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$405.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,188.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,012.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$270.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$175.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$418.50
|
| Rate for Payer: PHCS Commercial |
$1,296.00
|
| Rate for Payer: United Healthcare All Payer |
$1,188.00
|
|
|
REVISION - OPEN - ARTERIOVEN
|
Professional
|
Both
|
$1,350.00
|
|
|
Service Code
|
HCPCS 36832
|
| Hospital Charge Code |
76101511
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$429.83 |
| Max. Negotiated Rate |
$1,350.00 |
| Rate for Payer: Aetna Commercial |
$929.16
|
| Rate for Payer: Anthem Medicaid |
$429.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,350.00
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cigna Commercial |
$887.10
|
| Rate for Payer: Healthspan PPO |
$742.95
|
| Rate for Payer: Humana Medicaid |
$429.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$778.35
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$438.43
|
| Rate for Payer: Molina Healthcare Passport |
$429.83
|
| Rate for Payer: Multiplan PHCS |
$810.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$945.00
|
| Rate for Payer: UHCCP Medicaid |
$472.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$434.13
|
|
|
REVISION - OPEN - ARTERIOVEN
|
Facility
|
OP
|
$1,350.00
|
|
|
Service Code
|
HCPCS 36832
|
| Hospital Charge Code |
76101511
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$175.50 |
| Max. Negotiated Rate |
$6,652.97 |
| Rate for Payer: Aetna Commercial |
$1,039.50
|
| Rate for Payer: Anthem Medicaid |
$464.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,752.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,053.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,652.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,415.36
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cigna Commercial |
$1,120.50
|
| Rate for Payer: First Health Commercial |
$1,282.50
|
| Rate for Payer: Humana Commercial |
$1,147.50
|
| Rate for Payer: Humana KY Medicaid |
$464.26
|
| Rate for Payer: Humana Medicare Advantage |
$4,752.12
|
| Rate for Payer: Kentucky WC Medicaid |
$468.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,107.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$996.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,702.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$473.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,188.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,012.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$270.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$175.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$418.50
|
| Rate for Payer: PHCS Commercial |
$1,296.00
|
| Rate for Payer: United Healthcare All Payer |
$1,188.00
|
|
|
REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$6,652.97
|
|
|
Service Code
|
CPT 36832
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,752.12 |
| Max. Negotiated Rate |
$6,652.97 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,752.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,652.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,415.36
|
| Rate for Payer: Humana Medicare Advantage |
$4,752.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,702.54
|
|
|
REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$6,652.97
|
|
|
Service Code
|
CPT 36833
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,752.12 |
| Max. Negotiated Rate |
$6,652.97 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,752.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,652.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,415.36
|
| Rate for Payer: Humana Medicare Advantage |
$4,752.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,702.54
|
|
|
REVISION - OPEN - ARTERIOVEN(P
|
Professional
|
Both
|
$1,017.00
|
|
|
Service Code
|
HCPCS 36833
|
| Hospital Charge Code |
761P1512
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$355.95 |
| Max. Negotiated Rate |
$1,050.84 |
| Rate for Payer: Aetna Commercial |
$1,050.84
|
| Rate for Payer: Anthem Medicaid |
$492.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,017.00
|
| Rate for Payer: Cash Price |
$508.50
|
| Rate for Payer: Cash Price |
$508.50
|
| Rate for Payer: Cigna Commercial |
$1,001.71
|
| Rate for Payer: Healthspan PPO |
$840.24
|
| Rate for Payer: Humana Medicaid |
$492.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$880.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$501.86
|
| Rate for Payer: Molina Healthcare Passport |
$492.02
|
| Rate for Payer: Multiplan PHCS |
$610.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$711.90
|
| Rate for Payer: UHCCP Medicaid |
$355.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$496.94
|
|
|
REVISION - OPEN - ARTERIOVEN(P
|
Professional
|
Both
|
$1,350.00
|
|
|
Service Code
|
HCPCS 36832
|
| Hospital Charge Code |
761P1511
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$429.83 |
| Max. Negotiated Rate |
$1,350.00 |
| Rate for Payer: Aetna Commercial |
$929.16
|
| Rate for Payer: Anthem Medicaid |
$429.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,350.00
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cash Price |
$675.00
|
| Rate for Payer: Cigna Commercial |
$887.10
|
| Rate for Payer: Healthspan PPO |
$742.95
|
| Rate for Payer: Humana Medicaid |
$429.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$778.35
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$438.43
|
| Rate for Payer: Molina Healthcare Passport |
$429.83
|
| Rate for Payer: Multiplan PHCS |
$810.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$945.00
|
| Rate for Payer: UHCCP Medicaid |
$472.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$434.13
|
|
|
REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY
|
Facility
|
OP
|
$4,119.29
|
|
|
Service Code
|
CPT 64585
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,942.35 |
| Max. Negotiated Rate |
$4,119.29 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,942.35
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,119.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,972.17
|
| Rate for Payer: Humana Medicare Advantage |
$2,942.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,530.82
|
|
|
REVISION OR REMOVAL OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY
|
Facility
|
OP
|
$4,119.29
|
|
|
Service Code
|
CPT 64595
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,942.35 |
| Max. Negotiated Rate |
$4,119.29 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,942.35
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,119.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,972.17
|
| Rate for Payer: Humana Medicare Advantage |
$2,942.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,530.82
|
|
|
REVISION RECONSTRUCTED BREAS(P
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 19380
|
| Hospital Charge Code |
761P0323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$508.91 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: Aetna Commercial |
$1,105.64
|
| Rate for Payer: Anthem Medicaid |
$508.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,600.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,050.38
|
| Rate for Payer: Healthspan PPO |
$884.06
|
| Rate for Payer: Humana Medicaid |
$508.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$990.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$519.09
|
| Rate for Payer: Molina Healthcare Passport |
$508.91
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,120.00
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$514.00
|
|
|
REVISION RECONSTRUCTED BREAS(T
|
Facility
|
OP
|
$7,501.00
|
|
|
Service Code
|
HCPCS 19380
|
| Hospital Charge Code |
761T0323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$975.13 |
| Max. Negotiated Rate |
$7,894.80 |
| Rate for Payer: Aetna Commercial |
$5,775.77
|
| Rate for Payer: Anthem Medicaid |
$2,579.59
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,639.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,850.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,894.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,612.84
|
| Rate for Payer: Cash Price |
$3,750.50
|
| Rate for Payer: Cash Price |
$3,750.50
|
| Rate for Payer: Cigna Commercial |
$6,225.83
|
| Rate for Payer: First Health Commercial |
$7,125.95
|
| Rate for Payer: Humana Commercial |
$6,375.85
|
| Rate for Payer: Humana KY Medicaid |
$2,579.59
|
| Rate for Payer: Humana Medicare Advantage |
$5,639.14
|
| Rate for Payer: Kentucky WC Medicaid |
$2,605.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,150.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,535.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,766.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,631.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,600.88
|
| Rate for Payer: Ohio Health Group HMO |
$5,625.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,500.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$975.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,325.31
|
| Rate for Payer: PHCS Commercial |
$7,200.96
|
| Rate for Payer: United Healthcare All Payer |
$6,600.88
|
|
|
REVISION RECONSTRUCTED BREAS(T
|
Facility
|
IP
|
$7,501.00
|
|
|
Service Code
|
HCPCS 19380
|
| Hospital Charge Code |
761T0323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$975.13 |
| Max. Negotiated Rate |
$7,200.96 |
| Rate for Payer: Aetna Commercial |
$5,775.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,850.78
|
| Rate for Payer: Cash Price |
$3,750.50
|
| Rate for Payer: Cigna Commercial |
$6,225.83
|
| Rate for Payer: First Health Commercial |
$7,125.95
|
| Rate for Payer: Humana Commercial |
$6,375.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,150.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,535.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,250.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,600.88
|
| Rate for Payer: Ohio Health Group HMO |
$5,625.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,500.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$975.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,325.31
|
| Rate for Payer: PHCS Commercial |
$7,200.96
|
| Rate for Payer: United Healthcare All Payer |
$6,600.88
|
|
|
REVISION RECONSTRUCTED BREAST
|
Facility
|
IP
|
$9,101.00
|
|
|
Service Code
|
HCPCS 19380
|
| Hospital Charge Code |
76100323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,183.13 |
| Max. Negotiated Rate |
$8,736.96 |
| Rate for Payer: Aetna Commercial |
$7,007.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,098.78
|
| Rate for Payer: Cash Price |
$4,550.50
|
| Rate for Payer: Cigna Commercial |
$7,553.83
|
| Rate for Payer: First Health Commercial |
$8,645.95
|
| Rate for Payer: Humana Commercial |
$7,735.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,462.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,716.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,730.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,008.88
|
| Rate for Payer: Ohio Health Group HMO |
$6,825.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,820.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,183.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,821.31
|
| Rate for Payer: PHCS Commercial |
$8,736.96
|
| Rate for Payer: United Healthcare All Payer |
$8,008.88
|
|
|
REVISION RECONSTRUCTED BREAST
|
Professional
|
Both
|
$9,101.00
|
|
|
Service Code
|
HCPCS 19380
|
| Hospital Charge Code |
76100323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$508.91 |
| Max. Negotiated Rate |
$9,101.00 |
| Rate for Payer: Aetna Commercial |
$1,105.64
|
| Rate for Payer: Anthem Medicaid |
$508.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$9,101.00
|
| Rate for Payer: Cash Price |
$4,550.50
|
| Rate for Payer: Cash Price |
$4,550.50
|
| Rate for Payer: Cigna Commercial |
$1,050.38
|
| Rate for Payer: Healthspan PPO |
$884.06
|
| Rate for Payer: Humana Medicaid |
$508.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$990.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$519.09
|
| Rate for Payer: Molina Healthcare Passport |
$508.91
|
| Rate for Payer: Multiplan PHCS |
$5,460.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$6,370.70
|
| Rate for Payer: UHCCP Medicaid |
$3,185.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$514.00
|
|
|
REVISION RECONSTRUCTED BREAST
|
Facility
|
OP
|
$9,101.00
|
|
|
Service Code
|
HCPCS 19380
|
| Hospital Charge Code |
76100323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,183.13 |
| Max. Negotiated Rate |
$8,736.96 |
| Rate for Payer: Aetna Commercial |
$7,007.77
|
| Rate for Payer: Anthem Medicaid |
$3,129.83
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,639.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,098.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,894.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,612.84
|
| Rate for Payer: Cash Price |
$4,550.50
|
| Rate for Payer: Cash Price |
$4,550.50
|
| Rate for Payer: Cigna Commercial |
$7,553.83
|
| Rate for Payer: First Health Commercial |
$8,645.95
|
| Rate for Payer: Humana Commercial |
$7,735.85
|
| Rate for Payer: Humana KY Medicaid |
$3,129.83
|
| Rate for Payer: Humana Medicare Advantage |
$5,639.14
|
| Rate for Payer: Kentucky WC Medicaid |
$3,161.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,462.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,716.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,766.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,192.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,008.88
|
| Rate for Payer: Ohio Health Group HMO |
$6,825.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,820.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,183.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,821.31
|
| Rate for Payer: PHCS Commercial |
$8,736.96
|
| Rate for Payer: United Healthcare All Payer |
$8,008.88
|
|
|
REVIS SHLDR ARTHR HUM/GLENOID
|
Facility
|
IP
|
$2,500.00
|
|
|
Service Code
|
HCPCS 23473
|
| Hospital Charge Code |
76100467
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$325.00 |
| 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 |
$500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$325.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$775.00
|
| Rate for Payer: PHCS Commercial |
$2,400.00
|
| Rate for Payer: United Healthcare All Payer |
$2,200.00
|
|
