|
REVIS SHLDR ARTHR HUM/GLENOID
|
Facility
|
OP
|
$2,500.00
|
|
|
Service Code
|
HCPCS 23473
|
| Hospital Charge Code |
76100467
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$325.00 |
| Max. Negotiated Rate |
$15,933.60 |
| Rate for Payer: Aetna Commercial |
$1,925.00
|
| Rate for Payer: Anthem Medicaid |
$859.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$11,381.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,950.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$15,933.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$15,364.54
|
| Rate for Payer: Cash Price |
$1,250.00
|
| 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: Humana Medicare Advantage |
$11,381.14
|
| 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 |
$13,657.37
|
| 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 |
$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
|
|
|
REVIS SHLDR ARTHR HUM/GLENOID
|
Professional
|
Both
|
$2,500.00
|
|
|
Service Code
|
HCPCS 23473
|
| Hospital Charge Code |
76100467
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$3,137.42 |
| Rate for Payer: Anthem Medicaid |
$1,303.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,500.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$3,137.42
|
| Rate for Payer: Healthspan PPO |
$1,740.14
|
| Rate for Payer: Humana Medicaid |
$1,303.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,106.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,329.13
|
| Rate for Payer: Molina Healthcare Passport |
$1,303.07
|
| Rate for Payer: Multiplan PHCS |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,750.00
|
| Rate for Payer: UHCCP Medicaid |
$875.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,316.10
|
|
|
REVIS SHLDR ARTHR HUM/GLENOI(P
|
Professional
|
Both
|
$2,500.00
|
|
|
Service Code
|
HCPCS 23473
|
| Hospital Charge Code |
761P0467
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$875.00 |
| Max. Negotiated Rate |
$3,137.42 |
| Rate for Payer: Anthem Medicaid |
$1,303.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,500.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$3,137.42
|
| Rate for Payer: Healthspan PPO |
$1,740.14
|
| Rate for Payer: Humana Medicaid |
$1,303.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,106.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,329.13
|
| Rate for Payer: Molina Healthcare Passport |
$1,303.07
|
| Rate for Payer: Multiplan PHCS |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,750.00
|
| Rate for Payer: UHCCP Medicaid |
$875.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,316.10
|
|
|
REVIS SHOULDER ARTH HUM/GLEN
|
Professional
|
Both
|
$4,400.00
|
|
|
Service Code
|
HCPCS 23474
|
| Hospital Charge Code |
76100468
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,407.95 |
| Max. Negotiated Rate |
$4,400.00 |
| Rate for Payer: Anthem Medicaid |
$1,407.95
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,400.00
|
| Rate for Payer: Cash Price |
$2,200.00
|
| Rate for Payer: Cash Price |
$2,200.00
|
| Rate for Payer: Cigna Commercial |
$3,390.64
|
| Rate for Payer: Healthspan PPO |
$1,881.33
|
| Rate for Payer: Humana Medicaid |
$1,407.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,278.02
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,436.11
|
| Rate for Payer: Molina Healthcare Passport |
$1,407.95
|
| Rate for Payer: Multiplan PHCS |
$2,640.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,080.00
|
| Rate for Payer: UHCCP Medicaid |
$1,540.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,422.03
|
|
|
REVIS SHOULDER ARTH HUM/GLEN
|
Facility
|
IP
|
$4,400.00
|
|
|
Service Code
|
HCPCS 23474
|
| Hospital Charge Code |
76100468
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$572.00 |
| Max. Negotiated Rate |
$4,224.00 |
| Rate for Payer: Aetna Commercial |
$3,388.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,432.00
|
| Rate for Payer: Cash Price |
$2,200.00
|
| Rate for Payer: Cigna Commercial |
$3,652.00
|
| Rate for Payer: First Health Commercial |
$4,180.00
|
| Rate for Payer: Humana Commercial |
$3,740.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,608.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,247.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,320.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,872.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,300.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$572.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,364.00
|
| Rate for Payer: PHCS Commercial |
$4,224.00
|
| Rate for Payer: United Healthcare All Payer |
$3,872.00
|
|
|
REVIS SHOULDER ARTH HUM/GLEN
|
Facility
|
OP
|
$4,400.00
|
|
|
Service Code
|
HCPCS 23474
|
| Hospital Charge Code |
76100468
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$572.00 |
| Max. Negotiated Rate |
$4,224.00 |
| Rate for Payer: Aetna Commercial |
$3,388.00
|
| Rate for Payer: Anthem Medicaid |
$1,513.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,432.00
|
| Rate for Payer: Cash Price |
$2,200.00
|
| Rate for Payer: Cigna Commercial |
$3,652.00
|
| Rate for Payer: First Health Commercial |
$4,180.00
|
| Rate for Payer: Humana Commercial |
$3,740.00
|
| Rate for Payer: Humana KY Medicaid |
$1,513.16
|
| Rate for Payer: Kentucky WC Medicaid |
$1,528.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,608.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,247.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,320.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,543.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,872.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,300.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$572.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,364.00
|
| Rate for Payer: PHCS Commercial |
$4,224.00
|
| Rate for Payer: United Healthcare All Payer |
$3,872.00
|
|
|
REVIS SHOULDER ARTH HUM/GLEN(P
|
Professional
|
Both
|
$4,400.00
|
|
|
Service Code
|
HCPCS 23474
|
| Hospital Charge Code |
761P0468
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,407.95 |
| Max. Negotiated Rate |
$4,400.00 |
| Rate for Payer: Anthem Medicaid |
$1,407.95
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,400.00
|
| Rate for Payer: Cash Price |
$2,200.00
|
| Rate for Payer: Cash Price |
$2,200.00
|
| Rate for Payer: Cigna Commercial |
$3,390.64
|
| Rate for Payer: Healthspan PPO |
$1,881.33
|
| Rate for Payer: Humana Medicaid |
$1,407.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,278.02
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,436.11
|
| Rate for Payer: Molina Healthcare Passport |
$1,407.95
|
| Rate for Payer: Multiplan PHCS |
$2,640.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,080.00
|
| Rate for Payer: UHCCP Medicaid |
$1,540.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,422.03
|
|
|
REVIS VOLVUS
|
Professional
|
Both
|
$1,850.00
|
|
|
Service Code
|
HCPCS 44050
|
| Hospital Charge Code |
76101808
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$543.16 |
| Max. Negotiated Rate |
$1,850.00 |
| Rate for Payer: Aetna Commercial |
$1,347.03
|
| Rate for Payer: Anthem Medicaid |
$543.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,850.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cigna Commercial |
$1,252.47
|
| Rate for Payer: Healthspan PPO |
$1,135.97
|
| Rate for Payer: Humana Medicaid |
$543.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,190.43
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$554.02
|
| Rate for Payer: Molina Healthcare Passport |
$543.16
|
| Rate for Payer: Multiplan PHCS |
$1,110.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,295.00
|
| Rate for Payer: UHCCP Medicaid |
$647.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$548.59
|
|
|
REVIS VOLVUS
|
Facility
|
OP
|
$1,850.00
|
|
|
Service Code
|
HCPCS 44050
|
| Hospital Charge Code |
76101808
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$240.50 |
| Max. Negotiated Rate |
$1,776.00 |
| Rate for Payer: Aetna Commercial |
$1,424.50
|
| Rate for Payer: Anthem Medicaid |
$636.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,443.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cigna Commercial |
$1,535.50
|
| Rate for Payer: First Health Commercial |
$1,757.50
|
| Rate for Payer: Humana Commercial |
$1,572.50
|
| Rate for Payer: Humana KY Medicaid |
$636.22
|
| Rate for Payer: Kentucky WC Medicaid |
$642.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,517.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,365.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$648.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,628.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,387.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$370.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$240.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$573.50
|
| Rate for Payer: PHCS Commercial |
$1,776.00
|
| Rate for Payer: United Healthcare All Payer |
$1,628.00
|
|
|
REVIS VOLVUS
|
Facility
|
IP
|
$1,850.00
|
|
|
Service Code
|
HCPCS 44050
|
| Hospital Charge Code |
76101808
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$240.50 |
| Max. Negotiated Rate |
$1,776.00 |
| Rate for Payer: Aetna Commercial |
$1,424.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,443.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cigna Commercial |
$1,535.50
|
| Rate for Payer: First Health Commercial |
$1,757.50
|
| Rate for Payer: Humana Commercial |
$1,572.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,517.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,365.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,628.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,387.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$370.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$240.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$573.50
|
| Rate for Payer: PHCS Commercial |
$1,776.00
|
| Rate for Payer: United Healthcare All Payer |
$1,628.00
|
|
|
REVIS VOLVUS(P
|
Professional
|
Both
|
$1,850.00
|
|
|
Service Code
|
HCPCS 44050
|
| Hospital Charge Code |
761P1808
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$543.16 |
| Max. Negotiated Rate |
$1,850.00 |
| Rate for Payer: Aetna Commercial |
$1,347.03
|
| Rate for Payer: Anthem Medicaid |
$543.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,850.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cigna Commercial |
$1,252.47
|
| Rate for Payer: Healthspan PPO |
$1,135.97
|
| Rate for Payer: Humana Medicaid |
$543.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,190.43
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$554.02
|
| Rate for Payer: Molina Healthcare Passport |
$543.16
|
| Rate for Payer: Multiplan PHCS |
$1,110.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,295.00
|
| Rate for Payer: UHCCP Medicaid |
$647.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$548.59
|
|
|
REV KN ARTHRPLSTY WWOALLOGRAFT
|
Professional
|
Both
|
$3,600.00
|
|
|
Service Code
|
HCPCS 27486
|
| Hospital Charge Code |
76100852
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,162.27 |
| Max. Negotiated Rate |
$3,600.00 |
| Rate for Payer: Aetna Commercial |
$2,117.10
|
| Rate for Payer: Anthem Medicaid |
$1,162.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,600.00
|
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Cigna Commercial |
$2,286.70
|
| Rate for Payer: Healthspan PPO |
$1,917.64
|
| Rate for Payer: Humana Medicaid |
$1,162.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,770.37
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,185.52
|
| Rate for Payer: Molina Healthcare Passport |
$1,162.27
|
| Rate for Payer: Multiplan PHCS |
$2,160.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,520.00
|
| Rate for Payer: UHCCP Medicaid |
$1,260.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,173.89
|
|
|
REV KN ARTHRPLSTY WWOALLOGRAFT
|
Facility
|
OP
|
$3,600.00
|
|
|
Service Code
|
HCPCS 27486
|
| Hospital Charge Code |
76100852
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$468.00 |
| Max. Negotiated Rate |
$3,456.00 |
| Rate for Payer: Aetna Commercial |
$2,772.00
|
| Rate for Payer: Anthem Medicaid |
$1,238.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,808.00
|
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Cigna Commercial |
$2,988.00
|
| Rate for Payer: First Health Commercial |
$3,420.00
|
| Rate for Payer: Humana Commercial |
$3,060.00
|
| Rate for Payer: Humana KY Medicaid |
$1,238.04
|
| Rate for Payer: Kentucky WC Medicaid |
$1,250.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,952.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,656.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,080.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,262.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,168.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,700.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$720.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$468.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,116.00
|
| Rate for Payer: PHCS Commercial |
$3,456.00
|
| Rate for Payer: United Healthcare All Payer |
$3,168.00
|
|
|
REV KN ARTHRPLSTY WWOALLOGRAFT
|
Facility
|
IP
|
$5,600.00
|
|
|
Service Code
|
HCPCS 27487
|
| Hospital Charge Code |
76100853
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$728.00 |
| Max. Negotiated Rate |
$5,376.00 |
| Rate for Payer: Aetna Commercial |
$4,312.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,368.00
|
| Rate for Payer: Cash Price |
$2,800.00
|
| Rate for Payer: Cigna Commercial |
$4,648.00
|
| Rate for Payer: First Health Commercial |
$5,320.00
|
| Rate for Payer: Humana Commercial |
$4,760.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,592.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,132.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,680.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,928.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$728.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,736.00
|
| Rate for Payer: PHCS Commercial |
$5,376.00
|
| Rate for Payer: United Healthcare All Payer |
$4,928.00
|
|
|
REV KN ARTHRPLSTY WWOALLOGRAFT
|
Facility
|
IP
|
$3,600.00
|
|
|
Service Code
|
HCPCS 27486
|
| Hospital Charge Code |
76100852
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$468.00 |
| Max. Negotiated Rate |
$3,456.00 |
| Rate for Payer: Aetna Commercial |
$2,772.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,808.00
|
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Cigna Commercial |
$2,988.00
|
| Rate for Payer: First Health Commercial |
$3,420.00
|
| Rate for Payer: Humana Commercial |
$3,060.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,952.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,656.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,080.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,168.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,700.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$720.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$468.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,116.00
|
| Rate for Payer: PHCS Commercial |
$3,456.00
|
| Rate for Payer: United Healthcare All Payer |
$3,168.00
|
|
|
REV KN ARTHRPLSTY WWOALLOGRAFT
|
Professional
|
Both
|
$5,600.00
|
|
|
Service Code
|
HCPCS 27487
|
| Hospital Charge Code |
761P0853
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,526.10 |
| Max. Negotiated Rate |
$5,600.00 |
| Rate for Payer: Aetna Commercial |
$2,679.11
|
| Rate for Payer: Anthem Medicaid |
$1,526.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,600.00
|
| Rate for Payer: Cash Price |
$2,800.00
|
| Rate for Payer: Cash Price |
$2,800.00
|
| Rate for Payer: Cigna Commercial |
$2,892.50
|
| Rate for Payer: Healthspan PPO |
$2,426.71
|
| Rate for Payer: Humana Medicaid |
$1,526.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,224.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,556.62
|
| Rate for Payer: Molina Healthcare Passport |
$1,526.10
|
| Rate for Payer: Multiplan PHCS |
$3,360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,920.00
|
| Rate for Payer: UHCCP Medicaid |
$1,960.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,541.36
|
|
|
REV KN ARTHRPLSTY WWOALLOGRAFT
|
Professional
|
Both
|
$5,600.00
|
|
|
Service Code
|
HCPCS 27487
|
| Hospital Charge Code |
76100853
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,526.10 |
| Max. Negotiated Rate |
$5,600.00 |
| Rate for Payer: Aetna Commercial |
$2,679.11
|
| Rate for Payer: Anthem Medicaid |
$1,526.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,600.00
|
| Rate for Payer: Cash Price |
$2,800.00
|
| Rate for Payer: Cash Price |
$2,800.00
|
| Rate for Payer: Cigna Commercial |
$2,892.50
|
| Rate for Payer: Healthspan PPO |
$2,426.71
|
| Rate for Payer: Humana Medicaid |
$1,526.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,224.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,556.62
|
| Rate for Payer: Molina Healthcare Passport |
$1,526.10
|
| Rate for Payer: Multiplan PHCS |
$3,360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,920.00
|
| Rate for Payer: UHCCP Medicaid |
$1,960.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,541.36
|
|
|
REV KN ARTHRPLSTY WWOALLOGRAFT
|
Facility
|
OP
|
$5,600.00
|
|
|
Service Code
|
HCPCS 27487
|
| Hospital Charge Code |
76100853
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$728.00 |
| Max. Negotiated Rate |
$5,376.00 |
| Rate for Payer: Aetna Commercial |
$4,312.00
|
| Rate for Payer: Anthem Medicaid |
$1,925.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,368.00
|
| Rate for Payer: Cash Price |
$2,800.00
|
| Rate for Payer: Cigna Commercial |
$4,648.00
|
| Rate for Payer: First Health Commercial |
$5,320.00
|
| Rate for Payer: Humana Commercial |
$4,760.00
|
| Rate for Payer: Humana KY Medicaid |
$1,925.84
|
| Rate for Payer: Kentucky WC Medicaid |
$1,945.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,592.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,132.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,680.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,964.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,928.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$728.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,736.00
|
| Rate for Payer: PHCS Commercial |
$5,376.00
|
| Rate for Payer: United Healthcare All Payer |
$4,928.00
|
|
|
REV KN ARTHRPLSTY WWOALLOGRAFT
|
Professional
|
Both
|
$3,600.00
|
|
|
Service Code
|
HCPCS 27486
|
| Hospital Charge Code |
761P0852
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,162.27 |
| Max. Negotiated Rate |
$3,600.00 |
| Rate for Payer: Aetna Commercial |
$2,117.10
|
| Rate for Payer: Anthem Medicaid |
$1,162.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,600.00
|
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Cigna Commercial |
$2,286.70
|
| Rate for Payer: Healthspan PPO |
$1,917.64
|
| Rate for Payer: Humana Medicaid |
$1,162.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,770.37
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,185.52
|
| Rate for Payer: Molina Healthcare Passport |
$1,162.27
|
| Rate for Payer: Multiplan PHCS |
$2,160.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,520.00
|
| Rate for Payer: UHCCP Medicaid |
$1,260.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,173.89
|
|
|
REV LOWER EXT GRAFT PATCH
|
Facility
|
IP
|
$1,445.00
|
|
|
Service Code
|
HCPCS 35879
|
| Hospital Charge Code |
76101425
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$187.85 |
| Max. Negotiated Rate |
$1,387.20 |
| Rate for Payer: Aetna Commercial |
$1,112.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,127.10
|
| Rate for Payer: Cash Price |
$722.50
|
| Rate for Payer: Cigna Commercial |
$1,199.35
|
| Rate for Payer: First Health Commercial |
$1,372.75
|
| Rate for Payer: Humana Commercial |
$1,228.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,184.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,066.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$433.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,271.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,083.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$289.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$187.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$447.95
|
| Rate for Payer: PHCS Commercial |
$1,387.20
|
| Rate for Payer: United Healthcare All Payer |
$1,271.60
|
|
|
REV LOWER EXT GRAFT PATCH
|
Facility
|
OP
|
$1,445.00
|
|
|
Service Code
|
HCPCS 35879
|
| Hospital Charge Code |
76101425
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$187.85 |
| Max. Negotiated Rate |
$6,652.97 |
| Rate for Payer: Aetna Commercial |
$1,112.65
|
| Rate for Payer: Anthem Medicaid |
$496.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,752.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,127.10
|
| 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 |
$722.50
|
| Rate for Payer: Cash Price |
$722.50
|
| Rate for Payer: Cigna Commercial |
$1,199.35
|
| Rate for Payer: First Health Commercial |
$1,372.75
|
| Rate for Payer: Humana Commercial |
$1,228.25
|
| Rate for Payer: Humana KY Medicaid |
$496.94
|
| Rate for Payer: Humana Medicare Advantage |
$4,752.12
|
| Rate for Payer: Kentucky WC Medicaid |
$501.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,184.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,066.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,702.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$506.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,271.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,083.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$289.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$187.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$447.95
|
| Rate for Payer: PHCS Commercial |
$1,387.20
|
| Rate for Payer: United Healthcare All Payer |
$1,271.60
|
|
|
REV LOWER EXT GRAFT PATCH
|
Professional
|
Both
|
$1,445.00
|
|
|
Service Code
|
HCPCS 35879
|
| Hospital Charge Code |
76101425
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$505.75 |
| Max. Negotiated Rate |
$1,633.14 |
| Rate for Payer: Aetna Commercial |
$1,633.14
|
| Rate for Payer: Anthem Medicaid |
$727.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,445.00
|
| Rate for Payer: Cash Price |
$722.50
|
| Rate for Payer: Cash Price |
$722.50
|
| Rate for Payer: Cigna Commercial |
$1,575.26
|
| Rate for Payer: Healthspan PPO |
$1,605.70
|
| Rate for Payer: Humana Medicaid |
$727.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,275.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$741.57
|
| Rate for Payer: Molina Healthcare Passport |
$727.03
|
| Rate for Payer: Multiplan PHCS |
$867.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,011.50
|
| Rate for Payer: UHCCP Medicaid |
$505.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$734.30
|
|
|
REV LOWER EXT GRAFT PATCH(P
|
Professional
|
Both
|
$1,445.00
|
|
|
Service Code
|
HCPCS 35879
|
| Hospital Charge Code |
761P1425
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$505.75 |
| Max. Negotiated Rate |
$1,633.14 |
| Rate for Payer: Aetna Commercial |
$1,633.14
|
| Rate for Payer: Anthem Medicaid |
$727.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,445.00
|
| Rate for Payer: Cash Price |
$722.50
|
| Rate for Payer: Cash Price |
$722.50
|
| Rate for Payer: Cigna Commercial |
$1,575.26
|
| Rate for Payer: Healthspan PPO |
$1,605.70
|
| Rate for Payer: Humana Medicaid |
$727.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,275.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$741.57
|
| Rate for Payer: Molina Healthcare Passport |
$727.03
|
| Rate for Payer: Multiplan PHCS |
$867.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,011.50
|
| Rate for Payer: UHCCP Medicaid |
$505.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$734.30
|
|
|
REV MASTOID; RSLT RAD MSTDCTMY
|
Professional
|
Both
|
$3,200.00
|
|
|
Service Code
|
HCPCS 69603
|
| Hospital Charge Code |
76102426
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$909.84 |
| Max. Negotiated Rate |
$3,200.00 |
| Rate for Payer: Aetna Commercial |
$1,805.48
|
| Rate for Payer: Anthem Medicaid |
$909.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,200.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cigna Commercial |
$1,827.37
|
| Rate for Payer: Healthspan PPO |
$1,601.55
|
| Rate for Payer: Humana Medicaid |
$909.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,612.95
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$928.04
|
| Rate for Payer: Molina Healthcare Passport |
$909.84
|
| Rate for Payer: Multiplan PHCS |
$1,920.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,240.00
|
| Rate for Payer: UHCCP Medicaid |
$1,120.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$918.94
|
|
|
REV MASTOID; RSLT RAD MSTDCTMY
|
Professional
|
Both
|
$3,200.00
|
|
|
Service Code
|
HCPCS 69603
|
| Hospital Charge Code |
761P2426
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$909.84 |
| Max. Negotiated Rate |
$3,200.00 |
| Rate for Payer: Aetna Commercial |
$1,805.48
|
| Rate for Payer: Anthem Medicaid |
$909.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,200.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cigna Commercial |
$1,827.37
|
| Rate for Payer: Healthspan PPO |
$1,601.55
|
| Rate for Payer: Humana Medicaid |
$909.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,612.95
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$928.04
|
| Rate for Payer: Molina Healthcare Passport |
$909.84
|
| Rate for Payer: Multiplan PHCS |
$1,920.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,240.00
|
| Rate for Payer: UHCCP Medicaid |
$1,120.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$918.94
|
|
