|
REVISION OF RECONSTRUCTED BREAST (EG, SIGNIFICANT REMOVAL OF TISSUE, RE-ADVANCEMENT AND/OR RE-INSET OF FLAPS IN AUTOLOGOUS RECONSTRUCTION OR SIGNIFICANT CAPSULAR REVISION COMBINED WITH SOFT TISSUE EXCISION IN IMPLANT-BASED RECONSTRUCTION)
|
Facility
|
OP
|
$8,435.98
|
|
|
Service Code
|
CPT 19380
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,025.70 |
| Max. Negotiated Rate |
$8,435.98 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,025.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,435.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,134.69
|
| Rate for Payer: Humana Medicare Advantage |
$6,025.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,230.84
|
|
|
REVISION OF SCROTUM
|
Professional
|
Both
|
$865.00
|
|
|
Service Code
|
HCPCS 55175
|
| Hospital Charge Code |
76103035
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$276.76 |
| Max. Negotiated Rate |
$580.50 |
| Rate for Payer: Aetna Commercial |
$580.50
|
| Rate for Payer: Ambetter Exchange |
$346.54
|
| Rate for Payer: Anthem Medicaid |
$276.76
|
| Rate for Payer: Buckeye Individual/Medicaid |
$346.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$346.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$415.85
|
| Rate for Payer: Cash Price |
$432.50
|
| Rate for Payer: Cash Price |
$432.50
|
| Rate for Payer: Cigna Commercial |
$512.11
|
| Rate for Payer: Healthspan PPO |
$562.08
|
| Rate for Payer: Humana Medicaid |
$276.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$494.18
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$346.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$346.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$282.30
|
| Rate for Payer: Molina Healthcare Passport |
$276.76
|
| Rate for Payer: Multiplan PHCS |
$519.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$450.50
|
| Rate for Payer: UHCCP Medicaid |
$302.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$279.53
|
| Rate for Payer: Wellcare Medicare Advantage |
$346.54
|
|
|
REVISION OF TIPS
|
Facility
|
IP
|
$585.00
|
|
|
Service Code
|
HCPCS 37183
|
| Hospital Charge Code |
76101524
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$175.50 |
| Max. Negotiated Rate |
$561.60 |
| Rate for Payer: Aetna Commercial |
$450.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$456.30
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Cigna Commercial |
$485.55
|
| Rate for Payer: First Health Commercial |
$555.75
|
| Rate for Payer: Humana Commercial |
$497.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$479.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$431.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$175.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$514.80
|
| Rate for Payer: Ohio Health Group HMO |
$438.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$468.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$508.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$403.65
|
| Rate for Payer: PHCS Commercial |
$561.60
|
| Rate for Payer: United Healthcare All Payer |
$514.80
|
|
|
REVISION OF TIPS
|
Facility
|
OP
|
$585.00
|
|
|
Service Code
|
HCPCS 37183
|
| Hospital Charge Code |
76101524
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$201.18 |
| Max. Negotiated Rate |
$7,375.33 |
| Rate for Payer: Aetna Commercial |
$450.45
|
| Rate for Payer: Anthem Medicaid |
$201.18
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,268.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$456.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,375.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,111.92
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Cigna Commercial |
$485.55
|
| Rate for Payer: First Health Commercial |
$555.75
|
| Rate for Payer: Humana Commercial |
$497.25
|
| Rate for Payer: Humana KY Medicaid |
$201.18
|
| Rate for Payer: Humana Medicare Advantage |
$5,268.09
|
| Rate for Payer: Kentucky WC Medicaid |
$203.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$479.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$431.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,321.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$205.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$514.80
|
| Rate for Payer: Ohio Health Group HMO |
$438.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$468.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$508.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$403.65
|
| Rate for Payer: PHCS Commercial |
$561.60
|
| Rate for Payer: United Healthcare All Payer |
$514.80
|
|
|
REVISION OF TIPS
|
Professional
|
Both
|
$585.00
|
|
|
Service Code
|
HCPCS 37183
|
| Hospital Charge Code |
76101524
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$243.96 |
| Max. Negotiated Rate |
$672.44 |
| Rate for Payer: Aetna Commercial |
$672.44
|
| Rate for Payer: Ambetter Exchange |
$347.27
|
| 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 Individual/Medicaid |
$347.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$347.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$416.72
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$347.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$347.27
|
| 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 |
$451.45
|
| Rate for Payer: UHCCP Medicaid |
$256.16
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$324.81
|
| Rate for Payer: Wellcare Medicare Advantage |
$347.27
|
|
|
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: Ambetter Exchange |
$347.27
|
| 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 Individual/Medicaid |
$347.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$347.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$416.72
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$347.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$347.27
|
| 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 |
$451.45
|
| Rate for Payer: UHCCP Medicaid |
$256.16
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$324.81
|
| Rate for Payer: Wellcare Medicare Advantage |
$347.27
|
|
|
REVISION OF TRACH/BRONCH STENT
|
Facility
|
IP
|
$502.00
|
|
|
Service Code
|
HCPCS 31638
|
| Hospital Charge Code |
41000048
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$150.60 |
| Max. Negotiated Rate |
$481.92 |
| Rate for Payer: Aetna Commercial |
$386.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$391.56
|
| Rate for Payer: Cash Price |
$251.00
|
| Rate for Payer: Cigna Commercial |
$416.66
|
| Rate for Payer: First Health Commercial |
$476.90
|
| Rate for Payer: Humana Commercial |
$426.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$411.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$370.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$150.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$441.76
|
| Rate for Payer: Ohio Health Group HMO |
$376.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$401.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$436.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$346.38
|
| Rate for Payer: PHCS Commercial |
$481.92
|
| Rate for Payer: United Healthcare All Payer |
$441.76
|
|
|
REVISION OF TRACH/BRONCH STENT
|
Facility
|
OP
|
$502.00
|
|
|
Service Code
|
HCPCS 31638
|
| Hospital Charge Code |
41000048
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$172.64 |
| Max. Negotiated Rate |
$8,954.71 |
| Rate for Payer: Aetna Commercial |
$386.54
|
| Rate for Payer: Anthem Medicaid |
$172.64
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,396.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$391.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,954.71
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,634.90
|
| Rate for Payer: Cash Price |
$251.00
|
| Rate for Payer: Cash Price |
$251.00
|
| Rate for Payer: Cigna Commercial |
$416.66
|
| Rate for Payer: First Health Commercial |
$476.90
|
| Rate for Payer: Humana Commercial |
$426.70
|
| Rate for Payer: Humana KY Medicaid |
$172.64
|
| Rate for Payer: Humana Medicare Advantage |
$6,396.22
|
| Rate for Payer: Kentucky WC Medicaid |
$174.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$411.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$370.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,675.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$176.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$441.76
|
| Rate for Payer: Ohio Health Group HMO |
$376.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$401.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$436.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$346.38
|
| Rate for Payer: PHCS Commercial |
$481.92
|
| Rate for Payer: United Healthcare All Payer |
$441.76
|
|
|
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 |
$419.50 |
| Rate for Payer: Aetna Commercial |
$419.50
|
| Rate for Payer: Ambetter Exchange |
$229.37
|
| Rate for Payer: Anthem Medicaid |
$200.75
|
| Rate for Payer: Buckeye Individual/Medicaid |
$229.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$229.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$275.24
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$229.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$229.37
|
| 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 |
$298.18
|
| Rate for Payer: UHCCP Medicaid |
$175.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$202.76
|
| Rate for Payer: Wellcare Medicare Advantage |
$229.37
|
|
|
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 |
$419.50 |
| Rate for Payer: Aetna Commercial |
$419.50
|
| Rate for Payer: Ambetter Exchange |
$229.37
|
| Rate for Payer: Anthem Medicaid |
$200.75
|
| Rate for Payer: Buckeye Individual/Medicaid |
$229.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$229.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$275.24
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$229.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$229.37
|
| 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 |
$298.18
|
| Rate for Payer: UHCCP Medicaid |
$175.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$202.76
|
| Rate for Payer: Wellcare Medicare Advantage |
$229.37
|
|
|
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 |
$659.20 |
| Rate for Payer: Aetna Commercial |
$659.20
|
| Rate for Payer: Ambetter Exchange |
$388.42
|
| Rate for Payer: Anthem Medicaid |
$247.90
|
| Rate for Payer: Buckeye Individual/Medicaid |
$388.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$388.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$466.10
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$388.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$388.42
|
| 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 |
$504.95
|
| Rate for Payer: UHCCP Medicaid |
$341.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$250.38
|
| Rate for Payer: Wellcare Medicare Advantage |
$388.42
|
|
|
REVISION OF URETHRA
|
Facility
|
OP
|
$975.00
|
|
|
Service Code
|
HCPCS 53450
|
| Hospital Charge Code |
76102935
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$335.30 |
| Max. Negotiated Rate |
$4,461.49 |
| Rate for Payer: Aetna Commercial |
$750.75
|
| Rate for Payer: Anthem Medicaid |
$335.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,186.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$760.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,461.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,302.15
|
| 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 |
$3,186.78
|
| Rate for Payer: Kentucky WC Medicaid |
$338.71
|
| 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 |
$3,824.14
|
| 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 |
$780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$848.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$672.75
|
| Rate for Payer: PHCS Commercial |
$936.00
|
| Rate for Payer: United Healthcare All Payer |
$858.00
|
|
|
REVISION OF URETHRA
|
Facility
|
IP
|
$975.00
|
|
|
Service Code
|
HCPCS 53450
|
| Hospital Charge Code |
76102935
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$292.50 |
| 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 |
$780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$848.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$672.75
|
| Rate for Payer: PHCS Commercial |
$936.00
|
| Rate for Payer: United Healthcare All Payer |
$858.00
|
|
|
REVISION - OPEN - ARTERIOVEN
|
Facility
|
IP
|
$1,350.00
|
|
|
Service Code
|
HCPCS 36832
|
| Hospital Charge Code |
76101511
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$405.00 |
| 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 |
$1,080.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,174.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$931.50
|
| Rate for Payer: PHCS Commercial |
$1,296.00
|
| Rate for Payer: United Healthcare All Payer |
$1,188.00
|
|
|
REVISION - OPEN - ARTERIOVEN
|
Professional
|
Both
|
$1,017.00
|
|
|
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: Ambetter Exchange |
$755.28
|
| Rate for Payer: Anthem Medicaid |
$492.02
|
| Rate for Payer: Buckeye Individual/Medicaid |
$755.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$755.28
|
| Rate for Payer: CareSource Just4Me Medicare |
$906.34
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$755.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$755.28
|
| 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 |
$981.86
|
| Rate for Payer: UHCCP Medicaid |
$355.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$496.94
|
| Rate for Payer: Wellcare Medicare Advantage |
$755.28
|
|
|
REVISION - OPEN - ARTERIOVEN
|
Facility
|
OP
|
$1,017.00
|
|
|
Service Code
|
HCPCS 36833
|
| Hospital Charge Code |
76101512
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$349.75 |
| Max. Negotiated Rate |
$6,992.66 |
| Rate for Payer: Aetna Commercial |
$783.09
|
| Rate for Payer: Anthem Medicaid |
$349.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,994.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$793.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,992.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,742.93
|
| Rate for Payer: Cash Price |
$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 |
$4,994.76
|
| 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 |
$5,993.71
|
| 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 |
$813.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$884.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$701.73
|
| Rate for Payer: PHCS Commercial |
$976.32
|
| Rate for Payer: United Healthcare All Payer |
$894.96
|
|
|
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 |
$929.16 |
| Rate for Payer: Aetna Commercial |
$929.16
|
| Rate for Payer: Ambetter Exchange |
$707.50
|
| Rate for Payer: Anthem Medicaid |
$429.83
|
| Rate for Payer: Buckeye Individual/Medicaid |
$707.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$707.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$849.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$707.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$707.50
|
| 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 |
$919.75
|
| Rate for Payer: UHCCP Medicaid |
$472.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$434.13
|
| Rate for Payer: Wellcare Medicare Advantage |
$707.50
|
|
|
REVISION - OPEN - ARTERIOVEN
|
Facility
|
IP
|
$1,017.00
|
|
|
Service Code
|
HCPCS 36833
|
| Hospital Charge Code |
76101512
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$305.10 |
| 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 |
$813.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$884.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$701.73
|
| Rate for Payer: PHCS Commercial |
$976.32
|
| Rate for Payer: United Healthcare All Payer |
$894.96
|
|
|
REVISION - OPEN - ARTERIOVEN
|
Facility
|
OP
|
$1,350.00
|
|
|
Service Code
|
HCPCS 36832
|
| Hospital Charge Code |
76101511
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$464.26 |
| Max. Negotiated Rate |
$6,992.66 |
| Rate for Payer: Aetna Commercial |
$1,039.50
|
| Rate for Payer: Anthem Medicaid |
$464.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,994.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,053.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,992.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,742.93
|
| Rate for Payer: Cash Price |
$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 |
$4,994.76
|
| 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 |
$5,993.71
|
| 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 |
$1,080.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,174.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$931.50
|
| 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
|
$6,992.66
|
|
|
Service Code
|
CPT 36832
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,994.76 |
| Max. Negotiated Rate |
$6,992.66 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,994.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,992.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,742.93
|
| Rate for Payer: Humana Medicare Advantage |
$4,994.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,993.71
|
|
|
REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$6,992.66
|
|
|
Service Code
|
CPT 36833
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,994.76 |
| Max. Negotiated Rate |
$6,992.66 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,994.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,992.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,742.93
|
| Rate for Payer: Humana Medicare Advantage |
$4,994.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,993.71
|
|
|
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 |
$929.16 |
| Rate for Payer: Aetna Commercial |
$929.16
|
| Rate for Payer: Ambetter Exchange |
$707.50
|
| Rate for Payer: Anthem Medicaid |
$429.83
|
| Rate for Payer: Buckeye Individual/Medicaid |
$707.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$707.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$849.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$707.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$707.50
|
| 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 |
$919.75
|
| Rate for Payer: UHCCP Medicaid |
$472.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$434.13
|
| Rate for Payer: Wellcare Medicare Advantage |
$707.50
|
|
|
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: Ambetter Exchange |
$755.28
|
| Rate for Payer: Anthem Medicaid |
$492.02
|
| Rate for Payer: Buckeye Individual/Medicaid |
$755.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$755.28
|
| Rate for Payer: CareSource Just4Me Medicare |
$906.34
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$755.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$755.28
|
| 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 |
$981.86
|
| Rate for Payer: UHCCP Medicaid |
$355.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$496.94
|
| Rate for Payer: Wellcare Medicare Advantage |
$755.28
|
|
|
REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY
|
Facility
|
OP
|
$4,448.61
|
|
|
Service Code
|
CPT 64585
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,177.58 |
| Max. Negotiated Rate |
$4,448.61 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,177.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,448.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,289.73
|
| Rate for Payer: Humana Medicare Advantage |
$3,177.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,813.10
|
|
|
REVISION OR REMOVAL OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY
|
Facility
|
OP
|
$4,448.61
|
|
|
Service Code
|
CPT 64595
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,177.58 |
| Max. Negotiated Rate |
$4,448.61 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,177.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,448.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,289.73
|
| Rate for Payer: Humana Medicare Advantage |
$3,177.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,813.10
|
|
