|
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 |
$1,105.64 |
| Rate for Payer: Aetna Commercial |
$1,105.64
|
| Rate for Payer: Ambetter Exchange |
$763.76
|
| Rate for Payer: Anthem Medicaid |
$508.91
|
| Rate for Payer: Buckeye Individual/Medicaid |
$763.76
|
| Rate for Payer: Buckeye Medicare Advantage |
$763.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$916.51
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$763.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$763.76
|
| 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 |
$992.89
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$514.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$763.76
|
|
|
REVISION RECONSTRUCTED BREAS(T
|
Facility
|
IP
|
$7,501.00
|
|
|
Service Code
|
HCPCS 19380
|
| Hospital Charge Code |
761T0323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,250.30 |
| 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 |
$6,000.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,525.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,175.69
|
| Rate for Payer: PHCS Commercial |
$7,200.96
|
| Rate for Payer: United Healthcare All Payer |
$6,600.88
|
|
|
REVISION RECONSTRUCTED BREAS(T
|
Facility
|
OP
|
$7,501.00
|
|
|
Service Code
|
HCPCS 19380
|
| Hospital Charge Code |
761T0323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,579.59 |
| Max. Negotiated Rate |
$8,435.98 |
| Rate for Payer: Aetna Commercial |
$5,775.77
|
| Rate for Payer: Anthem Medicaid |
$2,579.59
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,025.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,850.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,435.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,134.69
|
| 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 |
$6,025.70
|
| 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 |
$7,230.84
|
| 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 |
$6,000.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,525.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,175.69
|
| 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 |
$2,730.30 |
| 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 |
$7,280.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,917.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,279.69
|
| 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 |
$5,460.60 |
| Rate for Payer: Aetna Commercial |
$1,105.64
|
| Rate for Payer: Ambetter Exchange |
$763.76
|
| Rate for Payer: Anthem Medicaid |
$508.91
|
| Rate for Payer: Buckeye Individual/Medicaid |
$763.76
|
| Rate for Payer: Buckeye Medicare Advantage |
$763.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$916.51
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$763.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$763.76
|
| 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 |
$992.89
|
| Rate for Payer: UHCCP Medicaid |
$3,185.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$514.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$763.76
|
|
|
REVISION RECONSTRUCTED BREAST
|
Facility
|
OP
|
$9,101.00
|
|
|
Service Code
|
HCPCS 19380
|
| Hospital Charge Code |
76100323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$3,129.83 |
| 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 |
$6,025.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,098.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,435.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,134.69
|
| 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 |
$6,025.70
|
| 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 |
$7,230.84
|
| 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 |
$7,280.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,917.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,279.69
|
| Rate for Payer: PHCS Commercial |
$8,736.96
|
| Rate for Payer: United Healthcare All Payer |
$8,008.88
|
|
|
REVISION TIBIAL BASEPLATE
|
Facility
|
IP
|
$24,411.88
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,323.56 |
| Max. Negotiated Rate |
$23,435.40 |
| Rate for Payer: Aetna Commercial |
$18,797.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,041.27
|
| Rate for Payer: Cash Price |
$12,205.94
|
| Rate for Payer: Cigna Commercial |
$20,261.86
|
| Rate for Payer: First Health Commercial |
$23,191.29
|
| Rate for Payer: Humana Commercial |
$20,750.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,017.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,015.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,323.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,482.45
|
| Rate for Payer: Ohio Health Group HMO |
$18,308.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,529.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,238.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,844.20
|
| Rate for Payer: PHCS Commercial |
$23,435.40
|
| Rate for Payer: United Healthcare All Payer |
$21,482.45
|
|
|
REVISION TIBIAL BASEPLATE
|
Facility
|
OP
|
$24,411.88
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,323.56 |
| Max. Negotiated Rate |
$23,435.40 |
| Rate for Payer: Aetna Commercial |
$18,797.15
|
| Rate for Payer: Anthem Medicaid |
$8,395.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,041.27
|
| Rate for Payer: Cash Price |
$12,205.94
|
| Rate for Payer: Cigna Commercial |
$20,261.86
|
| Rate for Payer: First Health Commercial |
$23,191.29
|
| Rate for Payer: Humana Commercial |
$20,750.10
|
| Rate for Payer: Humana KY Medicaid |
$8,395.25
|
| Rate for Payer: Kentucky WC Medicaid |
$8,480.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,017.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,015.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,323.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,563.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,482.45
|
| Rate for Payer: Ohio Health Group HMO |
$18,308.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,529.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,238.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,844.20
|
| Rate for Payer: PHCS Commercial |
$23,435.40
|
| Rate for Payer: United Healthcare All Payer |
$21,482.45
|
|
|
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 |
$750.00 |
| Max. Negotiated Rate |
$2,400.00 |
| Rate for Payer: Aetna Commercial |
$1,925.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,950.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$2,075.00
|
| Rate for Payer: First Health Commercial |
$2,375.00
|
| Rate for Payer: Humana Commercial |
$2,125.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,050.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,845.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$750.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,200.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,875.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,175.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,725.00
|
| Rate for Payer: PHCS Commercial |
$2,400.00
|
| Rate for Payer: United Healthcare All Payer |
$2,200.00
|
|
|
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: Ambetter Exchange |
$1,523.91
|
| Rate for Payer: Anthem Medicaid |
$1,303.07
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,523.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,523.91
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,828.69
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$1,523.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,523.91
|
| 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 |
$1,981.08
|
| Rate for Payer: UHCCP Medicaid |
$875.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,316.10
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,523.91
|
|
|
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 |
$859.75 |
| Max. Negotiated Rate |
$16,644.15 |
| Rate for Payer: Aetna Commercial |
$1,925.00
|
| Rate for Payer: Anthem Medicaid |
$859.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$11,888.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,950.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$16,644.15
|
| Rate for Payer: CareSource Just4Me Medicare |
$16,049.72
|
| 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 |
$11,888.68
|
| 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 |
$14,266.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$877.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,200.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,875.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,175.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,725.00
|
| Rate for Payer: PHCS Commercial |
$2,400.00
|
| Rate for Payer: United Healthcare All Payer |
$2,200.00
|
|
|
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: Ambetter Exchange |
$1,523.91
|
| Rate for Payer: Anthem Medicaid |
$1,303.07
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,523.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,523.91
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,828.69
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$1,523.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,523.91
|
| 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 |
$1,981.08
|
| Rate for Payer: UHCCP Medicaid |
$875.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,316.10
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,523.91
|
|
|
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 |
$1,320.00 |
| 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 |
$3,520.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,828.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,036.00
|
| Rate for Payer: PHCS Commercial |
$4,224.00
|
| Rate for Payer: United Healthcare All Payer |
$3,872.00
|
|
|
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 |
$3,390.64 |
| Rate for Payer: Ambetter Exchange |
$1,645.50
|
| Rate for Payer: Anthem Medicaid |
$1,407.95
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,645.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,645.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,974.60
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$1,645.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,645.50
|
| 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 |
$2,139.15
|
| Rate for Payer: UHCCP Medicaid |
$1,540.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,422.03
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,645.50
|
|
|
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 |
$1,320.00 |
| 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 |
$3,520.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,828.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,036.00
|
| 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 |
$3,390.64 |
| Rate for Payer: Ambetter Exchange |
$1,645.50
|
| Rate for Payer: Anthem Medicaid |
$1,407.95
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,645.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,645.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,974.60
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$1,645.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,645.50
|
| 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 |
$2,139.15
|
| Rate for Payer: UHCCP Medicaid |
$1,540.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,422.03
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,645.50
|
|
|
REVIS TIBIAL BASEPLATE
|
Facility
|
OP
|
$24,411.88
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,323.56 |
| Max. Negotiated Rate |
$23,435.40 |
| Rate for Payer: Aetna Commercial |
$18,797.15
|
| Rate for Payer: Anthem Medicaid |
$8,395.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,041.27
|
| Rate for Payer: Cash Price |
$12,205.94
|
| Rate for Payer: Cigna Commercial |
$20,261.86
|
| Rate for Payer: First Health Commercial |
$23,191.29
|
| Rate for Payer: Humana Commercial |
$20,750.10
|
| Rate for Payer: Humana KY Medicaid |
$8,395.25
|
| Rate for Payer: Kentucky WC Medicaid |
$8,480.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,017.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,015.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,323.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,563.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,482.45
|
| Rate for Payer: Ohio Health Group HMO |
$18,308.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,529.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,238.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,844.20
|
| Rate for Payer: PHCS Commercial |
$23,435.40
|
| Rate for Payer: United Healthcare All Payer |
$21,482.45
|
|
|
REVIS TIBIAL BASEPLATE
|
Facility
|
IP
|
$24,411.88
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,323.56 |
| Max. Negotiated Rate |
$23,435.40 |
| Rate for Payer: Aetna Commercial |
$18,797.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,041.27
|
| Rate for Payer: Cash Price |
$12,205.94
|
| Rate for Payer: Cigna Commercial |
$20,261.86
|
| Rate for Payer: First Health Commercial |
$23,191.29
|
| Rate for Payer: Humana Commercial |
$20,750.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,017.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,015.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,323.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,482.45
|
| Rate for Payer: Ohio Health Group HMO |
$18,308.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,529.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21,238.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,844.20
|
| Rate for Payer: PHCS Commercial |
$23,435.40
|
| Rate for Payer: United Healthcare All Payer |
$21,482.45
|
|
|
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 |
$1,347.03 |
| Rate for Payer: Aetna Commercial |
$1,347.03
|
| Rate for Payer: Ambetter Exchange |
$892.94
|
| Rate for Payer: Anthem Medicaid |
$543.16
|
| Rate for Payer: Buckeye Individual/Medicaid |
$892.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$892.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,071.53
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$892.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$892.94
|
| 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 |
$1,160.82
|
| Rate for Payer: UHCCP Medicaid |
$647.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$548.59
|
| Rate for Payer: Wellcare Medicare Advantage |
$892.94
|
|
|
REVIS VOLVUS
|
Facility
|
OP
|
$1,850.00
|
|
|
Service Code
|
HCPCS 44050
|
| Hospital Charge Code |
76101808
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$555.00 |
| 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 |
$1,480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,609.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,276.50
|
| 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 |
$555.00 |
| 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 |
$1,480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,609.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,276.50
|
| 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 |
$1,347.03 |
| Rate for Payer: Aetna Commercial |
$1,347.03
|
| Rate for Payer: Ambetter Exchange |
$892.94
|
| Rate for Payer: Anthem Medicaid |
$543.16
|
| Rate for Payer: Buckeye Individual/Medicaid |
$892.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$892.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,071.53
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$892.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$892.94
|
| 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 |
$1,160.82
|
| Rate for Payer: UHCCP Medicaid |
$647.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$548.59
|
| Rate for Payer: Wellcare Medicare Advantage |
$892.94
|
|
|
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 |
$3,360.00 |
| Rate for Payer: Aetna Commercial |
$2,679.11
|
| Rate for Payer: Ambetter Exchange |
$1,661.61
|
| Rate for Payer: Anthem Medicaid |
$1,526.10
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,661.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,661.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,993.93
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$1,661.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,661.61
|
| 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 |
$2,160.09
|
| Rate for Payer: UHCCP Medicaid |
$1,960.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,541.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,661.61
|
|
|
REV KN ARTHRPLSTY WWOALLOGRAFT
|
Facility
|
OP
|
$5,600.00
|
|
|
Service Code
|
HCPCS 27487
|
| Hospital Charge Code |
76100853
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,680.00 |
| 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 |
$4,480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,872.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,864.00
|
| 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 |
76100852
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,162.27 |
| Max. Negotiated Rate |
$2,286.70 |
| Rate for Payer: Aetna Commercial |
$2,117.10
|
| Rate for Payer: Ambetter Exchange |
$1,333.09
|
| Rate for Payer: Anthem Medicaid |
$1,162.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,333.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,333.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,599.71
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$1,333.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,333.09
|
| 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 |
$1,733.02
|
| Rate for Payer: UHCCP Medicaid |
$1,260.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,173.89
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,333.09
|
|
