|
UPPER EXT VEIN HARVEST 1 SEG
|
Facility
|
OP
|
$650.00
|
|
|
Service Code
|
HCPCS 35500
|
| Hospital Charge Code |
76101391
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$84.50 |
| Max. Negotiated Rate |
$624.00 |
| Rate for Payer: Aetna Commercial |
$500.50
|
| Rate for Payer: Anthem Medicaid |
$223.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$507.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$539.50
|
| Rate for Payer: First Health Commercial |
$617.50
|
| Rate for Payer: Humana Commercial |
$552.50
|
| Rate for Payer: Humana KY Medicaid |
$223.54
|
| Rate for Payer: Kentucky WC Medicaid |
$225.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$533.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$479.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$195.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$228.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$572.00
|
| Rate for Payer: Ohio Health Group HMO |
$487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$84.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$201.50
|
| Rate for Payer: PHCS Commercial |
$624.00
|
| Rate for Payer: United Healthcare All Payer |
$572.00
|
|
|
UPPER EXT VEIN HARVEST 1 SEG
|
Facility
|
IP
|
$650.00
|
|
|
Service Code
|
HCPCS 35500
|
| Hospital Charge Code |
76101391
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$84.50 |
| Max. Negotiated Rate |
$624.00 |
| Rate for Payer: Aetna Commercial |
$500.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$507.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$539.50
|
| Rate for Payer: First Health Commercial |
$617.50
|
| Rate for Payer: Humana Commercial |
$552.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$533.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$479.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$195.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$572.00
|
| Rate for Payer: Ohio Health Group HMO |
$487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$84.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$201.50
|
| Rate for Payer: PHCS Commercial |
$624.00
|
| Rate for Payer: United Healthcare All Payer |
$572.00
|
|
|
UPPER EXT VEIN HARVEST 1 SEG
|
Professional
|
Both
|
$650.00
|
|
|
Service Code
|
HCPCS 35500
|
| Hospital Charge Code |
76101391
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$210.19 |
| Max. Negotiated Rate |
$650.00 |
| Rate for Payer: Aetna Commercial |
$577.11
|
| Rate for Payer: Anthem Medicaid |
$210.19
|
| Rate for Payer: Buckeye Medicare Advantage |
$650.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$545.11
|
| Rate for Payer: Healthspan PPO |
$567.41
|
| Rate for Payer: Humana Medicaid |
$210.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$441.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$214.39
|
| Rate for Payer: Molina Healthcare Passport |
$210.19
|
| Rate for Payer: Multiplan PHCS |
$390.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$455.00
|
| Rate for Payer: UHCCP Medicaid |
$227.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$212.29
|
|
|
UPPER EXT VEIN HARVEST 1 SEG(P
|
Professional
|
Both
|
$650.00
|
|
|
Service Code
|
HCPCS 35500
|
| Hospital Charge Code |
761P1391
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$210.19 |
| Max. Negotiated Rate |
$650.00 |
| Rate for Payer: Aetna Commercial |
$577.11
|
| Rate for Payer: Anthem Medicaid |
$210.19
|
| Rate for Payer: Buckeye Medicare Advantage |
$650.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$545.11
|
| Rate for Payer: Healthspan PPO |
$567.41
|
| Rate for Payer: Humana Medicaid |
$210.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$441.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$214.39
|
| Rate for Payer: Molina Healthcare Passport |
$210.19
|
| Rate for Payer: Multiplan PHCS |
$390.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$455.00
|
| Rate for Payer: UHCCP Medicaid |
$227.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$212.29
|
|
|
UPPER GASTROINTESTINAL ENDO/BX
|
Facility
|
OP
|
$550.00
|
|
|
Service Code
|
HCPCS 43239
|
| Hospital Charge Code |
76101738
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$71.50 |
| Max. Negotiated Rate |
$1,097.45 |
| Rate for Payer: Aetna Commercial |
$423.50
|
| Rate for Payer: Anthem Medicaid |
$189.14
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$783.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$429.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,097.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,058.25
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$456.50
|
| Rate for Payer: First Health Commercial |
$522.50
|
| Rate for Payer: Humana Commercial |
$467.50
|
| Rate for Payer: Humana KY Medicaid |
$189.14
|
| Rate for Payer: Humana Medicare Advantage |
$783.89
|
| Rate for Payer: Kentucky WC Medicaid |
$191.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$451.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$405.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$940.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$192.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$484.00
|
| Rate for Payer: Ohio Health Group HMO |
$412.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$110.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$71.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$170.50
|
| Rate for Payer: PHCS Commercial |
$528.00
|
| Rate for Payer: United Healthcare All Payer |
$484.00
|
|
|
UPPER GASTROINTESTINAL ENDO/BX
|
Facility
|
IP
|
$550.00
|
|
|
Service Code
|
HCPCS 43239
|
| Hospital Charge Code |
76101738
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$71.50 |
| Max. Negotiated Rate |
$528.00 |
| Rate for Payer: Aetna Commercial |
$423.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$429.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$456.50
|
| Rate for Payer: First Health Commercial |
$522.50
|
| Rate for Payer: Humana Commercial |
$467.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$451.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$405.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$165.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$484.00
|
| Rate for Payer: Ohio Health Group HMO |
$412.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$110.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$71.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$170.50
|
| Rate for Payer: PHCS Commercial |
$528.00
|
| Rate for Payer: United Healthcare All Payer |
$484.00
|
|
|
UPPER GASTROINTESTINAL ENDO/BX
|
Professional
|
Both
|
$550.00
|
|
|
Service Code
|
HCPCS 43239
|
| Hospital Charge Code |
76101738
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$139.81 |
| Max. Negotiated Rate |
$550.00 |
| Rate for Payer: Aetna Commercial |
$261.64
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$139.81
|
| Rate for Payer: Anthem Medicaid |
$179.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$550.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$235.94
|
| Rate for Payer: Healthspan PPO |
$417.88
|
| Rate for Payer: Humana Medicaid |
$179.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$223.94
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$182.80
|
| Rate for Payer: Molina Healthcare Passport |
$179.22
|
| Rate for Payer: Multiplan PHCS |
$330.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$385.00
|
| Rate for Payer: UHCCP Medicaid |
$146.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$181.01
|
|
|
UPPER GASTROINTESTINAL ENDO/BX
|
Professional
|
Both
|
$550.00
|
|
|
Service Code
|
HCPCS 43239
|
| Hospital Charge Code |
761P1738
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$139.81 |
| Max. Negotiated Rate |
$550.00 |
| Rate for Payer: Aetna Commercial |
$261.64
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$139.81
|
| Rate for Payer: Anthem Medicaid |
$179.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$550.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$235.94
|
| Rate for Payer: Healthspan PPO |
$417.88
|
| Rate for Payer: Humana Medicaid |
$179.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$223.94
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$182.80
|
| Rate for Payer: Molina Healthcare Passport |
$179.22
|
| Rate for Payer: Multiplan PHCS |
$330.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$385.00
|
| Rate for Payer: UHCCP Medicaid |
$146.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$181.01
|
|
|
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC
|
Facility
|
IP
|
$19,181.55
|
|
|
Service Code
|
MSDRG 256
|
| Min. Negotiated Rate |
$13,016.05 |
| Max. Negotiated Rate |
$19,181.55 |
| Rate for Payer: Anthem Medicaid |
$13,016.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$13,701.11
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$19,181.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$18,496.50
|
| Rate for Payer: Humana KY Medicaid |
$13,016.05
|
| Rate for Payer: Humana Medicare Advantage |
$13,701.11
|
| Rate for Payer: Kentucky WC Medicaid |
$13,146.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16,441.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,276.38
|
|
|
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC
|
Facility
|
IP
|
$32,139.65
|
|
|
Service Code
|
MSDRG 255
|
| Min. Negotiated Rate |
$21,809.05 |
| Max. Negotiated Rate |
$32,139.65 |
| Rate for Payer: Anthem Medicaid |
$21,809.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$22,956.89
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$32,139.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$30,991.80
|
| Rate for Payer: Humana KY Medicaid |
$21,809.05
|
| Rate for Payer: Humana Medicare Advantage |
$22,956.89
|
| Rate for Payer: Kentucky WC Medicaid |
$22,027.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27,548.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$22,245.23
|
|
|
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$11,592.92
|
|
|
Service Code
|
MSDRG 257
|
| Min. Negotiated Rate |
$7,866.63 |
| Max. Negotiated Rate |
$11,592.92 |
| Rate for Payer: Anthem Medicaid |
$7,866.63
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8,280.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11,592.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$11,178.89
|
| Rate for Payer: Humana KY Medicaid |
$7,866.63
|
| Rate for Payer: Humana Medicare Advantage |
$8,280.66
|
| Rate for Payer: Kentucky WC Medicaid |
$7,945.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,936.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,023.96
|
|
|
Upper Lip Laser Hair Removal
|
Professional
|
Both
|
$100.00
|
|
| Hospital Charge Code |
22200179
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$100.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$70.00
|
| Rate for Payer: UHCCP Medicaid |
$35.00
|
|
|
Upper Lip LsrHairRem-PP#1 50%
|
Professional
|
Both
|
$129.00
|
|
| Hospital Charge Code |
22200343
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$45.15 |
| Max. Negotiated Rate |
$129.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$129.00
|
| Rate for Payer: Cash Price |
$64.50
|
| Rate for Payer: Multiplan PHCS |
$77.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$90.30
|
| Rate for Payer: UHCCP Medicaid |
$45.15
|
|
|
UPPR GI SCOPE W/SUBMUC INJ
|
Professional
|
Both
|
$925.00
|
|
|
Service Code
|
HCPCS 43236
|
| Hospital Charge Code |
76101737
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$120.05 |
| Max. Negotiated Rate |
$925.00 |
| Rate for Payer: Aetna Commercial |
$268.09
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$139.12
|
| Rate for Payer: Anthem Medicaid |
$120.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$925.00
|
| Rate for Payer: Cash Price |
$462.50
|
| Rate for Payer: Cash Price |
$462.50
|
| Rate for Payer: Cigna Commercial |
$240.51
|
| Rate for Payer: Healthspan PPO |
$448.15
|
| Rate for Payer: Humana Medicaid |
$120.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$229.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$122.45
|
| Rate for Payer: Molina Healthcare Passport |
$120.05
|
| Rate for Payer: Multiplan PHCS |
$555.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$647.50
|
| Rate for Payer: UHCCP Medicaid |
$146.08
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$121.25
|
|
|
UPPR GI SCOPE W/SUBMUC INJ
|
Facility
|
OP
|
$925.00
|
|
|
Service Code
|
HCPCS 43236
|
| Hospital Charge Code |
76101737
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$120.25 |
| Max. Negotiated Rate |
$1,097.45 |
| Rate for Payer: Aetna Commercial |
$712.25
|
| Rate for Payer: Anthem Medicaid |
$318.11
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$783.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$721.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,097.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,058.25
|
| Rate for Payer: Cash Price |
$462.50
|
| Rate for Payer: Cash Price |
$462.50
|
| Rate for Payer: Cigna Commercial |
$767.75
|
| Rate for Payer: First Health Commercial |
$878.75
|
| Rate for Payer: Humana Commercial |
$786.25
|
| Rate for Payer: Humana KY Medicaid |
$318.11
|
| Rate for Payer: Humana Medicare Advantage |
$783.89
|
| Rate for Payer: Kentucky WC Medicaid |
$321.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$758.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$682.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$940.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$324.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$814.00
|
| Rate for Payer: Ohio Health Group HMO |
$693.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$185.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$120.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$286.75
|
| Rate for Payer: PHCS Commercial |
$888.00
|
| Rate for Payer: United Healthcare All Payer |
$814.00
|
|
|
UPPR GI SCOPE W/SUBMUC INJ
|
Facility
|
IP
|
$925.00
|
|
|
Service Code
|
HCPCS 43236
|
| Hospital Charge Code |
76101737
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$120.25 |
| Max. Negotiated Rate |
$888.00 |
| Rate for Payer: Aetna Commercial |
$712.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$721.50
|
| Rate for Payer: Cash Price |
$462.50
|
| Rate for Payer: Cigna Commercial |
$767.75
|
| Rate for Payer: First Health Commercial |
$878.75
|
| Rate for Payer: Humana Commercial |
$786.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$758.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$682.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$277.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$814.00
|
| Rate for Payer: Ohio Health Group HMO |
$693.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$185.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$120.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$286.75
|
| Rate for Payer: PHCS Commercial |
$888.00
|
| Rate for Payer: United Healthcare All Payer |
$814.00
|
|
|
UPPR GI SCOPE W/SUBMUC INJ(P
|
Professional
|
Both
|
$925.00
|
|
|
Service Code
|
HCPCS 43236
|
| Hospital Charge Code |
761P1737
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$120.05 |
| Max. Negotiated Rate |
$925.00 |
| Rate for Payer: Aetna Commercial |
$268.09
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$139.12
|
| Rate for Payer: Anthem Medicaid |
$120.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$925.00
|
| Rate for Payer: Cash Price |
$462.50
|
| Rate for Payer: Cash Price |
$462.50
|
| Rate for Payer: Cigna Commercial |
$240.51
|
| Rate for Payer: Healthspan PPO |
$448.15
|
| Rate for Payer: Humana Medicaid |
$120.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$229.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$122.45
|
| Rate for Payer: Molina Healthcare Passport |
$120.05
|
| Rate for Payer: Multiplan PHCS |
$555.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$647.50
|
| Rate for Payer: UHCCP Medicaid |
$146.08
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$121.25
|
|
|
Uppr Lip LsrHairRem-PP#2/3 25%
|
Professional
|
Both
|
$63.00
|
|
| Hospital Charge Code |
22200459
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$22.05 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$63.00
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Multiplan PHCS |
$37.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$44.10
|
| Rate for Payer: UHCCP Medicaid |
$22.05
|
|
|
UPR/L XTREMITY ART 2 LEVELS
|
Facility
|
OP
|
$653.00
|
|
|
Service Code
|
HCPCS 93922
|
| Hospital Charge Code |
92100004
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$84.89 |
| Max. Negotiated Rate |
$626.88 |
| Rate for Payer: Aetna Commercial |
$502.81
|
| Rate for Payer: Anthem Medicaid |
$224.57
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$509.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
| Rate for Payer: Cash Price |
$326.50
|
| Rate for Payer: Cash Price |
$326.50
|
| Rate for Payer: Cigna Commercial |
$541.99
|
| Rate for Payer: First Health Commercial |
$620.35
|
| Rate for Payer: Humana Commercial |
$555.05
|
| Rate for Payer: Humana KY Medicaid |
$224.57
|
| Rate for Payer: Humana Medicare Advantage |
$110.46
|
| Rate for Payer: Kentucky WC Medicaid |
$226.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$535.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$481.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$229.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$574.64
|
| Rate for Payer: Ohio Health Group HMO |
$489.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$84.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$202.43
|
| Rate for Payer: PHCS Commercial |
$626.88
|
| Rate for Payer: United Healthcare All Payer |
$574.64
|
|
|
UPR/L XTREMITY ART 2 LEVELS
|
Facility
|
OP
|
$565.00
|
|
|
Service Code
|
HCPCS 93922
|
| Hospital Charge Code |
92000007
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$73.45 |
| Max. Negotiated Rate |
$542.40 |
| Rate for Payer: Aetna Commercial |
$435.05
|
| Rate for Payer: Anthem Medicaid |
$194.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$440.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
| Rate for Payer: Cash Price |
$282.50
|
| Rate for Payer: Cash Price |
$282.50
|
| Rate for Payer: Cigna Commercial |
$468.95
|
| Rate for Payer: First Health Commercial |
$536.75
|
| Rate for Payer: Humana Commercial |
$480.25
|
| Rate for Payer: Humana KY Medicaid |
$194.30
|
| Rate for Payer: Humana Medicare Advantage |
$110.46
|
| Rate for Payer: Kentucky WC Medicaid |
$196.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$463.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$416.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$198.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$497.20
|
| Rate for Payer: Ohio Health Group HMO |
$423.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$113.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$175.15
|
| Rate for Payer: PHCS Commercial |
$542.40
|
| Rate for Payer: United Healthcare All Payer |
$497.20
|
|
|
UPR/L XTREMITY ART 2 LEVELS
|
Facility
|
IP
|
$565.00
|
|
|
Service Code
|
HCPCS 93922
|
| Hospital Charge Code |
92000007
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$73.45 |
| Max. Negotiated Rate |
$542.40 |
| Rate for Payer: Aetna Commercial |
$435.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$440.70
|
| Rate for Payer: Cash Price |
$282.50
|
| Rate for Payer: Cigna Commercial |
$468.95
|
| Rate for Payer: First Health Commercial |
$536.75
|
| Rate for Payer: Humana Commercial |
$480.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$463.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$416.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$169.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$497.20
|
| Rate for Payer: Ohio Health Group HMO |
$423.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$113.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$175.15
|
| Rate for Payer: PHCS Commercial |
$542.40
|
| Rate for Payer: United Healthcare All Payer |
$497.20
|
|
|
UPR/L XTREMITY ART 2 LEVELS
|
Professional
|
Both
|
$653.00
|
|
|
Service Code
|
HCPCS 93922
|
| Hospital Charge Code |
92100004
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$16.22 |
| Max. Negotiated Rate |
$653.00 |
| Rate for Payer: Aetna Commercial |
$182.46
|
| Rate for Payer: Anthem Medicaid |
$48.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$653.00
|
| Rate for Payer: Cash Price |
$326.50
|
| Rate for Payer: Cash Price |
$326.50
|
| Rate for Payer: Cigna Commercial |
$151.98
|
| Rate for Payer: Healthspan PPO |
$194.91
|
| Rate for Payer: Humana Medicaid |
$48.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$16.22
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$49.95
|
| Rate for Payer: Molina Healthcare Passport |
$48.97
|
| Rate for Payer: Multiplan PHCS |
$391.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$457.10
|
| Rate for Payer: UHCCP Medicaid |
$228.55
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$49.46
|
|
|
UPR/L XTREMITY ART 2 LEVELS
|
Facility
|
IP
|
$653.00
|
|
|
Service Code
|
HCPCS 93922
|
| Hospital Charge Code |
92100004
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$84.89 |
| Max. Negotiated Rate |
$626.88 |
| Rate for Payer: Aetna Commercial |
$502.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$509.34
|
| Rate for Payer: Cash Price |
$326.50
|
| Rate for Payer: Cigna Commercial |
$541.99
|
| Rate for Payer: First Health Commercial |
$620.35
|
| Rate for Payer: Humana Commercial |
$555.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$535.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$481.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$195.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$574.64
|
| Rate for Payer: Ohio Health Group HMO |
$489.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$84.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$202.43
|
| Rate for Payer: PHCS Commercial |
$626.88
|
| Rate for Payer: United Healthcare All Payer |
$574.64
|
|
|
UPR/L XTREMITY ART 2 LEVELS(P
|
Professional
|
Both
|
$88.00
|
|
|
Service Code
|
HCPCS 93922
|
| Hospital Charge Code |
921P0004
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$16.22 |
| Max. Negotiated Rate |
$194.91 |
| Rate for Payer: Aetna Commercial |
$182.46
|
| Rate for Payer: Anthem Medicaid |
$48.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$88.00
|
| Rate for Payer: Cash Price |
$44.00
|
| Rate for Payer: Cash Price |
$44.00
|
| Rate for Payer: Cigna Commercial |
$151.98
|
| Rate for Payer: Healthspan PPO |
$194.91
|
| Rate for Payer: Humana Medicaid |
$48.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$16.22
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$49.95
|
| Rate for Payer: Molina Healthcare Passport |
$48.97
|
| Rate for Payer: Multiplan PHCS |
$52.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$61.60
|
| Rate for Payer: UHCCP Medicaid |
$30.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$49.46
|
|
|
UPR/L XTREMITY ART 2 LEVELS(T
|
Facility
|
OP
|
$565.00
|
|
|
Service Code
|
HCPCS 93922
|
| Hospital Charge Code |
921T0004
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$73.45 |
| Max. Negotiated Rate |
$542.40 |
| Rate for Payer: Aetna Commercial |
$435.05
|
| Rate for Payer: Anthem Medicaid |
$194.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$440.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
| Rate for Payer: Cash Price |
$282.50
|
| Rate for Payer: Cash Price |
$282.50
|
| Rate for Payer: Cigna Commercial |
$468.95
|
| Rate for Payer: First Health Commercial |
$536.75
|
| Rate for Payer: Humana Commercial |
$480.25
|
| Rate for Payer: Humana KY Medicaid |
$194.30
|
| Rate for Payer: Humana Medicare Advantage |
$110.46
|
| Rate for Payer: Kentucky WC Medicaid |
$196.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$463.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$416.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$198.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$497.20
|
| Rate for Payer: Ohio Health Group HMO |
$423.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$113.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$175.15
|
| Rate for Payer: PHCS Commercial |
$542.40
|
| Rate for Payer: United Healthcare All Payer |
$497.20
|
|
