|
UNLISTED PROCEDURE, STOMACH
|
Facility
|
OP
|
$1,212.81
|
|
|
Service Code
|
CPT 43999
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$866.29 |
| Max. Negotiated Rate |
$1,212.81 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$866.29
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,212.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,169.49
|
| Rate for Payer: Humana Medicare Advantage |
$866.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,039.55
|
|
|
UNLISTED PROCEDURE, VASCULAR SURGERY
|
Facility
|
OP
|
$799.76
|
|
|
Service Code
|
CPT 37799
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$571.26 |
| Max. Negotiated Rate |
$799.76 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$571.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$799.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$771.20
|
| Rate for Payer: Humana Medicare Advantage |
$571.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$685.51
|
|
|
UNRETURNED HOLTER MONITOR FEE
|
Facility
|
OP
|
$1,832.00
|
|
| Hospital Charge Code |
22200716
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$549.60 |
| Max. Negotiated Rate |
$1,758.72 |
| Rate for Payer: Aetna Commercial |
$1,410.64
|
| Rate for Payer: Anthem Medicaid |
$630.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,428.96
|
| Rate for Payer: Cash Price |
$916.00
|
| Rate for Payer: Cigna Commercial |
$1,520.56
|
| Rate for Payer: First Health Commercial |
$1,740.40
|
| Rate for Payer: Humana Commercial |
$1,557.20
|
| Rate for Payer: Humana KY Medicaid |
$630.02
|
| Rate for Payer: Kentucky WC Medicaid |
$636.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,502.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,352.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$549.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$642.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,612.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,374.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,465.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,593.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,264.08
|
| Rate for Payer: PHCS Commercial |
$1,758.72
|
| Rate for Payer: United Healthcare All Payer |
$1,612.16
|
|
|
UNRETURNED HOLTER MONITOR FEE
|
Facility
|
IP
|
$1,832.00
|
|
| Hospital Charge Code |
22200716
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$549.60 |
| Max. Negotiated Rate |
$1,758.72 |
| Rate for Payer: Aetna Commercial |
$1,410.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,428.96
|
| Rate for Payer: Cash Price |
$916.00
|
| Rate for Payer: Cigna Commercial |
$1,520.56
|
| Rate for Payer: First Health Commercial |
$1,740.40
|
| Rate for Payer: Humana Commercial |
$1,557.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,502.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,352.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$549.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,612.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,374.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,465.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,593.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,264.08
|
| Rate for Payer: PHCS Commercial |
$1,758.72
|
| Rate for Payer: United Healthcare All Payer |
$1,612.16
|
|
|
UNVRSL C-TAPR+0MM ADJSTMT SLV
|
Facility
|
OP
|
$11,133.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,340.08 |
| Max. Negotiated Rate |
$10,688.26 |
| Rate for Payer: Aetna Commercial |
$8,572.87
|
| Rate for Payer: Anthem Medicaid |
$3,828.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,684.21
|
| Rate for Payer: Cash Price |
$5,566.80
|
| Rate for Payer: Cigna Commercial |
$9,240.89
|
| Rate for Payer: First Health Commercial |
$10,576.92
|
| Rate for Payer: Humana Commercial |
$9,463.56
|
| Rate for Payer: Humana KY Medicaid |
$3,828.85
|
| Rate for Payer: Kentucky WC Medicaid |
$3,867.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,129.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,216.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,340.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,905.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,797.57
|
| Rate for Payer: Ohio Health Group HMO |
$8,350.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,906.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,686.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,682.18
|
| Rate for Payer: PHCS Commercial |
$10,688.26
|
| Rate for Payer: United Healthcare All Payer |
$9,797.57
|
|
|
UNVRSL C-TAPR+0MM ADJSTMT SLV
|
Facility
|
IP
|
$11,133.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,340.08 |
| Max. Negotiated Rate |
$10,688.26 |
| Rate for Payer: Aetna Commercial |
$8,572.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,684.21
|
| Rate for Payer: Cash Price |
$5,566.80
|
| Rate for Payer: Cigna Commercial |
$9,240.89
|
| Rate for Payer: First Health Commercial |
$10,576.92
|
| Rate for Payer: Humana Commercial |
$9,463.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,129.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,216.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,340.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,797.57
|
| Rate for Payer: Ohio Health Group HMO |
$8,350.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,906.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,686.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,682.18
|
| Rate for Payer: PHCS Commercial |
$10,688.26
|
| Rate for Payer: United Healthcare All Payer |
$9,797.57
|
|
|
UNVRSL C- TAPR -2.5MM ADJST SL
|
Facility
|
IP
|
$2,090.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$627.12 |
| Max. Negotiated Rate |
$2,006.78 |
| Rate for Payer: Aetna Commercial |
$1,609.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,630.51
|
| Rate for Payer: Cash Price |
$1,045.20
|
| Rate for Payer: Cigna Commercial |
$1,735.03
|
| Rate for Payer: First Health Commercial |
$1,985.88
|
| Rate for Payer: Humana Commercial |
$1,776.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,714.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,542.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$627.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,839.55
|
| Rate for Payer: Ohio Health Group HMO |
$1,567.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,672.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,818.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,442.38
|
| Rate for Payer: PHCS Commercial |
$2,006.78
|
| Rate for Payer: United Healthcare All Payer |
$1,839.55
|
|
|
UNVRSL C- TAPR -2.5MM ADJST SL
|
Facility
|
OP
|
$2,090.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$627.12 |
| Max. Negotiated Rate |
$2,006.78 |
| Rate for Payer: Aetna Commercial |
$1,609.61
|
| Rate for Payer: Anthem Medicaid |
$718.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,630.51
|
| Rate for Payer: Cash Price |
$1,045.20
|
| Rate for Payer: Cigna Commercial |
$1,735.03
|
| Rate for Payer: First Health Commercial |
$1,985.88
|
| Rate for Payer: Humana Commercial |
$1,776.84
|
| Rate for Payer: Humana KY Medicaid |
$718.89
|
| Rate for Payer: Kentucky WC Medicaid |
$726.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,714.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,542.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$627.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$733.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,839.55
|
| Rate for Payer: Ohio Health Group HMO |
$1,567.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,672.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,818.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,442.38
|
| Rate for Payer: PHCS Commercial |
$2,006.78
|
| Rate for Payer: United Healthcare All Payer |
$1,839.55
|
|
|
UNVRSL C-TAPR+2.5MM ADJST SLV
|
Facility
|
IP
|
$2,090.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$627.12 |
| Max. Negotiated Rate |
$2,006.78 |
| Rate for Payer: Aetna Commercial |
$1,609.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,630.51
|
| Rate for Payer: Cash Price |
$1,045.20
|
| Rate for Payer: Cigna Commercial |
$1,735.03
|
| Rate for Payer: First Health Commercial |
$1,985.88
|
| Rate for Payer: Humana Commercial |
$1,776.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,714.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,542.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$627.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,839.55
|
| Rate for Payer: Ohio Health Group HMO |
$1,567.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,672.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,818.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,442.38
|
| Rate for Payer: PHCS Commercial |
$2,006.78
|
| Rate for Payer: United Healthcare All Payer |
$1,839.55
|
|
|
UNVRSL C-TAPR+2.5MM ADJST SLV
|
Facility
|
OP
|
$2,090.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$627.12 |
| Max. Negotiated Rate |
$2,006.78 |
| Rate for Payer: Aetna Commercial |
$1,609.61
|
| Rate for Payer: Anthem Medicaid |
$718.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,630.51
|
| Rate for Payer: Cash Price |
$1,045.20
|
| Rate for Payer: Cigna Commercial |
$1,735.03
|
| Rate for Payer: First Health Commercial |
$1,985.88
|
| Rate for Payer: Humana Commercial |
$1,776.84
|
| Rate for Payer: Humana KY Medicaid |
$718.89
|
| Rate for Payer: Kentucky WC Medicaid |
$726.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,714.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,542.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$627.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$733.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,839.55
|
| Rate for Payer: Ohio Health Group HMO |
$1,567.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,672.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,818.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,442.38
|
| Rate for Payer: PHCS Commercial |
$2,006.78
|
| Rate for Payer: United Healthcare All Payer |
$1,839.55
|
|
|
UPGRADE OF PACEMAKER SYSTEM
|
Facility
|
OP
|
$1,840.00
|
|
|
Service Code
|
HCPCS 33214
|
| Hospital Charge Code |
76101248
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$632.78 |
| Max. Negotiated Rate |
$13,537.66 |
| Rate for Payer: Aetna Commercial |
$1,416.80
|
| Rate for Payer: Anthem Medicaid |
$632.78
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9,669.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,435.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13,537.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$13,054.18
|
| Rate for Payer: Cash Price |
$920.00
|
| Rate for Payer: Cash Price |
$920.00
|
| Rate for Payer: Cigna Commercial |
$1,527.20
|
| Rate for Payer: First Health Commercial |
$1,748.00
|
| Rate for Payer: Humana Commercial |
$1,564.00
|
| Rate for Payer: Humana KY Medicaid |
$632.78
|
| Rate for Payer: Humana Medicare Advantage |
$9,669.76
|
| Rate for Payer: Kentucky WC Medicaid |
$639.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,508.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,357.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,603.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$645.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,619.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,380.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,472.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,600.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,269.60
|
| Rate for Payer: PHCS Commercial |
$1,766.40
|
| Rate for Payer: United Healthcare All Payer |
$1,619.20
|
|
|
UPGRADE OF PACEMAKER SYSTEM
|
Professional
|
Both
|
$1,840.00
|
|
|
Service Code
|
HCPCS 33214
|
| Hospital Charge Code |
76101248
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$388.62 |
| Max. Negotiated Rate |
$1,104.00 |
| Rate for Payer: Aetna Commercial |
$829.76
|
| Rate for Payer: Ambetter Exchange |
$446.78
|
| Rate for Payer: Anthem Medicaid |
$388.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$446.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$446.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$536.14
|
| Rate for Payer: Cash Price |
$920.00
|
| Rate for Payer: Cash Price |
$920.00
|
| Rate for Payer: Cigna Commercial |
$786.42
|
| Rate for Payer: Healthspan PPO |
$815.81
|
| Rate for Payer: Humana Medicaid |
$388.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$679.68
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$446.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$446.78
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$396.39
|
| Rate for Payer: Molina Healthcare Passport |
$388.62
|
| Rate for Payer: Multiplan PHCS |
$1,104.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$580.81
|
| Rate for Payer: UHCCP Medicaid |
$644.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$392.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$446.78
|
|
|
UPGRADE OF PACEMAKER SYSTEM
|
Facility
|
IP
|
$1,840.00
|
|
|
Service Code
|
HCPCS 33214
|
| Hospital Charge Code |
76101248
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$552.00 |
| Max. Negotiated Rate |
$1,766.40 |
| Rate for Payer: Aetna Commercial |
$1,416.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,435.20
|
| Rate for Payer: Cash Price |
$920.00
|
| Rate for Payer: Cigna Commercial |
$1,527.20
|
| Rate for Payer: First Health Commercial |
$1,748.00
|
| Rate for Payer: Humana Commercial |
$1,564.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,508.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,357.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$552.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,619.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,380.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,472.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,600.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,269.60
|
| Rate for Payer: PHCS Commercial |
$1,766.40
|
| Rate for Payer: United Healthcare All Payer |
$1,619.20
|
|
|
UPGRADE OF PACEMAKER SYSTEM(P
|
Professional
|
Both
|
$1,840.00
|
|
|
Service Code
|
HCPCS 33214
|
| Hospital Charge Code |
761P1248
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$388.62 |
| Max. Negotiated Rate |
$1,104.00 |
| Rate for Payer: Aetna Commercial |
$829.76
|
| Rate for Payer: Ambetter Exchange |
$446.78
|
| Rate for Payer: Anthem Medicaid |
$388.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$446.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$446.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$536.14
|
| Rate for Payer: Cash Price |
$920.00
|
| Rate for Payer: Cash Price |
$920.00
|
| Rate for Payer: Cigna Commercial |
$786.42
|
| Rate for Payer: Healthspan PPO |
$815.81
|
| Rate for Payer: Humana Medicaid |
$388.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$679.68
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$446.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$446.78
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$396.39
|
| Rate for Payer: Molina Healthcare Passport |
$388.62
|
| Rate for Payer: Multiplan PHCS |
$1,104.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$580.81
|
| Rate for Payer: UHCCP Medicaid |
$644.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$392.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$446.78
|
|
|
UPPER ARM/ELBOW SURGERY
|
Facility
|
IP
|
$800.00
|
|
|
Service Code
|
HCPCS 24999
|
| Hospital Charge Code |
76102619
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$240.00 |
| Max. Negotiated Rate |
$768.00 |
| Rate for Payer: Aetna Commercial |
$616.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$664.00
|
| Rate for Payer: First Health Commercial |
$760.00
|
| Rate for Payer: Humana Commercial |
$680.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$590.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.00
|
| Rate for Payer: Ohio Health Group HMO |
$600.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$696.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$552.00
|
| Rate for Payer: PHCS Commercial |
$768.00
|
| Rate for Payer: United Healthcare All Payer |
$704.00
|
|
|
UPPER ARM/ELBOW SURGERY
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 24999
|
| Hospital Charge Code |
761P2619
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$560.00 |
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$560.00
|
| Rate for Payer: UHCCP Medicaid |
$280.00
|
|
|
UPPER ARM/ELBOW SURGERY
|
Facility
|
OP
|
$800.00
|
|
|
Service Code
|
HCPCS 24999
|
| Hospital Charge Code |
76102619
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$221.64 |
| Max. Negotiated Rate |
$768.00 |
| Rate for Payer: Aetna Commercial |
$616.00
|
| Rate for Payer: Anthem Medicaid |
$275.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$221.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$310.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$299.21
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$664.00
|
| Rate for Payer: First Health Commercial |
$760.00
|
| Rate for Payer: Humana Commercial |
$680.00
|
| Rate for Payer: Humana KY Medicaid |
$275.12
|
| Rate for Payer: Humana Medicare Advantage |
$221.64
|
| Rate for Payer: Kentucky WC Medicaid |
$277.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$590.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$280.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.00
|
| Rate for Payer: Ohio Health Group HMO |
$600.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$696.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$552.00
|
| Rate for Payer: PHCS Commercial |
$768.00
|
| Rate for Payer: United Healthcare All Payer |
$704.00
|
|
|
UPPER ARM/ELBOW SURGERY
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 24999
|
| Hospital Charge Code |
76102619
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$560.00 |
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$560.00
|
| Rate for Payer: UHCCP Medicaid |
$280.00
|
|
|
UPPER EXT. FOREARM LT 2V
|
Facility
|
IP
|
$394.00
|
|
|
Service Code
|
HCPCS 73090
|
| Hospital Charge Code |
32000082
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$118.20 |
| Max. Negotiated Rate |
$378.24 |
| Rate for Payer: Aetna Commercial |
$303.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$307.32
|
| Rate for Payer: Cash Price |
$197.00
|
| Rate for Payer: Cigna Commercial |
$327.02
|
| Rate for Payer: First Health Commercial |
$374.30
|
| Rate for Payer: Humana Commercial |
$334.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$323.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$290.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$118.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$346.72
|
| Rate for Payer: Ohio Health Group HMO |
$295.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$315.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$342.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$271.86
|
| Rate for Payer: PHCS Commercial |
$378.24
|
| Rate for Payer: United Healthcare All Payer |
$346.72
|
|
|
UPPER EXT. FOREARM LT 2V
|
Facility
|
OP
|
$394.00
|
|
|
Service Code
|
HCPCS 73090
|
| Hospital Charge Code |
32000082
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$378.24 |
| Rate for Payer: Aetna Commercial |
$303.38
|
| Rate for Payer: Anthem Medicaid |
$135.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$307.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$197.00
|
| Rate for Payer: Cash Price |
$197.00
|
| Rate for Payer: Cigna Commercial |
$327.02
|
| Rate for Payer: First Health Commercial |
$374.30
|
| Rate for Payer: Humana Commercial |
$334.90
|
| Rate for Payer: Humana KY Medicaid |
$135.50
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$136.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$323.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$290.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$138.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$346.72
|
| Rate for Payer: Ohio Health Group HMO |
$295.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$315.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$342.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$271.86
|
| Rate for Payer: PHCS Commercial |
$378.24
|
| Rate for Payer: United Healthcare All Payer |
$346.72
|
|
|
UPPER EXT. FOREARM LT 2V
|
Professional
|
Both
|
$394.00
|
|
|
Service Code
|
HCPCS 73090
|
| Hospital Charge Code |
32000082
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$236.40 |
| Rate for Payer: Aetna Commercial |
$40.80
|
| Rate for Payer: Ambetter Exchange |
$26.47
|
| Rate for Payer: Anthem Medicaid |
$20.96
|
| Rate for Payer: Buckeye Individual/Medicaid |
$26.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$26.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$31.76
|
| Rate for Payer: Cash Price |
$197.00
|
| Rate for Payer: Cash Price |
$197.00
|
| Rate for Payer: Cigna Commercial |
$40.84
|
| Rate for Payer: Healthspan PPO |
$38.23
|
| Rate for Payer: Humana Medicaid |
$20.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$10.38
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$26.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$21.38
|
| Rate for Payer: Molina Healthcare Passport |
$20.96
|
| Rate for Payer: Multiplan PHCS |
$236.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$34.41
|
| Rate for Payer: UHCCP Medicaid |
$137.90
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$21.17
|
| Rate for Payer: Wellcare Medicare Advantage |
$26.47
|
|
|
UPPER EXT. FOREARM LT 2V(P
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 73090
|
| Hospital Charge Code |
320P0082
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$40.84 |
| Rate for Payer: Aetna Commercial |
$40.80
|
| Rate for Payer: Ambetter Exchange |
$26.47
|
| Rate for Payer: Anthem Medicaid |
$20.96
|
| Rate for Payer: Buckeye Individual/Medicaid |
$26.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$26.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$31.76
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$40.84
|
| Rate for Payer: Healthspan PPO |
$38.23
|
| Rate for Payer: Humana Medicaid |
$20.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$10.38
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$26.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$21.38
|
| Rate for Payer: Molina Healthcare Passport |
$20.96
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$34.41
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$21.17
|
| Rate for Payer: Wellcare Medicare Advantage |
$26.47
|
|
|
UPPER EXT. FOREARM LT 2V(T
|
Facility
|
OP
|
$354.00
|
|
|
Service Code
|
HCPCS 73090
|
| Hospital Charge Code |
320T0082
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$339.84 |
| Rate for Payer: Aetna Commercial |
$272.58
|
| Rate for Payer: Anthem Medicaid |
$121.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$276.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cigna Commercial |
$293.82
|
| Rate for Payer: First Health Commercial |
$336.30
|
| Rate for Payer: Humana Commercial |
$300.90
|
| Rate for Payer: Humana KY Medicaid |
$121.74
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$122.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$290.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$261.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$124.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$311.52
|
| Rate for Payer: Ohio Health Group HMO |
$265.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$283.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$307.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$244.26
|
| Rate for Payer: PHCS Commercial |
$339.84
|
| Rate for Payer: United Healthcare All Payer |
$311.52
|
|
|
UPPER EXT. FOREARM LT 2V(T
|
Facility
|
IP
|
$354.00
|
|
|
Service Code
|
HCPCS 73090
|
| Hospital Charge Code |
320T0082
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$106.20 |
| Max. Negotiated Rate |
$339.84 |
| Rate for Payer: Aetna Commercial |
$272.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$276.12
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cigna Commercial |
$293.82
|
| Rate for Payer: First Health Commercial |
$336.30
|
| Rate for Payer: Humana Commercial |
$300.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$290.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$261.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$106.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$311.52
|
| Rate for Payer: Ohio Health Group HMO |
$265.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$283.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$307.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$244.26
|
| Rate for Payer: PHCS Commercial |
$339.84
|
| Rate for Payer: United Healthcare All Payer |
$311.52
|
|
|
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 |
$195.00 |
| 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 |
$520.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$565.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$448.50
|
| Rate for Payer: PHCS Commercial |
$624.00
|
| Rate for Payer: United Healthcare All Payer |
$572.00
|
|
