|
CARPECTOMY BONES OF PROX ROW
|
Professional
|
Both
|
$1,400.00
|
|
|
Service Code
|
HCPCS 25215
|
| Hospital Charge Code |
76100591
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$484.46 |
| Max. Negotiated Rate |
$1,400.00 |
| Rate for Payer: Aetna Commercial |
$914.31
|
| Rate for Payer: Anthem Medicaid |
$484.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,400.00
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cigna Commercial |
$1,073.57
|
| Rate for Payer: Healthspan PPO |
$828.17
|
| Rate for Payer: Humana Medicaid |
$484.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$768.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$494.15
|
| Rate for Payer: Molina Healthcare Passport |
$484.46
|
| Rate for Payer: Multiplan PHCS |
$840.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$980.00
|
| Rate for Payer: UHCCP Medicaid |
$490.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$489.30
|
|
|
CARPECTOMY BONES OF PROX ROW
|
Facility
|
OP
|
$1,400.00
|
|
|
Service Code
|
HCPCS 25215
|
| Hospital Charge Code |
76100591
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$182.00 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Aetna Commercial |
$1,078.00
|
| Rate for Payer: Anthem Medicaid |
$481.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,092.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cigna Commercial |
$1,162.00
|
| Rate for Payer: First Health Commercial |
$1,330.00
|
| Rate for Payer: Humana Commercial |
$1,190.00
|
| Rate for Payer: Humana KY Medicaid |
$481.46
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Kentucky WC Medicaid |
$486.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,148.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,033.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$491.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,232.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,050.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$182.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$434.00
|
| Rate for Payer: PHCS Commercial |
$1,344.00
|
| Rate for Payer: United Healthcare All Payer |
$1,232.00
|
|
|
CARPECTOMY BONES OF PROX ROW
|
Facility
|
IP
|
$1,400.00
|
|
|
Service Code
|
HCPCS 25215
|
| Hospital Charge Code |
76100591
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$182.00 |
| Max. Negotiated Rate |
$1,344.00 |
| Rate for Payer: Aetna Commercial |
$1,078.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,092.00
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cigna Commercial |
$1,162.00
|
| Rate for Payer: First Health Commercial |
$1,330.00
|
| Rate for Payer: Humana Commercial |
$1,190.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,148.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,033.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$420.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,232.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,050.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$182.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$434.00
|
| Rate for Payer: PHCS Commercial |
$1,344.00
|
| Rate for Payer: United Healthcare All Payer |
$1,232.00
|
|
|
CARPECTOMY BONES OF PROX ROW(P
|
Professional
|
Both
|
$1,400.00
|
|
|
Service Code
|
HCPCS 25215
|
| Hospital Charge Code |
761P0591
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$484.46 |
| Max. Negotiated Rate |
$1,400.00 |
| Rate for Payer: Aetna Commercial |
$914.31
|
| Rate for Payer: Anthem Medicaid |
$484.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,400.00
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cigna Commercial |
$1,073.57
|
| Rate for Payer: Healthspan PPO |
$828.17
|
| Rate for Payer: Humana Medicaid |
$484.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$768.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$494.15
|
| Rate for Payer: Molina Healthcare Passport |
$484.46
|
| Rate for Payer: Multiplan PHCS |
$840.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$980.00
|
| Rate for Payer: UHCCP Medicaid |
$490.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$489.30
|
|
|
CA SCREEN;FLEXI SIGMOIDSCOPE
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
HCPCS G0104
|
| Hospital Charge Code |
51000133
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$20.15 |
| Max. Negotiated Rate |
$148.80 |
| Rate for Payer: Aetna Commercial |
$119.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$120.90
|
| Rate for Payer: Cash Price |
$77.50
|
| Rate for Payer: Cigna Commercial |
$128.65
|
| Rate for Payer: First Health Commercial |
$147.25
|
| Rate for Payer: Humana Commercial |
$131.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$127.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$114.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$136.40
|
| Rate for Payer: Ohio Health Group HMO |
$116.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$31.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$48.05
|
| Rate for Payer: PHCS Commercial |
$148.80
|
| Rate for Payer: United Healthcare All Payer |
$136.40
|
|
|
CA SCREEN;FLEXI SIGMOIDSCOPE
|
Facility
|
OP
|
$155.00
|
|
|
Service Code
|
HCPCS G0104
|
| Hospital Charge Code |
51000133
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$20.15 |
| Max. Negotiated Rate |
$1,106.49 |
| Rate for Payer: Aetna Commercial |
$119.35
|
| Rate for Payer: Anthem Medicaid |
$53.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$790.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$120.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,106.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,066.97
|
| Rate for Payer: Cash Price |
$77.50
|
| Rate for Payer: Cash Price |
$77.50
|
| Rate for Payer: Cigna Commercial |
$128.65
|
| Rate for Payer: First Health Commercial |
$147.25
|
| Rate for Payer: Humana Commercial |
$131.75
|
| Rate for Payer: Humana KY Medicaid |
$53.30
|
| Rate for Payer: Humana Medicare Advantage |
$790.35
|
| Rate for Payer: Kentucky WC Medicaid |
$53.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$127.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$114.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$948.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$54.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$136.40
|
| Rate for Payer: Ohio Health Group HMO |
$116.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$31.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$48.05
|
| Rate for Payer: PHCS Commercial |
$148.80
|
| Rate for Payer: United Healthcare All Payer |
$136.40
|
|
|
CA SCREEN;FLEXI SIGMOIDSCOPE
|
Professional
|
Both
|
$155.00
|
|
|
Service Code
|
HCPCS G0104
|
| Hospital Charge Code |
51000133
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$54.25 |
| Max. Negotiated Rate |
$155.00 |
| Rate for Payer: Aetna Commercial |
$93.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$155.00
|
| Rate for Payer: Cash Price |
$77.50
|
| Rate for Payer: Cash Price |
$77.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$80.76
|
| Rate for Payer: Multiplan PHCS |
$93.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$108.50
|
| Rate for Payer: UHCCP Medicaid |
$54.25
|
|
|
Casiri and imdev repeat
|
Facility
|
IP
|
$775.00
|
|
|
Service Code
|
HCPCS M0240
|
| Hospital Charge Code |
77000073
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$100.75 |
| Max. Negotiated Rate |
$744.00 |
| Rate for Payer: Aetna Commercial |
$596.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$604.50
|
| Rate for Payer: Cash Price |
$387.50
|
| Rate for Payer: Cigna Commercial |
$643.25
|
| Rate for Payer: First Health Commercial |
$736.25
|
| Rate for Payer: Humana Commercial |
$658.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$635.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$571.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$232.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$682.00
|
| Rate for Payer: Ohio Health Group HMO |
$581.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$155.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$240.25
|
| Rate for Payer: PHCS Commercial |
$744.00
|
| Rate for Payer: United Healthcare All Payer |
$682.00
|
|
|
Casiri and imdev repeat
|
Facility
|
OP
|
$775.00
|
|
|
Service Code
|
HCPCS M0240
|
| Hospital Charge Code |
77000073
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$100.75 |
| Max. Negotiated Rate |
$744.00 |
| Rate for Payer: Aetna Commercial |
$596.75
|
| Rate for Payer: Anthem Medicaid |
$266.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$408.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$604.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$572.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$551.97
|
| Rate for Payer: Cash Price |
$387.50
|
| Rate for Payer: Cash Price |
$387.50
|
| Rate for Payer: Cigna Commercial |
$643.25
|
| Rate for Payer: First Health Commercial |
$736.25
|
| Rate for Payer: Humana Commercial |
$658.75
|
| Rate for Payer: Humana KY Medicaid |
$266.52
|
| Rate for Payer: Humana Medicare Advantage |
$408.87
|
| Rate for Payer: Kentucky WC Medicaid |
$269.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$635.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$571.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$490.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$271.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$682.00
|
| Rate for Payer: Ohio Health Group HMO |
$581.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$155.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$240.25
|
| Rate for Payer: PHCS Commercial |
$744.00
|
| Rate for Payer: United Healthcare All Payer |
$682.00
|
|
|
CASIRIVI AND IMDEVI ADM
|
Facility
|
IP
|
$803.00
|
|
|
Service Code
|
HCPCS M0243
|
| Hospital Charge Code |
77000062
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$104.39 |
| Max. Negotiated Rate |
$770.88 |
| Rate for Payer: Aetna Commercial |
$618.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$626.34
|
| Rate for Payer: Cash Price |
$401.50
|
| Rate for Payer: Cigna Commercial |
$666.49
|
| Rate for Payer: First Health Commercial |
$762.85
|
| Rate for Payer: Humana Commercial |
$682.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$658.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$592.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$706.64
|
| Rate for Payer: Ohio Health Group HMO |
$602.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.93
|
| Rate for Payer: PHCS Commercial |
$770.88
|
| Rate for Payer: United Healthcare All Payer |
$706.64
|
|
|
CASIRIVI AND IMDEVI ADM
|
Facility
|
OP
|
$803.00
|
|
|
Service Code
|
HCPCS M0243
|
| Hospital Charge Code |
77000062
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$104.39 |
| Max. Negotiated Rate |
$770.88 |
| Rate for Payer: Aetna Commercial |
$618.31
|
| Rate for Payer: Anthem Medicaid |
$276.15
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$408.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$626.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$572.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$551.97
|
| Rate for Payer: Cash Price |
$401.50
|
| Rate for Payer: Cash Price |
$401.50
|
| Rate for Payer: Cigna Commercial |
$666.49
|
| Rate for Payer: First Health Commercial |
$762.85
|
| Rate for Payer: Humana Commercial |
$682.55
|
| Rate for Payer: Humana KY Medicaid |
$276.15
|
| Rate for Payer: Humana Medicare Advantage |
$408.87
|
| Rate for Payer: Kentucky WC Medicaid |
$278.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$658.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$592.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$490.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$281.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$706.64
|
| Rate for Payer: Ohio Health Group HMO |
$602.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.93
|
| Rate for Payer: PHCS Commercial |
$770.88
|
| Rate for Payer: United Healthcare All Payer |
$706.64
|
|
|
CASODEX (BICALUTAMID 50MG 1 T)
|
Facility
|
IP
|
$4.14
|
|
|
Service Code
|
NDC 16729002301
|
| Hospital Charge Code |
25000392
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$3.97 |
| Rate for Payer: Aetna Commercial |
$3.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Cash Price |
$2.07
|
| Rate for Payer: Cigna Commercial |
$3.44
|
| Rate for Payer: First Health Commercial |
$3.93
|
| Rate for Payer: Humana Commercial |
$3.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.64
|
| Rate for Payer: Ohio Health Group HMO |
$3.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.28
|
| Rate for Payer: PHCS Commercial |
$3.97
|
| Rate for Payer: United Healthcare All Payer |
$3.64
|
|
|
CASODEX (BICALUTAMID 50MG 1 T)
|
Facility
|
OP
|
$4.14
|
|
|
Service Code
|
NDC 16729002301
|
| Hospital Charge Code |
25000392
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$3.97 |
| Rate for Payer: Aetna Commercial |
$3.19
|
| Rate for Payer: Anthem Medicaid |
$1.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Cash Price |
$2.07
|
| Rate for Payer: Cigna Commercial |
$3.44
|
| Rate for Payer: First Health Commercial |
$3.93
|
| Rate for Payer: Humana Commercial |
$3.52
|
| Rate for Payer: Humana KY Medicaid |
$1.42
|
| Rate for Payer: Kentucky WC Medicaid |
$1.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.64
|
| Rate for Payer: Ohio Health Group HMO |
$3.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.28
|
| Rate for Payer: PHCS Commercial |
$3.97
|
| Rate for Payer: United Healthcare All Payer |
$3.64
|
|
|
CAST SUP GAUNTLET FIBERGLASS
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
HCPCS Q4014
|
| Hospital Charge Code |
27000144
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Aetna Commercial |
$48.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$75.00
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$28.52
|
| Rate for Payer: Multiplan PHCS |
$45.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$52.50
|
| Rate for Payer: UHCCP Medicaid |
$26.25
|
|
|
CAST SUP GAUNTLET PED FBRGLS
|
Professional
|
Both
|
$45.00
|
|
|
Service Code
|
HCPCS Q4016
|
| Hospital Charge Code |
27000146
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.25 |
| Max. Negotiated Rate |
$48.02 |
| Rate for Payer: Aetna Commercial |
$48.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$45.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$14.25
|
| Rate for Payer: Multiplan PHCS |
$27.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$31.50
|
| Rate for Payer: UHCCP Medicaid |
$15.75
|
|
|
CAST SUP GAUNTLET PED PLSTER
|
Professional
|
Both
|
$30.00
|
|
|
Service Code
|
HCPCS Q4015
|
| Hospital Charge Code |
27000145
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: Aetna Commercial |
$28.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$30.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$8.45
|
| Rate for Payer: Multiplan PHCS |
$18.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$21.00
|
| Rate for Payer: UHCCP Medicaid |
$10.50
|
|
|
CAST SUP GAUNTLET PLASTER
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS Q4013
|
| Hospital Charge Code |
27000143
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$40.00 |
| Rate for Payer: Aetna Commercial |
$28.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$40.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$16.89
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$28.00
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
|
|
Cast sup hip spica fiberglas
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS Q4026
|
| Hospital Charge Code |
27000247
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Aetna Commercial |
$105.65
|
| Rate for Payer: Buckeye Medicare Advantage |
$150.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$126.66
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
|
|
CAST SUP HIP SPICA PED PLSTR
|
Professional
|
Both
|
$30.00
|
|
|
Service Code
|
HCPCS Q4027
|
| Hospital Charge Code |
27000156
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$64.03 |
| Rate for Payer: Aetna Commercial |
$64.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$30.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$20.29
|
| Rate for Payer: Multiplan PHCS |
$18.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$21.00
|
| Rate for Payer: UHCCP Medicaid |
$10.50
|
|
|
Cast sup hip spica plaster
|
Professional
|
Both
|
$50.00
|
|
|
Service Code
|
HCPCS Q4025
|
| Hospital Charge Code |
27000246
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$64.03 |
| Rate for Payer: Aetna Commercial |
$64.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$50.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$40.57
|
| Rate for Payer: Multiplan PHCS |
$30.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$35.00
|
| Rate for Payer: UHCCP Medicaid |
$17.50
|
|
|
CAST SUP LNG ARM SPLINT FBRG
|
Professional
|
Both
|
$65.00
|
|
|
Service Code
|
HCPCS Q4018
|
| Hospital Charge Code |
27000148
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.58 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Aetna Commercial |
$52.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$65.00
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$15.58
|
| Rate for Payer: Multiplan PHCS |
$39.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$45.50
|
| Rate for Payer: UHCCP Medicaid |
$22.75
|
|
|
CAST SUP LNG ARM SPLINT PLST
|
Professional
|
Both
|
$35.00
|
|
|
Service Code
|
HCPCS Q4017
|
| Hospital Charge Code |
27000147
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.78 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: UHCCP Medicaid |
$12.25
|
| Rate for Payer: Aetna Commercial |
$32.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$35.00
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$9.78
|
| Rate for Payer: Multiplan PHCS |
$21.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$24.50
|
|
|
CAST SUP LNG ARM SPLNT PED F
|
Professional
|
Both
|
$50.00
|
|
|
Service Code
|
HCPCS Q4020
|
| Hospital Charge Code |
27000150
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$52.83 |
| Rate for Payer: Aetna Commercial |
$52.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$50.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$7.80
|
| Rate for Payer: Multiplan PHCS |
$30.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$35.00
|
| Rate for Payer: UHCCP Medicaid |
$17.50
|
|
|
CAST SUP LNG ARM SPLNT PED P
|
Professional
|
Both
|
$35.00
|
|
|
Service Code
|
HCPCS Q4019
|
| Hospital Charge Code |
27000149
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4.89 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna Commercial |
$32.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$35.00
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$4.89
|
| Rate for Payer: Multiplan PHCS |
$21.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$24.50
|
| Rate for Payer: UHCCP Medicaid |
$12.25
|
|
|
CAST SUP LNG LEG CYLINDER FB
|
Professional
|
Both
|
$115.00
|
|
|
Service Code
|
HCPCS Q4034
|
| Hospital Charge Code |
27000162
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$40.25 |
| Max. Negotiated Rate |
$115.00 |
| Rate for Payer: Aetna Commercial |
$52.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$115.00
|
| Rate for Payer: Cash Price |
$57.50
|
| Rate for Payer: Cash Price |
$57.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$71.97
|
| Rate for Payer: Multiplan PHCS |
$69.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$80.50
|
| Rate for Payer: UHCCP Medicaid |
$40.25
|
|
