|
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 |
$1,073.57 |
| Rate for Payer: Aetna Commercial |
$914.31
|
| Rate for Payer: Ambetter Exchange |
$593.19
|
| Rate for Payer: Anthem Medicaid |
$484.46
|
| Rate for Payer: Buckeye Individual/Medicaid |
$593.19
|
| Rate for Payer: Buckeye Medicare Advantage |
$593.19
|
| Rate for Payer: CareSource Just4Me Medicare |
$711.83
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$593.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$593.19
|
| 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 |
$771.15
|
| Rate for Payer: UHCCP Medicaid |
$490.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$489.30
|
| Rate for Payer: Wellcare Medicare Advantage |
$593.19
|
|
|
CA SCREEN;FLEXI SIGMOIDSCOPE
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
HCPCS G0104
|
| Hospital Charge Code |
51000133
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$46.50 |
| 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 |
$124.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$134.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$106.95
|
| 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 |
$53.30 |
| Max. Negotiated Rate |
$1,179.36 |
| Rate for Payer: Aetna Commercial |
$119.35
|
| Rate for Payer: Anthem Medicaid |
$53.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$842.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$120.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,179.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,137.24
|
| 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 |
$842.40
|
| 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 |
$1,010.88
|
| 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 |
$124.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$134.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$106.95
|
| 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 |
$52.99 |
| Max. Negotiated Rate |
$127.01 |
| Rate for Payer: Aetna Commercial |
$93.23
|
| Rate for Payer: Ambetter Exchange |
$52.99
|
| Rate for Payer: Anthem Medicaid |
$124.52
|
| Rate for Payer: Buckeye Individual/Medicaid |
$52.99
|
| Rate for Payer: Buckeye Medicare Advantage |
$52.99
|
| Rate for Payer: CareSource Just4Me Medicare |
$63.59
|
| Rate for Payer: Cash Price |
$77.50
|
| Rate for Payer: Cash Price |
$77.50
|
| Rate for Payer: Humana Medicaid |
$124.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$80.76
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$52.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$52.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$127.01
|
| Rate for Payer: Molina Healthcare Passport |
$124.52
|
| Rate for Payer: Multiplan PHCS |
$93.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$68.89
|
| Rate for Payer: UHCCP Medicaid |
$54.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$125.77
|
| Rate for Payer: Wellcare Medicare Advantage |
$52.99
|
|
|
CASODEX (BICALUTAMID 50MG 1 T)
|
Facility
|
IP
|
$4.14
|
|
|
Service Code
|
NDC 16729002301
|
| Hospital Charge Code |
25000392
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| 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 |
$3.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.86
|
| 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 |
$1.24 |
| 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 |
$3.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.86
|
| 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 |
$48.02 |
| Rate for Payer: Aetna Commercial |
$48.02
|
| Rate for Payer: Ambetter Exchange |
$33.18
|
| Rate for Payer: Buckeye Individual/Medicaid |
$33.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$33.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$39.82
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$33.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.18
|
| Rate for Payer: Multiplan PHCS |
$45.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$43.13
|
| Rate for Payer: UHCCP Medicaid |
$26.25
|
| Rate for Payer: Wellcare Medicare Advantage |
$33.18
|
|
|
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: Ambetter Exchange |
$16.58
|
| Rate for Payer: Buckeye Individual/Medicaid |
$16.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$16.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$19.90
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$16.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.58
|
| Rate for Payer: Multiplan PHCS |
$27.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$21.55
|
| Rate for Payer: UHCCP Medicaid |
$15.75
|
| Rate for Payer: Wellcare Medicare Advantage |
$16.58
|
|
|
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 |
$28.81 |
| Rate for Payer: Aetna Commercial |
$28.81
|
| Rate for Payer: Ambetter Exchange |
$9.85
|
| Rate for Payer: Buckeye Individual/Medicaid |
$9.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$9.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$11.82
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$9.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.85
|
| Rate for Payer: Multiplan PHCS |
$18.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$12.80
|
| Rate for Payer: UHCCP Medicaid |
$10.50
|
| Rate for Payer: Wellcare Medicare Advantage |
$9.85
|
|
|
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 |
$28.81 |
| Rate for Payer: Aetna Commercial |
$28.81
|
| Rate for Payer: Ambetter Exchange |
$19.68
|
| Rate for Payer: Buckeye Individual/Medicaid |
$19.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$19.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$23.62
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$19.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.68
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$25.58
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$19.68
|
|
|
CAST SUP HIP SPICA FIBERGL ADT
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS Q4026
|
| Hospital Charge Code |
27000247
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$191.58 |
| Rate for Payer: Aetna Commercial |
$105.65
|
| Rate for Payer: Ambetter Exchange |
$147.37
|
| Rate for Payer: Buckeye Individual/Medicaid |
$147.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$147.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$176.84
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$147.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.37
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$191.58
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare Medicare Advantage |
$147.37
|
|
|
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: Ambetter Exchange |
$23.61
|
| Rate for Payer: Buckeye Individual/Medicaid |
$23.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$23.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$28.33
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$23.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.61
|
| Rate for Payer: Multiplan PHCS |
$18.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$30.69
|
| Rate for Payer: UHCCP Medicaid |
$10.50
|
| Rate for Payer: Wellcare Medicare Advantage |
$23.61
|
|
|
CAST SUP HIP SPICA PLASTER ADT
|
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: Ambetter Exchange |
$47.18
|
| Rate for Payer: Buckeye Individual/Medicaid |
$47.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$47.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$56.62
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$47.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.18
|
| Rate for Payer: Multiplan PHCS |
$30.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$61.33
|
| Rate for Payer: UHCCP Medicaid |
$17.50
|
| Rate for Payer: Wellcare Medicare Advantage |
$47.18
|
|
|
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 |
$52.83 |
| Rate for Payer: Aetna Commercial |
$52.83
|
| Rate for Payer: Ambetter Exchange |
$18.12
|
| Rate for Payer: Buckeye Individual/Medicaid |
$18.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$18.12
|
| Rate for Payer: CareSource Just4Me Medicare |
$21.74
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$18.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.12
|
| Rate for Payer: Multiplan PHCS |
$39.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$23.56
|
| Rate for Payer: UHCCP Medicaid |
$22.75
|
| Rate for Payer: Wellcare Medicare Advantage |
$18.12
|
|
|
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 |
$32.02 |
| Rate for Payer: Aetna Commercial |
$32.02
|
| Rate for Payer: Ambetter Exchange |
$11.37
|
| Rate for Payer: Buckeye Individual/Medicaid |
$11.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$11.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$13.64
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$11.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.37
|
| Rate for Payer: Multiplan PHCS |
$21.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$14.78
|
| Rate for Payer: UHCCP Medicaid |
$12.25
|
| Rate for Payer: Wellcare Medicare Advantage |
$11.37
|
|
|
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: Ambetter Exchange |
$9.10
|
| Rate for Payer: Buckeye Individual/Medicaid |
$9.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$9.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$10.92
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$9.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.10
|
| Rate for Payer: Multiplan PHCS |
$30.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$11.83
|
| Rate for Payer: UHCCP Medicaid |
$17.50
|
| Rate for Payer: Wellcare Medicare Advantage |
$9.10
|
|
|
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 |
$32.02 |
| Rate for Payer: Aetna Commercial |
$32.02
|
| Rate for Payer: Ambetter Exchange |
$5.69
|
| Rate for Payer: Buckeye Individual/Medicaid |
$5.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$5.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$6.83
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$5.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.69
|
| Rate for Payer: Multiplan PHCS |
$21.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$7.40
|
| Rate for Payer: UHCCP Medicaid |
$12.25
|
| Rate for Payer: Wellcare Medicare Advantage |
$5.69
|
|
|
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 |
$108.84 |
| Rate for Payer: Aetna Commercial |
$52.83
|
| Rate for Payer: Ambetter Exchange |
$83.72
|
| Rate for Payer: Buckeye Individual/Medicaid |
$83.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$83.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$100.46
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$83.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$83.72
|
| Rate for Payer: Multiplan PHCS |
$69.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$108.84
|
| Rate for Payer: UHCCP Medicaid |
$40.25
|
| Rate for Payer: Wellcare Medicare Advantage |
$83.72
|
|
|
CAST SUP LNG LEG CYLINDER PL
|
Professional
|
Both
|
$60.00
|
|
|
Service Code
|
HCPCS Q4033
|
| Hospital Charge Code |
27000161
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$43.78 |
| Rate for Payer: Aetna Commercial |
$32.02
|
| Rate for Payer: Ambetter Exchange |
$33.68
|
| Rate for Payer: Buckeye Individual/Medicaid |
$33.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$33.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$40.42
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$28.93
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$33.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.68
|
| Rate for Payer: Multiplan PHCS |
$36.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$43.78
|
| Rate for Payer: UHCCP Medicaid |
$21.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$33.68
|
|
|
CAST SUP LNGLEG CYLNDR PED F
|
Professional
|
Both
|
$60.00
|
|
|
Service Code
|
HCPCS Q4036
|
| Hospital Charge Code |
27000164
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$54.46 |
| Rate for Payer: Aetna Commercial |
$52.83
|
| Rate for Payer: Ambetter Exchange |
$41.89
|
| Rate for Payer: Buckeye Individual/Medicaid |
$41.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$41.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$50.27
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$35.99
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$41.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41.89
|
| Rate for Payer: Multiplan PHCS |
$36.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$54.46
|
| Rate for Payer: UHCCP Medicaid |
$21.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$41.89
|
|
|
CAST SUP LNGLEG CYLNDR PED P
|
Professional
|
Both
|
$35.00
|
|
|
Service Code
|
HCPCS Q4035
|
| Hospital Charge Code |
27000163
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$32.02 |
| Rate for Payer: Aetna Commercial |
$32.02
|
| Rate for Payer: Ambetter Exchange |
$16.83
|
| Rate for Payer: Buckeye Individual/Medicaid |
$16.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$16.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.20
|
| 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 |
$14.48
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$16.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.83
|
| Rate for Payer: Multiplan PHCS |
$21.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$21.88
|
| Rate for Payer: UHCCP Medicaid |
$12.25
|
| Rate for Payer: Wellcare Medicare Advantage |
$16.83
|
|
|
CAST SUP LNG LEG PED FBRGLS
|
Professional
|
Both
|
$70.00
|
|
|
Service Code
|
HCPCS Q4032
|
| Hospital Charge Code |
27000160
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$61.76 |
| Rate for Payer: Aetna Commercial |
$52.83
|
| Rate for Payer: Ambetter Exchange |
$47.51
|
| Rate for Payer: Buckeye Individual/Medicaid |
$47.51
|
| Rate for Payer: Buckeye Medicare Advantage |
$47.51
|
| Rate for Payer: CareSource Just4Me Medicare |
$57.01
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$40.83
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$47.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.51
|
| Rate for Payer: Multiplan PHCS |
$42.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$61.76
|
| Rate for Payer: UHCCP Medicaid |
$24.50
|
| Rate for Payer: Wellcare Medicare Advantage |
$47.51
|
|
|
CAST SUP LNG LEG PED PLASTER
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS Q4031
|
| Hospital Charge Code |
27000159
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$32.02 |
| Rate for Payer: Aetna Commercial |
$32.02
|
| Rate for Payer: Ambetter Exchange |
$18.03
|
| Rate for Payer: Buckeye Individual/Medicaid |
$18.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$18.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$21.64
|
| 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 |
$15.51
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$18.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.03
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$23.44
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$18.03
|
|
|
CAST SUP LNG LEG SPLNT FBRGL
|
Professional
|
Both
|
$90.00
|
|
|
Service Code
|
HCPCS Q4042
|
| Hospital Charge Code |
27000170
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$55.43 |
| Rate for Payer: Aetna Commercial |
$52.83
|
| Rate for Payer: Ambetter Exchange |
$42.64
|
| Rate for Payer: Buckeye Individual/Medicaid |
$42.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$42.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$51.17
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$36.64
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$42.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.64
|
| Rate for Payer: Multiplan PHCS |
$54.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$55.43
|
| Rate for Payer: UHCCP Medicaid |
$31.50
|
| Rate for Payer: Wellcare Medicare Advantage |
$42.64
|
|
|
CAST SUP LNG LEG SPLNT PED F
|
Professional
|
Both
|
$50.00
|
|
|
Service Code
|
HCPCS Q4044
|
| Hospital Charge Code |
27000172
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$52.83 |
| Rate for Payer: Aetna Commercial |
$52.83
|
| Rate for Payer: Ambetter Exchange |
$21.35
|
| Rate for Payer: Buckeye Individual/Medicaid |
$21.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$21.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$25.62
|
| 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 |
$18.32
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$21.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.35
|
| Rate for Payer: Multiplan PHCS |
$30.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$27.75
|
| Rate for Payer: UHCCP Medicaid |
$17.50
|
| Rate for Payer: Wellcare Medicare Advantage |
$21.35
|
|
