|
DIRECT REPAIR OF ANEURYSM - P
|
Facility
|
IP
|
$2,800.00
|
|
|
Service Code
|
HCPCS 35102
|
| Hospital Charge Code |
76101361
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$364.00 |
| Max. Negotiated Rate |
$2,688.00 |
| Rate for Payer: Aetna Commercial |
$2,156.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,184.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,324.00
|
| Rate for Payer: First Health Commercial |
$2,660.00
|
| Rate for Payer: Humana Commercial |
$2,380.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,296.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,066.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$840.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,464.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,100.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$560.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$364.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$868.00
|
| Rate for Payer: PHCS Commercial |
$2,688.00
|
| Rate for Payer: United Healthcare All Payer |
$2,464.00
|
|
|
DIRECT REPAIR OF ANEURYSM - P
|
Professional
|
Both
|
$2,800.00
|
|
|
Service Code
|
HCPCS 35102
|
| Hospital Charge Code |
76101361
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$980.00 |
| Max. Negotiated Rate |
$3,310.02 |
| Rate for Payer: Aetna Commercial |
$3,310.02
|
| Rate for Payer: Anthem Medicaid |
$1,386.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,800.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$3,104.53
|
| Rate for Payer: Healthspan PPO |
$3,254.40
|
| Rate for Payer: Humana Medicaid |
$1,386.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,596.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,414.63
|
| Rate for Payer: Molina Healthcare Passport |
$1,386.89
|
| Rate for Payer: Multiplan PHCS |
$1,680.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,960.00
|
| Rate for Payer: UHCCP Medicaid |
$980.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,400.76
|
|
|
DIRECT REPAIR OF ANEURYSM - P
|
Facility
|
OP
|
$3,200.00
|
|
|
Service Code
|
HCPCS 35081
|
| Hospital Charge Code |
76101358
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$416.00 |
| Max. Negotiated Rate |
$3,072.00 |
| Rate for Payer: Aetna Commercial |
$2,464.00
|
| Rate for Payer: Anthem Medicaid |
$1,100.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,496.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cigna Commercial |
$2,656.00
|
| Rate for Payer: First Health Commercial |
$3,040.00
|
| Rate for Payer: Humana Commercial |
$2,720.00
|
| Rate for Payer: Humana KY Medicaid |
$1,100.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1,111.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,624.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,361.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$960.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,122.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,816.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$416.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$992.00
|
| Rate for Payer: PHCS Commercial |
$3,072.00
|
| Rate for Payer: United Healthcare All Payer |
$2,816.00
|
|
|
DIRECT REPAIR OF ANEURYSM - P
|
Facility
|
OP
|
$4,000.00
|
|
|
Service Code
|
HCPCS 35091
|
| Hospital Charge Code |
76101360
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$520.00 |
| Max. Negotiated Rate |
$3,840.00 |
| Rate for Payer: Aetna Commercial |
$3,080.00
|
| Rate for Payer: Anthem Medicaid |
$1,375.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,120.00
|
| Rate for Payer: Cash Price |
$2,000.00
|
| Rate for Payer: Cigna Commercial |
$3,320.00
|
| Rate for Payer: First Health Commercial |
$3,800.00
|
| Rate for Payer: Humana Commercial |
$3,400.00
|
| Rate for Payer: Humana KY Medicaid |
$1,375.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1,389.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,280.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,952.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,200.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,403.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,520.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$520.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,240.00
|
| Rate for Payer: PHCS Commercial |
$3,840.00
|
| Rate for Payer: United Healthcare All Payer |
$3,520.00
|
|
|
DIRECT REPAIR OF ANEURYSM - P
|
Professional
|
Both
|
$3,200.00
|
|
|
Service Code
|
HCPCS 35132
|
| Hospital Charge Code |
76101364
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,120.00 |
| Max. Negotiated Rate |
$3,200.00 |
| Rate for Payer: Aetna Commercial |
$2,993.88
|
| Rate for Payer: Anthem Medicaid |
$1,186.63
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,200.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cigna Commercial |
$2,847.75
|
| Rate for Payer: Healthspan PPO |
$2,943.57
|
| Rate for Payer: Humana Medicaid |
$1,186.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,281.14
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,210.36
|
| Rate for Payer: Molina Healthcare Passport |
$1,186.63
|
| Rate for Payer: Multiplan PHCS |
$1,920.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,240.00
|
| Rate for Payer: UHCCP Medicaid |
$1,120.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,198.50
|
|
|
DIRECT REPAIR OF ANEURYSM - P
|
Facility
|
IP
|
$2,800.00
|
|
|
Service Code
|
HCPCS 35141
|
| Hospital Charge Code |
76101365
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$364.00 |
| Max. Negotiated Rate |
$2,688.00 |
| Rate for Payer: Aetna Commercial |
$2,156.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,184.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,324.00
|
| Rate for Payer: First Health Commercial |
$2,660.00
|
| Rate for Payer: Humana Commercial |
$2,380.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,296.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,066.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$840.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,464.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,100.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$560.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$364.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$868.00
|
| Rate for Payer: PHCS Commercial |
$2,688.00
|
| Rate for Payer: United Healthcare All Payer |
$2,464.00
|
|
|
DIRECT REPAIR OF ANEURYSM - P
|
Facility
|
IP
|
$4,000.00
|
|
|
Service Code
|
HCPCS 35091
|
| Hospital Charge Code |
76101360
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$520.00 |
| Max. Negotiated Rate |
$3,840.00 |
| Rate for Payer: Aetna Commercial |
$3,080.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,120.00
|
| Rate for Payer: Cash Price |
$2,000.00
|
| Rate for Payer: Cigna Commercial |
$3,320.00
|
| Rate for Payer: First Health Commercial |
$3,800.00
|
| Rate for Payer: Humana Commercial |
$3,400.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,280.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,952.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,520.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$520.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,240.00
|
| Rate for Payer: PHCS Commercial |
$3,840.00
|
| Rate for Payer: United Healthcare All Payer |
$3,520.00
|
|
|
DIRECT REPAIR OF ANEURYSM - P
|
Facility
|
OP
|
$2,800.00
|
|
|
Service Code
|
HCPCS 35102
|
| Hospital Charge Code |
76101361
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$364.00 |
| Max. Negotiated Rate |
$2,688.00 |
| Rate for Payer: Aetna Commercial |
$2,156.00
|
| Rate for Payer: Anthem Medicaid |
$962.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,184.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,324.00
|
| Rate for Payer: First Health Commercial |
$2,660.00
|
| Rate for Payer: Humana Commercial |
$2,380.00
|
| Rate for Payer: Humana KY Medicaid |
$962.92
|
| Rate for Payer: Kentucky WC Medicaid |
$972.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,296.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,066.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$840.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$982.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,464.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,100.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$560.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$364.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$868.00
|
| Rate for Payer: PHCS Commercial |
$2,688.00
|
| Rate for Payer: United Healthcare All Payer |
$2,464.00
|
|
|
DIRECT REPAIR OF ANEURYSM - P
|
Facility
|
IP
|
$3,200.00
|
|
|
Service Code
|
HCPCS 35081
|
| Hospital Charge Code |
76101358
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$416.00 |
| Max. Negotiated Rate |
$3,072.00 |
| Rate for Payer: Aetna Commercial |
$2,464.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,496.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cigna Commercial |
$2,656.00
|
| Rate for Payer: First Health Commercial |
$3,040.00
|
| Rate for Payer: Humana Commercial |
$2,720.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,624.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,361.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$960.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,816.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$416.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$992.00
|
| Rate for Payer: PHCS Commercial |
$3,072.00
|
| Rate for Payer: United Healthcare All Payer |
$2,816.00
|
|
|
DIRECT REPAIR OF ANEURYSM - P
|
Facility
|
OP
|
$2,800.00
|
|
|
Service Code
|
HCPCS 35141
|
| Hospital Charge Code |
76101365
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$364.00 |
| Max. Negotiated Rate |
$2,688.00 |
| Rate for Payer: Aetna Commercial |
$2,156.00
|
| Rate for Payer: Anthem Medicaid |
$962.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,184.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,324.00
|
| Rate for Payer: First Health Commercial |
$2,660.00
|
| Rate for Payer: Humana Commercial |
$2,380.00
|
| Rate for Payer: Humana KY Medicaid |
$962.92
|
| Rate for Payer: Kentucky WC Medicaid |
$972.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,296.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,066.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$840.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$982.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,464.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,100.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$560.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$364.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$868.00
|
| Rate for Payer: PHCS Commercial |
$2,688.00
|
| Rate for Payer: United Healthcare All Payer |
$2,464.00
|
|
|
DIRECT REPAIR OF ANEURYSM - P
|
Facility
|
IP
|
$3,200.00
|
|
|
Service Code
|
HCPCS 35132
|
| Hospital Charge Code |
76101364
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$416.00 |
| Max. Negotiated Rate |
$3,072.00 |
| Rate for Payer: Aetna Commercial |
$2,464.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,496.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cigna Commercial |
$2,656.00
|
| Rate for Payer: First Health Commercial |
$3,040.00
|
| Rate for Payer: Humana Commercial |
$2,720.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,624.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,361.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$960.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,816.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$416.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$992.00
|
| Rate for Payer: PHCS Commercial |
$3,072.00
|
| Rate for Payer: United Healthcare All Payer |
$2,816.00
|
|
|
DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, RADIAL OR ULNAR ARTERY
|
Facility
|
OP
|
$6,652.97
|
|
|
Service Code
|
CPT 35045
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,752.12 |
| Max. Negotiated Rate |
$6,652.97 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,752.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,652.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,415.36
|
| Rate for Payer: Humana Medicare Advantage |
$4,752.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,702.54
|
|
|
DISABILITY EXAMINATION/FORMS +
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 99456
|
| Hospital Charge Code |
22200667
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$63.65
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
|
|
DISALCID(SALSALATE) 750MG/1TAB
|
Facility
|
IP
|
$4.69
|
|
|
Service Code
|
NDC 10135040401
|
| Hospital Charge Code |
25000572
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Aetna Commercial |
$3.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.66
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna Commercial |
$3.89
|
| Rate for Payer: First Health Commercial |
$4.46
|
| Rate for Payer: Humana Commercial |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.13
|
| Rate for Payer: Ohio Health Group HMO |
$3.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.45
|
| Rate for Payer: PHCS Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Payer |
$4.13
|
|
|
DISALCID(SALSALATE) 750MG/1TAB
|
Facility
|
OP
|
$4.69
|
|
|
Service Code
|
NDC 10135040401
|
| Hospital Charge Code |
25000572
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Aetna Commercial |
$3.61
|
| Rate for Payer: Anthem Medicaid |
$1.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.66
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna Commercial |
$3.89
|
| Rate for Payer: First Health Commercial |
$4.46
|
| Rate for Payer: Humana Commercial |
$3.99
|
| Rate for Payer: Humana KY Medicaid |
$1.61
|
| Rate for Payer: Kentucky WC Medicaid |
$1.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.13
|
| Rate for Payer: Ohio Health Group HMO |
$3.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.45
|
| Rate for Payer: PHCS Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Payer |
$4.13
|
|
|
DISARTICULATION FOOT
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 27889
|
| Hospital Charge Code |
76100961
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$195.00 |
| Max. Negotiated Rate |
$1,440.00 |
| Rate for Payer: Aetna Commercial |
$1,155.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,245.00
|
| Rate for Payer: First Health Commercial |
$1,425.00
|
| Rate for Payer: Humana Commercial |
$1,275.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$450.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$195.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$465.00
|
| Rate for Payer: PHCS Commercial |
$1,440.00
|
| Rate for Payer: United Healthcare All Payer |
$1,320.00
|
|
|
DISARTICULATION FOOT
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 27889
|
| Hospital Charge Code |
76100961
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$522.58 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Aetna Commercial |
$1,028.93
|
| Rate for Payer: Anthem Medicaid |
$522.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,500.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,122.76
|
| Rate for Payer: Healthspan PPO |
$931.99
|
| Rate for Payer: Humana Medicaid |
$522.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$872.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$533.03
|
| Rate for Payer: Molina Healthcare Passport |
$522.58
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,050.00
|
| Rate for Payer: UHCCP Medicaid |
$525.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$527.81
|
|
|
DISARTICULATION FOOT
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 27889
|
| Hospital Charge Code |
76100961
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$195.00 |
| Max. Negotiated Rate |
$8,661.10 |
| Rate for Payer: Aetna Commercial |
$1,155.00
|
| Rate for Payer: Anthem Medicaid |
$515.85
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,186.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,661.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,351.78
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,245.00
|
| Rate for Payer: First Health Commercial |
$1,425.00
|
| Rate for Payer: Humana Commercial |
$1,275.00
|
| Rate for Payer: Humana KY Medicaid |
$515.85
|
| Rate for Payer: Humana Medicare Advantage |
$6,186.50
|
| Rate for Payer: Kentucky WC Medicaid |
$521.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,423.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$526.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$195.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$465.00
|
| Rate for Payer: PHCS Commercial |
$1,440.00
|
| Rate for Payer: United Healthcare All Payer |
$1,320.00
|
|
|
DISARTICULATION FOOT(P
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 27889
|
| Hospital Charge Code |
761P0961
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$522.58 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Aetna Commercial |
$1,028.93
|
| Rate for Payer: Anthem Medicaid |
$522.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,500.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,122.76
|
| Rate for Payer: Healthspan PPO |
$931.99
|
| Rate for Payer: Humana Medicaid |
$522.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$872.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$533.03
|
| Rate for Payer: Molina Healthcare Passport |
$522.58
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,050.00
|
| Rate for Payer: UHCCP Medicaid |
$525.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$527.81
|
|
|
DISC CLIPS
|
Facility
|
OP
|
$1,813.05
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$235.70 |
| Max. Negotiated Rate |
$1,740.53 |
| Rate for Payer: Aetna Commercial |
$1,396.05
|
| Rate for Payer: Anthem Medicaid |
$623.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,414.18
|
| Rate for Payer: Cash Price |
$906.52
|
| Rate for Payer: Cigna Commercial |
$1,504.83
|
| Rate for Payer: First Health Commercial |
$1,722.40
|
| Rate for Payer: Humana Commercial |
$1,541.09
|
| Rate for Payer: Humana KY Medicaid |
$623.51
|
| Rate for Payer: Kentucky WC Medicaid |
$629.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,486.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,338.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$543.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$636.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,595.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,359.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$235.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$562.05
|
| Rate for Payer: PHCS Commercial |
$1,740.53
|
| Rate for Payer: United Healthcare All Payer |
$1,595.48
|
|
|
DISC CLIPS
|
Facility
|
IP
|
$1,813.05
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$235.70 |
| Max. Negotiated Rate |
$1,740.53 |
| Rate for Payer: Aetna Commercial |
$1,396.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,414.18
|
| Rate for Payer: Cash Price |
$906.52
|
| Rate for Payer: Cigna Commercial |
$1,504.83
|
| Rate for Payer: First Health Commercial |
$1,722.40
|
| Rate for Payer: Humana Commercial |
$1,541.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,486.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,338.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$543.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,595.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,359.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$235.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$562.05
|
| Rate for Payer: PHCS Commercial |
$1,740.53
|
| Rate for Payer: United Healthcare All Payer |
$1,595.48
|
|
|
DISCOVERY ELBOW 4*100MM LT HUM
|
Facility
|
IP
|
$16,292.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,118.01 |
| Max. Negotiated Rate |
$15,640.70 |
| Rate for Payer: Aetna Commercial |
$12,545.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,708.07
|
| Rate for Payer: Cash Price |
$8,146.20
|
| Rate for Payer: Cigna Commercial |
$13,522.69
|
| Rate for Payer: First Health Commercial |
$15,477.78
|
| Rate for Payer: Humana Commercial |
$13,848.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,359.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,023.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,887.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,337.31
|
| Rate for Payer: Ohio Health Group HMO |
$12,219.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,258.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,118.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,050.64
|
| Rate for Payer: PHCS Commercial |
$15,640.70
|
| Rate for Payer: United Healthcare All Payer |
$14,337.31
|
|
|
DISCOVERY ELBOW 4*100MM LT HUM
|
Facility
|
OP
|
$16,292.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,118.01 |
| Max. Negotiated Rate |
$15,640.70 |
| Rate for Payer: Aetna Commercial |
$12,545.15
|
| Rate for Payer: Anthem Medicaid |
$5,602.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,708.07
|
| Rate for Payer: Cash Price |
$8,146.20
|
| Rate for Payer: Cigna Commercial |
$13,522.69
|
| Rate for Payer: First Health Commercial |
$15,477.78
|
| Rate for Payer: Humana Commercial |
$13,848.54
|
| Rate for Payer: Humana KY Medicaid |
$5,602.96
|
| Rate for Payer: Kentucky WC Medicaid |
$5,659.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,359.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,023.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,887.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,715.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,337.31
|
| Rate for Payer: Ohio Health Group HMO |
$12,219.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,258.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,118.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,050.64
|
| Rate for Payer: PHCS Commercial |
$15,640.70
|
| Rate for Payer: United Healthcare All Payer |
$14,337.31
|
|
|
DISCOVERY ELBOW 4*100MM RT HUM
|
Facility
|
IP
|
$16,292.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,118.01 |
| Max. Negotiated Rate |
$15,640.70 |
| Rate for Payer: Aetna Commercial |
$12,545.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,708.07
|
| Rate for Payer: Cash Price |
$8,146.20
|
| Rate for Payer: Cigna Commercial |
$13,522.69
|
| Rate for Payer: First Health Commercial |
$15,477.78
|
| Rate for Payer: Humana Commercial |
$13,848.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,359.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,023.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,887.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,337.31
|
| Rate for Payer: Ohio Health Group HMO |
$12,219.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,258.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,118.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,050.64
|
| Rate for Payer: PHCS Commercial |
$15,640.70
|
| Rate for Payer: United Healthcare All Payer |
$14,337.31
|
|
|
DISCOVERY ELBOW 4*100MM RT HUM
|
Facility
|
OP
|
$16,292.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,118.01 |
| Max. Negotiated Rate |
$15,640.70 |
| Rate for Payer: Aetna Commercial |
$12,545.15
|
| Rate for Payer: Anthem Medicaid |
$5,602.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,708.07
|
| Rate for Payer: Cash Price |
$8,146.20
|
| Rate for Payer: Cigna Commercial |
$13,522.69
|
| Rate for Payer: First Health Commercial |
$15,477.78
|
| Rate for Payer: Humana Commercial |
$13,848.54
|
| Rate for Payer: Humana KY Medicaid |
$5,602.96
|
| Rate for Payer: Kentucky WC Medicaid |
$5,659.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,359.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,023.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,887.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,715.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,337.31
|
| Rate for Payer: Ohio Health Group HMO |
$12,219.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,258.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,118.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,050.64
|
| Rate for Payer: PHCS Commercial |
$15,640.70
|
| Rate for Payer: United Healthcare All Payer |
$14,337.31
|
|
