|
EX ARM/ELBOW TUM DEEP > 5 CM(P
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 24073
|
| Hospital Charge Code |
761P0501
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$350.00 |
| Max. Negotiated Rate |
$1,219.02 |
| Rate for Payer: Aetna Commercial |
$1,070.69
|
| Rate for Payer: Anthem Medicaid |
$503.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,000.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$1,219.02
|
| Rate for Payer: Healthspan PPO |
$763.51
|
| Rate for Payer: Humana Medicaid |
$503.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$883.53
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$513.65
|
| Rate for Payer: Molina Healthcare Passport |
$503.58
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$350.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$508.62
|
|
|
EX ARM/ELBOW TUM DEEP > 5 CM(T
|
Facility
|
OP
|
$6,389.25
|
|
|
Service Code
|
HCPCS 24073
|
| Hospital Charge Code |
761T0501
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$830.60 |
| Max. Negotiated Rate |
$6,133.68 |
| Rate for Payer: Aetna Commercial |
$4,919.72
|
| Rate for Payer: Anthem Medicaid |
$2,197.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,983.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,440.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,317.21
|
| Rate for Payer: Cash Price |
$3,194.62
|
| Rate for Payer: Cash Price |
$3,194.62
|
| Rate for Payer: Cigna Commercial |
$5,303.08
|
| Rate for Payer: First Health Commercial |
$6,069.79
|
| Rate for Payer: Humana Commercial |
$5,430.86
|
| Rate for Payer: Humana KY Medicaid |
$2,197.26
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$2,219.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,239.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,715.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,241.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,622.54
|
| Rate for Payer: Ohio Health Group HMO |
$4,791.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,277.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$830.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,980.67
|
| Rate for Payer: PHCS Commercial |
$6,133.68
|
| Rate for Payer: United Healthcare All Payer |
$5,622.54
|
|
|
EX ARM/ELBOW TUM DEEP > 5 CM(T
|
Facility
|
IP
|
$6,389.25
|
|
|
Service Code
|
HCPCS 24073
|
| Hospital Charge Code |
761T0501
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$830.60 |
| Max. Negotiated Rate |
$6,133.68 |
| Rate for Payer: Aetna Commercial |
$4,919.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,983.62
|
| Rate for Payer: Cash Price |
$3,194.62
|
| Rate for Payer: Cigna Commercial |
$5,303.08
|
| Rate for Payer: First Health Commercial |
$6,069.79
|
| Rate for Payer: Humana Commercial |
$5,430.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,239.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,715.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,916.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,622.54
|
| Rate for Payer: Ohio Health Group HMO |
$4,791.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,277.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$830.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,980.67
|
| Rate for Payer: PHCS Commercial |
$6,133.68
|
| Rate for Payer: United Healthcare All Payer |
$5,622.54
|
|
|
EX BRS LESIONWPREOPMARKOPNSING
|
Facility
|
IP
|
$4,524.00
|
|
|
Service Code
|
HCPCS 19125
|
| Hospital Charge Code |
761T0289
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$588.12 |
| Max. Negotiated Rate |
$4,343.04 |
| Rate for Payer: Aetna Commercial |
$3,483.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,528.72
|
| Rate for Payer: Cash Price |
$2,262.00
|
| Rate for Payer: Cigna Commercial |
$3,754.92
|
| Rate for Payer: First Health Commercial |
$4,297.80
|
| Rate for Payer: Humana Commercial |
$3,845.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,709.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,338.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,357.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,981.12
|
| Rate for Payer: Ohio Health Group HMO |
$3,393.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$904.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$588.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,402.44
|
| Rate for Payer: PHCS Commercial |
$4,343.04
|
| Rate for Payer: United Healthcare All Payer |
$3,981.12
|
|
|
EX BRS LESIONWPREOPMARKOPNSING
|
Facility
|
OP
|
$5,524.00
|
|
|
Service Code
|
HCPCS 19125
|
| Hospital Charge Code |
76100289
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$718.12 |
| Max. Negotiated Rate |
$5,303.04 |
| Rate for Payer: Aetna Commercial |
$4,253.48
|
| Rate for Payer: Anthem Medicaid |
$1,899.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,296.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,308.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,614.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,449.88
|
| Rate for Payer: Cash Price |
$2,762.00
|
| Rate for Payer: Cash Price |
$2,762.00
|
| Rate for Payer: Cigna Commercial |
$4,584.92
|
| Rate for Payer: First Health Commercial |
$5,247.80
|
| Rate for Payer: Humana Commercial |
$4,695.40
|
| Rate for Payer: Humana KY Medicaid |
$1,899.70
|
| Rate for Payer: Humana Medicare Advantage |
$3,296.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,529.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,076.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,955.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,937.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,861.12
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,104.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.44
|
| Rate for Payer: PHCS Commercial |
$5,303.04
|
| Rate for Payer: United Healthcare All Payer |
$4,861.12
|
|
|
EX BRS LESIONWPREOPMARKOPNSING
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 19125
|
| Hospital Charge Code |
761P0289
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$238.61 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Aetna Commercial |
$630.59
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$238.61
|
| Rate for Payer: Anthem Medicaid |
$264.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,000.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$581.28
|
| Rate for Payer: Healthspan PPO |
$579.97
|
| Rate for Payer: Humana Medicaid |
$264.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$570.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$269.30
|
| Rate for Payer: Molina Healthcare Passport |
$264.02
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$250.54
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$266.66
|
|
|
EX BRS LESIONWPREOPMARKOPNSING
|
Facility
|
OP
|
$4,524.00
|
|
|
Service Code
|
HCPCS 19125
|
| Hospital Charge Code |
45000085
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$588.12 |
| Max. Negotiated Rate |
$4,614.69 |
| Rate for Payer: Aetna Commercial |
$3,483.48
|
| Rate for Payer: Anthem Medicaid |
$1,555.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,296.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,528.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,614.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,449.88
|
| Rate for Payer: Cash Price |
$2,262.00
|
| Rate for Payer: Cash Price |
$2,262.00
|
| Rate for Payer: Cigna Commercial |
$3,754.92
|
| Rate for Payer: First Health Commercial |
$4,297.80
|
| Rate for Payer: Humana Commercial |
$3,845.40
|
| Rate for Payer: Humana KY Medicaid |
$1,555.80
|
| Rate for Payer: Humana Medicare Advantage |
$3,296.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,571.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,709.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,338.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,955.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,587.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,981.12
|
| Rate for Payer: Ohio Health Group HMO |
$3,393.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$904.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$588.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,402.44
|
| Rate for Payer: PHCS Commercial |
$4,343.04
|
| Rate for Payer: United Healthcare All Payer |
$3,981.12
|
|
|
EX BRS LESIONWPREOPMARKOPNSING
|
Facility
|
IP
|
$5,524.00
|
|
|
Service Code
|
HCPCS 19125
|
| Hospital Charge Code |
76100289
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$718.12 |
| Max. Negotiated Rate |
$5,303.04 |
| Rate for Payer: Aetna Commercial |
$4,253.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,308.72
|
| Rate for Payer: Cash Price |
$2,762.00
|
| Rate for Payer: Cigna Commercial |
$4,584.92
|
| Rate for Payer: First Health Commercial |
$5,247.80
|
| Rate for Payer: Humana Commercial |
$4,695.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,529.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,076.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,861.12
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,104.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.44
|
| Rate for Payer: PHCS Commercial |
$5,303.04
|
| Rate for Payer: United Healthcare All Payer |
$4,861.12
|
|
|
EX BRS LESIONWPREOPMARKOPNSING
|
Facility
|
OP
|
$4,524.00
|
|
|
Service Code
|
HCPCS 19125
|
| Hospital Charge Code |
761T0289
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$588.12 |
| Max. Negotiated Rate |
$4,614.69 |
| Rate for Payer: Aetna Commercial |
$3,483.48
|
| Rate for Payer: Anthem Medicaid |
$1,555.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,296.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,528.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,614.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,449.88
|
| Rate for Payer: Cash Price |
$2,262.00
|
| Rate for Payer: Cash Price |
$2,262.00
|
| Rate for Payer: Cigna Commercial |
$3,754.92
|
| Rate for Payer: First Health Commercial |
$4,297.80
|
| Rate for Payer: Humana Commercial |
$3,845.40
|
| Rate for Payer: Humana KY Medicaid |
$1,555.80
|
| Rate for Payer: Humana Medicare Advantage |
$3,296.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,571.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,709.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,338.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,955.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,587.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,981.12
|
| Rate for Payer: Ohio Health Group HMO |
$3,393.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$904.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$588.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,402.44
|
| Rate for Payer: PHCS Commercial |
$4,343.04
|
| Rate for Payer: United Healthcare All Payer |
$3,981.12
|
|
|
EX BRS LESIONWPREOPMARKOPNSING
|
Facility
|
IP
|
$4,524.00
|
|
|
Service Code
|
HCPCS 19125
|
| Hospital Charge Code |
45000085
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$588.12 |
| Max. Negotiated Rate |
$4,343.04 |
| Rate for Payer: Aetna Commercial |
$3,483.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,528.72
|
| Rate for Payer: Cash Price |
$2,262.00
|
| Rate for Payer: Cigna Commercial |
$3,754.92
|
| Rate for Payer: First Health Commercial |
$4,297.80
|
| Rate for Payer: Humana Commercial |
$3,845.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,709.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,338.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,357.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,981.12
|
| Rate for Payer: Ohio Health Group HMO |
$3,393.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$904.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$588.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,402.44
|
| Rate for Payer: PHCS Commercial |
$4,343.04
|
| Rate for Payer: United Healthcare All Payer |
$3,981.12
|
|
|
EX BRS LESIONWPREOPMARKOPNSING
|
Professional
|
Both
|
$5,524.00
|
|
|
Service Code
|
HCPCS 19125
|
| Hospital Charge Code |
76100289
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$238.61 |
| Max. Negotiated Rate |
$5,524.00 |
| Rate for Payer: Aetna Commercial |
$630.59
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$238.61
|
| Rate for Payer: Anthem Medicaid |
$264.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,524.00
|
| Rate for Payer: Cash Price |
$2,762.00
|
| Rate for Payer: Cash Price |
$2,762.00
|
| Rate for Payer: Cigna Commercial |
$581.28
|
| Rate for Payer: Healthspan PPO |
$579.97
|
| Rate for Payer: Humana Medicaid |
$264.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$570.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$269.30
|
| Rate for Payer: Molina Healthcare Passport |
$264.02
|
| Rate for Payer: Multiplan PHCS |
$3,314.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,866.80
|
| Rate for Payer: UHCCP Medicaid |
$250.54
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$266.66
|
|
|
EXC ABD LES SC 3 CM/>
|
Professional
|
Both
|
$575.00
|
|
|
Service Code
|
HCPCS 22903
|
| Hospital Charge Code |
76100430
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$201.25 |
| Max. Negotiated Rate |
$770.20 |
| Rate for Payer: Aetna Commercial |
$675.66
|
| Rate for Payer: Anthem Medicaid |
$318.49
|
| Rate for Payer: Buckeye Medicare Advantage |
$575.00
|
| Rate for Payer: Cash Price |
$287.50
|
| Rate for Payer: Cash Price |
$287.50
|
| Rate for Payer: Cigna Commercial |
$770.20
|
| Rate for Payer: Healthspan PPO |
$481.50
|
| Rate for Payer: Humana Medicaid |
$318.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$559.76
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$324.86
|
| Rate for Payer: Molina Healthcare Passport |
$318.49
|
| Rate for Payer: Multiplan PHCS |
$345.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$402.50
|
| Rate for Payer: UHCCP Medicaid |
$201.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$321.67
|
|
|
EXC ABD LES SC 3 CM/>
|
Facility
|
IP
|
$575.00
|
|
|
Service Code
|
HCPCS 22903
|
| Hospital Charge Code |
76100430
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$74.75 |
| Max. Negotiated Rate |
$552.00 |
| Rate for Payer: Aetna Commercial |
$442.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$448.50
|
| Rate for Payer: Cash Price |
$287.50
|
| Rate for Payer: Cigna Commercial |
$477.25
|
| Rate for Payer: First Health Commercial |
$546.25
|
| Rate for Payer: Humana Commercial |
$488.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$471.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$424.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$172.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$506.00
|
| Rate for Payer: Ohio Health Group HMO |
$431.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$115.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$178.25
|
| Rate for Payer: PHCS Commercial |
$552.00
|
| Rate for Payer: United Healthcare All Payer |
$506.00
|
|
|
EXC ABD LES SC 3 CM/>
|
Facility
|
OP
|
$575.00
|
|
|
Service Code
|
HCPCS 22903
|
| Hospital Charge Code |
76100430
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$74.75 |
| Max. Negotiated Rate |
$3,440.07 |
| Rate for Payer: Aetna Commercial |
$442.75
|
| Rate for Payer: Anthem Medicaid |
$197.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$448.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,440.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,317.21
|
| Rate for Payer: Cash Price |
$287.50
|
| Rate for Payer: Cash Price |
$287.50
|
| Rate for Payer: Cigna Commercial |
$477.25
|
| Rate for Payer: First Health Commercial |
$546.25
|
| Rate for Payer: Humana Commercial |
$488.75
|
| Rate for Payer: Humana KY Medicaid |
$197.74
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$199.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$471.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$424.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$201.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$506.00
|
| Rate for Payer: Ohio Health Group HMO |
$431.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$115.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$178.25
|
| Rate for Payer: PHCS Commercial |
$552.00
|
| Rate for Payer: United Healthcare All Payer |
$506.00
|
|
|
EXC ABD LES SC 3 CM/>(P
|
Professional
|
Both
|
$575.00
|
|
|
Service Code
|
HCPCS 22903
|
| Hospital Charge Code |
761P0430
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$201.25 |
| Max. Negotiated Rate |
$770.20 |
| Rate for Payer: Aetna Commercial |
$675.66
|
| Rate for Payer: Anthem Medicaid |
$318.49
|
| Rate for Payer: Buckeye Medicare Advantage |
$575.00
|
| Rate for Payer: Cash Price |
$287.50
|
| Rate for Payer: Cash Price |
$287.50
|
| Rate for Payer: Cigna Commercial |
$770.20
|
| Rate for Payer: Healthspan PPO |
$481.50
|
| Rate for Payer: Humana Medicaid |
$318.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$559.76
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$324.86
|
| Rate for Payer: Molina Healthcare Passport |
$318.49
|
| Rate for Payer: Multiplan PHCS |
$345.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$402.50
|
| Rate for Payer: UHCCP Medicaid |
$201.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$321.67
|
|
|
EXC ABDL TUM DEEP 5 CM/>
|
Facility
|
OP
|
$1,100.00
|
|
|
Service Code
|
HCPCS 22901
|
| Hospital Charge Code |
76100428
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.00 |
| Max. Negotiated Rate |
$3,440.07 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem Medicaid |
$378.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,440.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,317.21
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Humana KY Medicaid |
$378.29
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$382.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$385.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$341.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
EXC ABDL TUM DEEP 5 CM/>
|
Facility
|
IP
|
$1,100.00
|
|
|
Service Code
|
HCPCS 22901
|
| Hospital Charge Code |
76100428
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$341.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
EXC ABDL TUM DEEP 5 CM/>
|
Professional
|
Both
|
$1,100.00
|
|
|
Service Code
|
HCPCS 22901
|
| Hospital Charge Code |
76100428
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$385.00 |
| Max. Negotiated Rate |
$1,166.64 |
| Rate for Payer: Aetna Commercial |
$1,026.53
|
| Rate for Payer: Anthem Medicaid |
$481.77
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,100.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$1,166.64
|
| Rate for Payer: Healthspan PPO |
$732.54
|
| Rate for Payer: Humana Medicaid |
$481.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$838.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$491.41
|
| Rate for Payer: Molina Healthcare Passport |
$481.77
|
| Rate for Payer: Multiplan PHCS |
$660.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$770.00
|
| Rate for Payer: UHCCP Medicaid |
$385.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$486.59
|
|
|
EXC ABDL TUM DEEP 5 CM/>(P
|
Professional
|
Both
|
$1,100.00
|
|
|
Service Code
|
HCPCS 22901
|
| Hospital Charge Code |
761P0428
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$385.00 |
| Max. Negotiated Rate |
$1,166.64 |
| Rate for Payer: Aetna Commercial |
$1,026.53
|
| Rate for Payer: Anthem Medicaid |
$481.77
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,100.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$1,166.64
|
| Rate for Payer: Healthspan PPO |
$732.54
|
| Rate for Payer: Humana Medicaid |
$481.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$838.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$491.41
|
| Rate for Payer: Molina Healthcare Passport |
$481.77
|
| Rate for Payer: Multiplan PHCS |
$660.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$770.00
|
| Rate for Payer: UHCCP Medicaid |
$385.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$486.59
|
|
|
EXC ABD TUM OVER 5 CM
|
Facility
|
IP
|
$2,000.00
|
|
|
Service Code
|
HCPCS 49204
|
| Hospital Charge Code |
76101983
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$260.00 |
| Max. Negotiated Rate |
$1,920.00 |
| Rate for Payer: Aetna Commercial |
$1,540.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,560.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,660.00
|
| Rate for Payer: First Health Commercial |
$1,900.00
|
| Rate for Payer: Humana Commercial |
$1,700.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,640.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,476.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$600.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,760.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,500.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$260.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$620.00
|
| Rate for Payer: PHCS Commercial |
$1,920.00
|
| Rate for Payer: United Healthcare All Payer |
$1,760.00
|
|
|
EXC ABD TUM OVER 5 CM
|
Facility
|
OP
|
$2,000.00
|
|
|
Service Code
|
HCPCS 49204
|
| Hospital Charge Code |
76101983
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$260.00 |
| Max. Negotiated Rate |
$1,920.00 |
| Rate for Payer: Aetna Commercial |
$1,540.00
|
| Rate for Payer: Anthem Medicaid |
$687.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,560.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,660.00
|
| Rate for Payer: First Health Commercial |
$1,900.00
|
| Rate for Payer: Humana Commercial |
$1,700.00
|
| Rate for Payer: Humana KY Medicaid |
$687.80
|
| Rate for Payer: Kentucky WC Medicaid |
$694.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,640.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,476.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$600.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$701.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,760.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,500.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$260.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$620.00
|
| Rate for Payer: PHCS Commercial |
$1,920.00
|
| Rate for Payer: United Healthcare All Payer |
$1,760.00
|
|
|
EXC ABD TUM OVER 5 CM
|
Professional
|
Both
|
$2,000.00
|
|
|
Service Code
|
HCPCS 49204
|
| Hospital Charge Code |
76101983
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$700.00 |
| Max. Negotiated Rate |
$2,232.63 |
| Rate for Payer: Aetna Commercial |
$2,232.63
|
| Rate for Payer: Anthem Medicaid |
$1,133.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$2,029.80
|
| Rate for Payer: Healthspan PPO |
$1,882.82
|
| Rate for Payer: Humana Medicaid |
$1,133.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,948.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,156.36
|
| Rate for Payer: Molina Healthcare Passport |
$1,133.69
|
| Rate for Payer: Multiplan PHCS |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,400.00
|
| Rate for Payer: UHCCP Medicaid |
$700.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,145.03
|
|
|
EXC ABD TUM OVER 5 CM(P
|
Professional
|
Both
|
$2,000.00
|
|
|
Service Code
|
HCPCS 49204
|
| Hospital Charge Code |
761P1983
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$700.00 |
| Max. Negotiated Rate |
$2,232.63 |
| Rate for Payer: Aetna Commercial |
$2,232.63
|
| Rate for Payer: Anthem Medicaid |
$1,133.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$2,029.80
|
| Rate for Payer: Healthspan PPO |
$1,882.82
|
| Rate for Payer: Humana Medicaid |
$1,133.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,948.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,156.36
|
| Rate for Payer: Molina Healthcare Passport |
$1,133.69
|
| Rate for Payer: Multiplan PHCS |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,400.00
|
| Rate for Payer: UHCCP Medicaid |
$700.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,145.03
|
|
|
EXC ARM/ELBOW LES SC 3 CM/>
|
Facility
|
OP
|
$5,853.25
|
|
|
Service Code
|
HCPCS 24071
|
| Hospital Charge Code |
76100500
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$760.92 |
| Max. Negotiated Rate |
$5,619.12 |
| Rate for Payer: Aetna Commercial |
$4,507.00
|
| Rate for Payer: Anthem Medicaid |
$2,012.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,565.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,440.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,317.21
|
| Rate for Payer: Cash Price |
$2,926.62
|
| Rate for Payer: Cash Price |
$2,926.62
|
| Rate for Payer: Cigna Commercial |
$4,858.20
|
| Rate for Payer: First Health Commercial |
$5,560.59
|
| Rate for Payer: Humana Commercial |
$4,975.26
|
| Rate for Payer: Humana KY Medicaid |
$2,012.93
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$2,033.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,799.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,319.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,053.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,150.86
|
| Rate for Payer: Ohio Health Group HMO |
$4,389.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,170.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$760.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,814.51
|
| Rate for Payer: PHCS Commercial |
$5,619.12
|
| Rate for Payer: United Healthcare All Payer |
$5,150.86
|
|
|
EXC ARM/ELBOW LES SC 3 CM/>
|
Facility
|
IP
|
$5,853.25
|
|
|
Service Code
|
HCPCS 24071
|
| Hospital Charge Code |
76100500
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$760.92 |
| Max. Negotiated Rate |
$5,619.12 |
| Rate for Payer: Aetna Commercial |
$4,507.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,565.54
|
| Rate for Payer: Cash Price |
$2,926.62
|
| Rate for Payer: Cigna Commercial |
$4,858.20
|
| Rate for Payer: First Health Commercial |
$5,560.59
|
| Rate for Payer: Humana Commercial |
$4,975.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,799.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,319.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,755.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,150.86
|
| Rate for Payer: Ohio Health Group HMO |
$4,389.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,170.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$760.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,814.51
|
| Rate for Payer: PHCS Commercial |
$5,619.12
|
| Rate for Payer: United Healthcare All Payer |
$5,150.86
|
|
