|
EXC FOOT/TOE TUM SC < 1.5 CM
|
Facility
|
OP
|
$940.00
|
|
|
Service Code
|
HCPCS 28043
|
| Hospital Charge Code |
76100970
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$122.20 |
| Max. Negotiated Rate |
$1,962.83 |
| Rate for Payer: Aetna Commercial |
$723.80
|
| Rate for Payer: Anthem Medicaid |
$323.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$733.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$470.00
|
| Rate for Payer: Cash Price |
$470.00
|
| Rate for Payer: Cigna Commercial |
$780.20
|
| Rate for Payer: First Health Commercial |
$893.00
|
| Rate for Payer: Humana Commercial |
$799.00
|
| Rate for Payer: Humana KY Medicaid |
$323.27
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$326.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$770.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$693.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$329.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$827.20
|
| Rate for Payer: Ohio Health Group HMO |
$705.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$188.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$122.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$291.40
|
| Rate for Payer: PHCS Commercial |
$902.40
|
| Rate for Payer: United Healthcare All Payer |
$827.20
|
|
|
EXC FOOT/TOE TUM SC < 1.5 CM
|
Facility
|
IP
|
$940.00
|
|
|
Service Code
|
HCPCS 28043
|
| Hospital Charge Code |
76100970
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$122.20 |
| Max. Negotiated Rate |
$902.40 |
| Rate for Payer: Aetna Commercial |
$723.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$733.20
|
| Rate for Payer: Cash Price |
$470.00
|
| Rate for Payer: Cigna Commercial |
$780.20
|
| Rate for Payer: First Health Commercial |
$893.00
|
| Rate for Payer: Humana Commercial |
$799.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$770.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$693.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$282.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$827.20
|
| Rate for Payer: Ohio Health Group HMO |
$705.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$188.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$122.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$291.40
|
| Rate for Payer: PHCS Commercial |
$902.40
|
| Rate for Payer: United Healthcare All Payer |
$827.20
|
|
|
EXC FOOT/TOE TUM SC < 1.5 CM
|
Professional
|
Both
|
$940.00
|
|
|
Service Code
|
HCPCS 28043
|
| Hospital Charge Code |
76100970
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$132.03 |
| Max. Negotiated Rate |
$940.00 |
| Rate for Payer: Aetna Commercial |
$389.82
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$132.03
|
| Rate for Payer: Anthem Medicaid |
$151.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$940.00
|
| Rate for Payer: Cash Price |
$470.00
|
| Rate for Payer: Cash Price |
$470.00
|
| Rate for Payer: Cigna Commercial |
$463.59
|
| Rate for Payer: Healthspan PPO |
$432.59
|
| Rate for Payer: Humana Medicaid |
$151.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$330.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$154.35
|
| Rate for Payer: Molina Healthcare Passport |
$151.32
|
| Rate for Payer: Multiplan PHCS |
$564.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$658.00
|
| Rate for Payer: UHCCP Medicaid |
$138.63
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$152.83
|
|
|
EXC FOOT/TOE TUM SC 1.5 CM/>
|
Facility
|
IP
|
$810.00
|
|
|
Service Code
|
HCPCS 28039
|
| Hospital Charge Code |
76100969
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$105.30 |
| Max. Negotiated Rate |
$777.60 |
| Rate for Payer: Aetna Commercial |
$623.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$631.80
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna Commercial |
$672.30
|
| Rate for Payer: First Health Commercial |
$769.50
|
| Rate for Payer: Humana Commercial |
$688.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$664.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$597.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$243.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$712.80
|
| Rate for Payer: Ohio Health Group HMO |
$607.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$162.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$105.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$251.10
|
| Rate for Payer: PHCS Commercial |
$777.60
|
| Rate for Payer: United Healthcare All Payer |
$712.80
|
|
|
EXC FOOT/TOE TUM SC 1.5 CM/>
|
Professional
|
Both
|
$810.00
|
|
|
Service Code
|
HCPCS 28039
|
| Hospital Charge Code |
76100969
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$177.19 |
| Max. Negotiated Rate |
$824.93 |
| Rate for Payer: Aetna Commercial |
$519.64
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$177.19
|
| Rate for Payer: Anthem Medicaid |
$249.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$810.00
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna Commercial |
$824.93
|
| Rate for Payer: Healthspan PPO |
$510.10
|
| Rate for Payer: Humana Medicaid |
$249.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$422.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$254.61
|
| Rate for Payer: Molina Healthcare Passport |
$249.62
|
| Rate for Payer: Multiplan PHCS |
$486.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$567.00
|
| Rate for Payer: UHCCP Medicaid |
$186.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$252.12
|
|
|
EXC FOOT/TOE TUM SC 1.5 CM/>
|
Facility
|
OP
|
$810.00
|
|
|
Service Code
|
HCPCS 28039
|
| Hospital Charge Code |
76100969
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$105.30 |
| Max. Negotiated Rate |
$3,440.07 |
| Rate for Payer: Aetna Commercial |
$623.70
|
| Rate for Payer: Anthem Medicaid |
$278.56
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$631.80
|
| 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 |
$405.00
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna Commercial |
$672.30
|
| Rate for Payer: First Health Commercial |
$769.50
|
| Rate for Payer: Humana Commercial |
$688.50
|
| Rate for Payer: Humana KY Medicaid |
$278.56
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$281.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$664.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$597.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$284.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$712.80
|
| Rate for Payer: Ohio Health Group HMO |
$607.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$162.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$105.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$251.10
|
| Rate for Payer: PHCS Commercial |
$777.60
|
| Rate for Payer: United Healthcare All Payer |
$712.80
|
|
|
EXC FOOT/TOE TUM SC 1.5 CM/(P
|
Professional
|
Both
|
$810.00
|
|
|
Service Code
|
HCPCS 28039
|
| Hospital Charge Code |
761P0969
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$177.19 |
| Max. Negotiated Rate |
$824.93 |
| Rate for Payer: Aetna Commercial |
$519.64
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$177.19
|
| Rate for Payer: Anthem Medicaid |
$249.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$810.00
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna Commercial |
$824.93
|
| Rate for Payer: Healthspan PPO |
$510.10
|
| Rate for Payer: Humana Medicaid |
$249.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$422.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$254.61
|
| Rate for Payer: Molina Healthcare Passport |
$249.62
|
| Rate for Payer: Multiplan PHCS |
$486.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$567.00
|
| Rate for Payer: UHCCP Medicaid |
$186.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$252.12
|
|
|
EXC FOOT/TOE TUM SC < 1.5 C(P
|
Professional
|
Both
|
$940.00
|
|
|
Service Code
|
HCPCS 28043
|
| Hospital Charge Code |
761P0970
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$132.03 |
| Max. Negotiated Rate |
$940.00 |
| Rate for Payer: Aetna Commercial |
$389.82
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$132.03
|
| Rate for Payer: Anthem Medicaid |
$151.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$940.00
|
| Rate for Payer: Cash Price |
$470.00
|
| Rate for Payer: Cash Price |
$470.00
|
| Rate for Payer: Cigna Commercial |
$463.59
|
| Rate for Payer: Healthspan PPO |
$432.59
|
| Rate for Payer: Humana Medicaid |
$151.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$330.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$154.35
|
| Rate for Payer: Molina Healthcare Passport |
$151.32
|
| Rate for Payer: Multiplan PHCS |
$564.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$658.00
|
| Rate for Payer: UHCCP Medicaid |
$138.63
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$152.83
|
|
|
EXC FOREARM LES SC > 3 CM
|
Facility
|
IP
|
$690.00
|
|
|
Service Code
|
HCPCS 25071
|
| Hospital Charge Code |
76100573
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$89.70 |
| Max. Negotiated Rate |
$662.40 |
| Rate for Payer: Aetna Commercial |
$531.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$538.20
|
| Rate for Payer: Cash Price |
$345.00
|
| Rate for Payer: Cigna Commercial |
$572.70
|
| Rate for Payer: First Health Commercial |
$655.50
|
| Rate for Payer: Humana Commercial |
$586.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$565.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$509.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$607.20
|
| Rate for Payer: Ohio Health Group HMO |
$517.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$138.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$89.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$213.90
|
| Rate for Payer: PHCS Commercial |
$662.40
|
| Rate for Payer: United Healthcare All Payer |
$607.20
|
|
|
EXC FOREARM LES SC > 3 CM
|
Facility
|
OP
|
$690.00
|
|
|
Service Code
|
HCPCS 25071
|
| Hospital Charge Code |
76100573
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$89.70 |
| Max. Negotiated Rate |
$1,962.83 |
| Rate for Payer: Aetna Commercial |
$531.30
|
| Rate for Payer: Anthem Medicaid |
$237.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$538.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$345.00
|
| Rate for Payer: Cash Price |
$345.00
|
| Rate for Payer: Cigna Commercial |
$572.70
|
| Rate for Payer: First Health Commercial |
$655.50
|
| Rate for Payer: Humana Commercial |
$586.50
|
| Rate for Payer: Humana KY Medicaid |
$237.29
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$239.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$565.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$509.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$242.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$607.20
|
| Rate for Payer: Ohio Health Group HMO |
$517.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$138.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$89.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$213.90
|
| Rate for Payer: PHCS Commercial |
$662.40
|
| Rate for Payer: United Healthcare All Payer |
$607.20
|
|
|
EXC FOREARM LES SC > 3 CM
|
Professional
|
Both
|
$690.00
|
|
|
Service Code
|
HCPCS 25071
|
| Hospital Charge Code |
76100573
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$241.50 |
| Max. Negotiated Rate |
$742.45 |
| Rate for Payer: Aetna Commercial |
$651.18
|
| Rate for Payer: Anthem Medicaid |
$306.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$690.00
|
| Rate for Payer: Cash Price |
$345.00
|
| Rate for Payer: Cash Price |
$345.00
|
| Rate for Payer: Cigna Commercial |
$742.45
|
| Rate for Payer: Healthspan PPO |
$464.55
|
| Rate for Payer: Humana Medicaid |
$306.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$543.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$312.85
|
| Rate for Payer: Molina Healthcare Passport |
$306.72
|
| Rate for Payer: Multiplan PHCS |
$414.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$483.00
|
| Rate for Payer: UHCCP Medicaid |
$241.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$309.79
|
|
|
EXC FOREARM LES SC > 3 CM(P
|
Professional
|
Both
|
$690.00
|
|
|
Service Code
|
HCPCS 25071
|
| Hospital Charge Code |
761P0573
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$241.50 |
| Max. Negotiated Rate |
$742.45 |
| Rate for Payer: Aetna Commercial |
$651.18
|
| Rate for Payer: Anthem Medicaid |
$306.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$690.00
|
| Rate for Payer: Cash Price |
$345.00
|
| Rate for Payer: Cash Price |
$345.00
|
| Rate for Payer: Cigna Commercial |
$742.45
|
| Rate for Payer: Healthspan PPO |
$464.55
|
| Rate for Payer: Humana Medicaid |
$306.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$543.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$312.85
|
| Rate for Payer: Molina Healthcare Passport |
$306.72
|
| Rate for Payer: Multiplan PHCS |
$414.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$483.00
|
| Rate for Payer: UHCCP Medicaid |
$241.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$309.79
|
|
|
EXC FOREARM TUM DEEP < 3 CM
|
Facility
|
IP
|
$6,020.00
|
|
|
Service Code
|
HCPCS 25076
|
| Hospital Charge Code |
76102658
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$782.60 |
| Max. Negotiated Rate |
$5,779.20 |
| Rate for Payer: Aetna Commercial |
$4,635.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,695.60
|
| Rate for Payer: Cash Price |
$3,010.00
|
| Rate for Payer: Cigna Commercial |
$4,996.60
|
| Rate for Payer: First Health Commercial |
$5,719.00
|
| Rate for Payer: Humana Commercial |
$5,117.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,936.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,442.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,806.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,297.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,515.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,204.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$782.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,866.20
|
| Rate for Payer: PHCS Commercial |
$5,779.20
|
| Rate for Payer: United Healthcare All Payer |
$5,297.60
|
|
|
EXC FOREARM TUM DEEP < 3 CM
|
Facility
|
OP
|
$6,020.00
|
|
|
Service Code
|
HCPCS 25076
|
| Hospital Charge Code |
76102658
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$782.60 |
| Max. Negotiated Rate |
$5,779.20 |
| Rate for Payer: Aetna Commercial |
$4,635.40
|
| Rate for Payer: Anthem Medicaid |
$2,070.28
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,695.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$3,010.00
|
| Rate for Payer: Cash Price |
$3,010.00
|
| Rate for Payer: Cigna Commercial |
$4,996.60
|
| Rate for Payer: First Health Commercial |
$5,719.00
|
| Rate for Payer: Humana Commercial |
$5,117.00
|
| Rate for Payer: Humana KY Medicaid |
$2,070.28
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$2,091.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,936.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,442.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,111.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,297.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,515.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,204.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$782.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,866.20
|
| Rate for Payer: PHCS Commercial |
$5,779.20
|
| Rate for Payer: United Healthcare All Payer |
$5,297.60
|
|
|
EXC FOREARM TUM DEEP < 3 CM
|
Professional
|
Both
|
$6,020.00
|
|
|
Service Code
|
HCPCS 25076
|
| Hospital Charge Code |
76102658
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$257.37 |
| Max. Negotiated Rate |
$6,020.00 |
| Rate for Payer: Aetna Commercial |
$635.03
|
| Rate for Payer: Anthem Medicaid |
$257.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,020.00
|
| Rate for Payer: Cash Price |
$3,010.00
|
| Rate for Payer: Cash Price |
$3,010.00
|
| Rate for Payer: Cigna Commercial |
$899.28
|
| Rate for Payer: Healthspan PPO |
$575.20
|
| Rate for Payer: Humana Medicaid |
$257.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$638.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$262.52
|
| Rate for Payer: Molina Healthcare Passport |
$257.37
|
| Rate for Payer: Multiplan PHCS |
$3,612.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,214.00
|
| Rate for Payer: UHCCP Medicaid |
$2,107.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$259.94
|
|
|
EXC FOREARM TUM DEEP 3 CM/>
|
Facility
|
IP
|
$882.00
|
|
|
Service Code
|
HCPCS 25073
|
| Hospital Charge Code |
76100574
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$114.66 |
| Max. Negotiated Rate |
$846.72 |
| Rate for Payer: Aetna Commercial |
$679.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$687.96
|
| Rate for Payer: Cash Price |
$441.00
|
| Rate for Payer: Cigna Commercial |
$732.06
|
| Rate for Payer: First Health Commercial |
$837.90
|
| Rate for Payer: Humana Commercial |
$749.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$723.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$650.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$264.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$776.16
|
| Rate for Payer: Ohio Health Group HMO |
$661.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$176.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$114.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$273.42
|
| Rate for Payer: PHCS Commercial |
$846.72
|
| Rate for Payer: United Healthcare All Payer |
$776.16
|
|
|
EXC FOREARM TUM DEEP 3 CM/>
|
Professional
|
Both
|
$882.00
|
|
|
Service Code
|
HCPCS 25073
|
| Hospital Charge Code |
76100574
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$308.70 |
| Max. Negotiated Rate |
$923.84 |
| Rate for Payer: Aetna Commercial |
$809.29
|
| Rate for Payer: Anthem Medicaid |
$381.76
|
| Rate for Payer: Buckeye Medicare Advantage |
$882.00
|
| Rate for Payer: Cash Price |
$441.00
|
| Rate for Payer: Cash Price |
$441.00
|
| Rate for Payer: Cigna Commercial |
$923.84
|
| Rate for Payer: Healthspan PPO |
$576.72
|
| Rate for Payer: Humana Medicaid |
$381.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$677.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$389.40
|
| Rate for Payer: Molina Healthcare Passport |
$381.76
|
| Rate for Payer: Multiplan PHCS |
$529.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$617.40
|
| Rate for Payer: UHCCP Medicaid |
$308.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$385.58
|
|
|
EXC FOREARM TUM DEEP 3 CM/>
|
Facility
|
OP
|
$882.00
|
|
|
Service Code
|
HCPCS 25073
|
| Hospital Charge Code |
76100574
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$114.66 |
| Max. Negotiated Rate |
$3,440.07 |
| Rate for Payer: Aetna Commercial |
$679.14
|
| Rate for Payer: Anthem Medicaid |
$303.32
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$687.96
|
| 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 |
$441.00
|
| Rate for Payer: Cash Price |
$441.00
|
| Rate for Payer: Cigna Commercial |
$732.06
|
| Rate for Payer: First Health Commercial |
$837.90
|
| Rate for Payer: Humana Commercial |
$749.70
|
| Rate for Payer: Humana KY Medicaid |
$303.32
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$306.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$723.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$650.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$309.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$776.16
|
| Rate for Payer: Ohio Health Group HMO |
$661.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$176.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$114.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$273.42
|
| Rate for Payer: PHCS Commercial |
$846.72
|
| Rate for Payer: United Healthcare All Payer |
$776.16
|
|
|
EXC FOREARM TUM DEEP < 3 CM (P
|
Professional
|
Both
|
$1,470.00
|
|
|
Service Code
|
HCPCS 25076
|
| Hospital Charge Code |
761P2658
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$257.37 |
| Max. Negotiated Rate |
$1,470.00 |
| Rate for Payer: Aetna Commercial |
$635.03
|
| Rate for Payer: Anthem Medicaid |
$257.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,470.00
|
| Rate for Payer: Cash Price |
$735.00
|
| Rate for Payer: Cash Price |
$735.00
|
| Rate for Payer: Cigna Commercial |
$899.28
|
| Rate for Payer: Healthspan PPO |
$575.20
|
| Rate for Payer: Humana Medicaid |
$257.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$638.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$262.52
|
| Rate for Payer: Molina Healthcare Passport |
$257.37
|
| Rate for Payer: Multiplan PHCS |
$882.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,029.00
|
| Rate for Payer: UHCCP Medicaid |
$514.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$259.94
|
|
|
EXC FOREARM TUM DEEP 3 CM/>(P
|
Professional
|
Both
|
$882.00
|
|
|
Service Code
|
HCPCS 25073
|
| Hospital Charge Code |
761P0574
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$308.70 |
| Max. Negotiated Rate |
$923.84 |
| Rate for Payer: Aetna Commercial |
$809.29
|
| Rate for Payer: Anthem Medicaid |
$381.76
|
| Rate for Payer: Buckeye Medicare Advantage |
$882.00
|
| Rate for Payer: Cash Price |
$441.00
|
| Rate for Payer: Cash Price |
$441.00
|
| Rate for Payer: Cigna Commercial |
$923.84
|
| Rate for Payer: Healthspan PPO |
$576.72
|
| Rate for Payer: Humana Medicaid |
$381.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$677.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$389.40
|
| Rate for Payer: Molina Healthcare Passport |
$381.76
|
| Rate for Payer: Multiplan PHCS |
$529.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$617.40
|
| Rate for Payer: UHCCP Medicaid |
$308.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$385.58
|
|
|
EXC FOREARM TUM DEEP < 3 CM (T
|
Facility
|
IP
|
$4,550.00
|
|
|
Service Code
|
HCPCS 25076
|
| Hospital Charge Code |
761T2658
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$591.50 |
| Max. Negotiated Rate |
$4,368.00 |
| Rate for Payer: Aetna Commercial |
$3,503.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,549.00
|
| Rate for Payer: Cash Price |
$2,275.00
|
| Rate for Payer: Cigna Commercial |
$3,776.50
|
| Rate for Payer: First Health Commercial |
$4,322.50
|
| Rate for Payer: Humana Commercial |
$3,867.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,731.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,357.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,365.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,004.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,412.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$910.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$591.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,410.50
|
| Rate for Payer: PHCS Commercial |
$4,368.00
|
| Rate for Payer: United Healthcare All Payer |
$4,004.00
|
|
|
EXC FOREARM TUM DEEP < 3 CM (T
|
Facility
|
OP
|
$4,550.00
|
|
|
Service Code
|
HCPCS 25076
|
| Hospital Charge Code |
761T2658
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$591.50 |
| Max. Negotiated Rate |
$4,368.00 |
| Rate for Payer: Aetna Commercial |
$3,503.50
|
| Rate for Payer: Anthem Medicaid |
$1,564.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,549.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$2,275.00
|
| Rate for Payer: Cash Price |
$2,275.00
|
| Rate for Payer: Cigna Commercial |
$3,776.50
|
| Rate for Payer: First Health Commercial |
$4,322.50
|
| Rate for Payer: Humana Commercial |
$3,867.50
|
| Rate for Payer: Humana KY Medicaid |
$1,564.74
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,580.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,731.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,357.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,596.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,004.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,412.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$910.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$591.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,410.50
|
| Rate for Payer: PHCS Commercial |
$4,368.00
|
| Rate for Payer: United Healthcare All Payer |
$4,004.00
|
|
|
EXC GANGLION - WRIST
|
Professional
|
Both
|
$662.00
|
|
|
Service Code
|
HCPCS 25111
|
| Hospital Charge Code |
76100582
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$194.80 |
| Max. Negotiated Rate |
$662.00 |
| Rate for Payer: Aetna Commercial |
$446.12
|
| Rate for Payer: Anthem Medicaid |
$194.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$662.00
|
| Rate for Payer: Cash Price |
$331.00
|
| Rate for Payer: Cash Price |
$331.00
|
| Rate for Payer: Cigna Commercial |
$523.81
|
| Rate for Payer: Healthspan PPO |
$404.09
|
| Rate for Payer: Humana Medicaid |
$194.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$387.93
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$198.70
|
| Rate for Payer: Molina Healthcare Passport |
$194.80
|
| Rate for Payer: Multiplan PHCS |
$397.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$463.40
|
| Rate for Payer: UHCCP Medicaid |
$231.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$196.75
|
|
|
EXC GANGLION - WRIST
|
Facility
|
IP
|
$662.00
|
|
|
Service Code
|
HCPCS 25111
|
| Hospital Charge Code |
76100582
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$86.06 |
| Max. Negotiated Rate |
$635.52 |
| Rate for Payer: Aetna Commercial |
$509.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$516.36
|
| Rate for Payer: Cash Price |
$331.00
|
| Rate for Payer: Cigna Commercial |
$549.46
|
| Rate for Payer: First Health Commercial |
$628.90
|
| Rate for Payer: Humana Commercial |
$562.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$542.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$488.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$198.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$582.56
|
| Rate for Payer: Ohio Health Group HMO |
$496.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$132.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$86.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$205.22
|
| Rate for Payer: PHCS Commercial |
$635.52
|
| Rate for Payer: United Healthcare All Payer |
$582.56
|
|
|
EXC GANGLION - WRIST
|
Facility
|
OP
|
$662.00
|
|
|
Service Code
|
HCPCS 25111
|
| Hospital Charge Code |
76100582
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$86.06 |
| Max. Negotiated Rate |
$1,945.78 |
| Rate for Payer: Aetna Commercial |
$509.74
|
| Rate for Payer: Anthem Medicaid |
$227.66
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,389.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$516.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,945.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,876.28
|
| Rate for Payer: Cash Price |
$331.00
|
| Rate for Payer: Cash Price |
$331.00
|
| Rate for Payer: Cigna Commercial |
$549.46
|
| Rate for Payer: First Health Commercial |
$628.90
|
| Rate for Payer: Humana Commercial |
$562.70
|
| Rate for Payer: Humana KY Medicaid |
$227.66
|
| Rate for Payer: Humana Medicare Advantage |
$1,389.84
|
| Rate for Payer: Kentucky WC Medicaid |
$229.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$542.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$488.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,667.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$232.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$582.56
|
| Rate for Payer: Ohio Health Group HMO |
$496.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$132.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$86.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$205.22
|
| Rate for Payer: PHCS Commercial |
$635.52
|
| Rate for Payer: United Healthcare All Payer |
$582.56
|
|
