|
EXTENDER CUFF ILIAC STR 13*13
|
Facility
|
OP
|
$11,421.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,484.76 |
| Max. Negotiated Rate |
$10,964.40 |
| Rate for Payer: Aetna Commercial |
$8,794.36
|
| Rate for Payer: Anthem Medicaid |
$3,927.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,908.58
|
| Rate for Payer: Cash Price |
$5,710.62
|
| Rate for Payer: Cigna Commercial |
$9,479.64
|
| Rate for Payer: First Health Commercial |
$10,850.19
|
| Rate for Payer: Humana Commercial |
$9,708.06
|
| Rate for Payer: Humana KY Medicaid |
$3,927.77
|
| Rate for Payer: Kentucky WC Medicaid |
$3,967.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,365.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,428.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,426.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,006.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,050.70
|
| Rate for Payer: Ohio Health Group HMO |
$8,565.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,284.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,484.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,540.59
|
| Rate for Payer: PHCS Commercial |
$10,964.40
|
| Rate for Payer: United Healthcare All Payer |
$10,050.70
|
|
|
EXTENDER CUFF ILIAC STR 13*13
|
Facility
|
IP
|
$11,421.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,484.76 |
| Max. Negotiated Rate |
$10,964.40 |
| Rate for Payer: Aetna Commercial |
$8,794.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,908.58
|
| Rate for Payer: Cash Price |
$5,710.62
|
| Rate for Payer: Cigna Commercial |
$9,479.64
|
| Rate for Payer: First Health Commercial |
$10,850.19
|
| Rate for Payer: Humana Commercial |
$9,708.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,365.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,428.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,426.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,050.70
|
| Rate for Payer: Ohio Health Group HMO |
$8,565.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,284.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,484.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,540.59
|
| Rate for Payer: PHCS Commercial |
$10,964.40
|
| Rate for Payer: United Healthcare All Payer |
$10,050.70
|
|
|
EXTENDER CUFF ILIAC STR 14*14
|
Facility
|
OP
|
$11,421.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,484.76 |
| Max. Negotiated Rate |
$10,964.40 |
| Rate for Payer: Aetna Commercial |
$8,794.36
|
| Rate for Payer: Anthem Medicaid |
$3,927.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,908.58
|
| Rate for Payer: Cash Price |
$5,710.62
|
| Rate for Payer: Cigna Commercial |
$9,479.64
|
| Rate for Payer: First Health Commercial |
$10,850.19
|
| Rate for Payer: Humana Commercial |
$9,708.06
|
| Rate for Payer: Humana KY Medicaid |
$3,927.77
|
| Rate for Payer: Kentucky WC Medicaid |
$3,967.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,365.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,428.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,426.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,006.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,050.70
|
| Rate for Payer: Ohio Health Group HMO |
$8,565.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,284.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,484.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,540.59
|
| Rate for Payer: PHCS Commercial |
$10,964.40
|
| Rate for Payer: United Healthcare All Payer |
$10,050.70
|
|
|
EXTENDER CUFF ILIAC STR 14*14
|
Facility
|
IP
|
$11,421.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,484.76 |
| Max. Negotiated Rate |
$10,964.40 |
| Rate for Payer: Aetna Commercial |
$8,794.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,908.58
|
| Rate for Payer: Cash Price |
$5,710.62
|
| Rate for Payer: Cigna Commercial |
$9,479.64
|
| Rate for Payer: First Health Commercial |
$10,850.19
|
| Rate for Payer: Humana Commercial |
$9,708.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,365.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,428.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,426.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,050.70
|
| Rate for Payer: Ohio Health Group HMO |
$8,565.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,284.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,484.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,540.59
|
| Rate for Payer: PHCS Commercial |
$10,964.40
|
| Rate for Payer: United Healthcare All Payer |
$10,050.70
|
|
|
EXTENDER CUFF ILIAC STR 15*15
|
Facility
|
OP
|
$11,421.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,484.76 |
| Max. Negotiated Rate |
$10,964.40 |
| Rate for Payer: Aetna Commercial |
$8,794.36
|
| Rate for Payer: Anthem Medicaid |
$3,927.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,908.58
|
| Rate for Payer: Cash Price |
$5,710.62
|
| Rate for Payer: Cigna Commercial |
$9,479.64
|
| Rate for Payer: First Health Commercial |
$10,850.19
|
| Rate for Payer: Humana Commercial |
$9,708.06
|
| Rate for Payer: Humana KY Medicaid |
$3,927.77
|
| Rate for Payer: Kentucky WC Medicaid |
$3,967.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,365.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,428.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,426.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,006.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,050.70
|
| Rate for Payer: Ohio Health Group HMO |
$8,565.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,284.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,484.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,540.59
|
| Rate for Payer: PHCS Commercial |
$10,964.40
|
| Rate for Payer: United Healthcare All Payer |
$10,050.70
|
|
|
EXTENDER CUFF ILIAC STR 15*15
|
Facility
|
IP
|
$11,421.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,484.76 |
| Max. Negotiated Rate |
$10,964.40 |
| Rate for Payer: Aetna Commercial |
$8,794.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,908.58
|
| Rate for Payer: Cash Price |
$5,710.62
|
| Rate for Payer: Cigna Commercial |
$9,479.64
|
| Rate for Payer: First Health Commercial |
$10,850.19
|
| Rate for Payer: Humana Commercial |
$9,708.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,365.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,428.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,426.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,050.70
|
| Rate for Payer: Ohio Health Group HMO |
$8,565.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,284.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,484.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,540.59
|
| Rate for Payer: PHCS Commercial |
$10,964.40
|
| Rate for Payer: United Healthcare All Payer |
$10,050.70
|
|
|
EXTENDER CUFF ILIAC STR 16*16
|
Facility
|
OP
|
$12,060.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,567.80 |
| Max. Negotiated Rate |
$11,577.60 |
| Rate for Payer: Aetna Commercial |
$9,286.20
|
| Rate for Payer: Anthem Medicaid |
$4,147.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,406.80
|
| Rate for Payer: Cash Price |
$6,030.00
|
| Rate for Payer: Cigna Commercial |
$10,009.80
|
| Rate for Payer: First Health Commercial |
$11,457.00
|
| Rate for Payer: Humana Commercial |
$10,251.00
|
| Rate for Payer: Humana KY Medicaid |
$4,147.43
|
| Rate for Payer: Kentucky WC Medicaid |
$4,189.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,889.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,900.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,618.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,230.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,612.80
|
| Rate for Payer: Ohio Health Group HMO |
$9,045.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,412.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,567.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,738.60
|
| Rate for Payer: PHCS Commercial |
$11,577.60
|
| Rate for Payer: United Healthcare All Payer |
$10,612.80
|
|
|
EXTENDER CUFF ILIAC STR 16*16
|
Facility
|
IP
|
$12,060.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,567.80 |
| Max. Negotiated Rate |
$11,577.60 |
| Rate for Payer: Aetna Commercial |
$9,286.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,406.80
|
| Rate for Payer: Cash Price |
$6,030.00
|
| Rate for Payer: Cigna Commercial |
$10,009.80
|
| Rate for Payer: First Health Commercial |
$11,457.00
|
| Rate for Payer: Humana Commercial |
$10,251.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,889.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,900.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,618.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,612.80
|
| Rate for Payer: Ohio Health Group HMO |
$9,045.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,412.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,567.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,738.60
|
| Rate for Payer: PHCS Commercial |
$11,577.60
|
| Rate for Payer: United Healthcare All Payer |
$10,612.80
|
|
|
EXTENDER CUFF ILIAC STR 18*18
|
Facility
|
IP
|
$13,337.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,733.88 |
| Max. Negotiated Rate |
$12,804.00 |
| Rate for Payer: Aetna Commercial |
$10,269.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,403.25
|
| Rate for Payer: Cash Price |
$6,668.75
|
| Rate for Payer: Cigna Commercial |
$11,070.12
|
| Rate for Payer: First Health Commercial |
$12,670.62
|
| Rate for Payer: Humana Commercial |
$11,336.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,936.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,843.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,001.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,737.00
|
| Rate for Payer: Ohio Health Group HMO |
$10,003.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,667.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,733.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,134.62
|
| Rate for Payer: PHCS Commercial |
$12,804.00
|
| Rate for Payer: United Healthcare All Payer |
$11,737.00
|
|
|
EXTENDER CUFF ILIAC STR 18*18
|
Facility
|
OP
|
$13,337.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,733.88 |
| Max. Negotiated Rate |
$12,804.00 |
| Rate for Payer: Aetna Commercial |
$10,269.88
|
| Rate for Payer: Anthem Medicaid |
$4,586.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,403.25
|
| Rate for Payer: Cash Price |
$6,668.75
|
| Rate for Payer: Cigna Commercial |
$11,070.12
|
| Rate for Payer: First Health Commercial |
$12,670.62
|
| Rate for Payer: Humana Commercial |
$11,336.88
|
| Rate for Payer: Humana KY Medicaid |
$4,586.77
|
| Rate for Payer: Kentucky WC Medicaid |
$4,633.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,936.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,843.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,001.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,678.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,737.00
|
| Rate for Payer: Ohio Health Group HMO |
$10,003.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,667.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,733.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,134.62
|
| Rate for Payer: PHCS Commercial |
$12,804.00
|
| Rate for Payer: United Healthcare All Payer |
$11,737.00
|
|
|
EXTENDER CUFF ILIAC STR 20*20
|
Facility
|
IP
|
$11,786.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,532.21 |
| Max. Negotiated Rate |
$11,314.80 |
| Rate for Payer: Aetna Commercial |
$9,075.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,193.28
|
| Rate for Payer: Cash Price |
$5,893.12
|
| Rate for Payer: Cigna Commercial |
$9,782.59
|
| Rate for Payer: First Health Commercial |
$11,196.94
|
| Rate for Payer: Humana Commercial |
$10,018.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,664.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,698.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,535.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,371.90
|
| Rate for Payer: Ohio Health Group HMO |
$8,839.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,357.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,532.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,653.74
|
| Rate for Payer: PHCS Commercial |
$11,314.80
|
| Rate for Payer: United Healthcare All Payer |
$10,371.90
|
|
|
EXTENDER CUFF ILIAC STR 20*20
|
Facility
|
OP
|
$11,786.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,532.21 |
| Max. Negotiated Rate |
$11,314.80 |
| Rate for Payer: Aetna Commercial |
$9,075.41
|
| Rate for Payer: Anthem Medicaid |
$4,053.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,193.28
|
| Rate for Payer: Cash Price |
$5,893.12
|
| Rate for Payer: Cigna Commercial |
$9,782.59
|
| Rate for Payer: First Health Commercial |
$11,196.94
|
| Rate for Payer: Humana Commercial |
$10,018.31
|
| Rate for Payer: Humana KY Medicaid |
$4,053.29
|
| Rate for Payer: Kentucky WC Medicaid |
$4,094.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,664.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,698.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,535.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,134.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,371.90
|
| Rate for Payer: Ohio Health Group HMO |
$8,839.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,357.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,532.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,653.74
|
| Rate for Payer: PHCS Commercial |
$11,314.80
|
| Rate for Payer: United Healthcare All Payer |
$10,371.90
|
|
|
EXTENSION KIT 1*8 40CM
|
Facility
|
OP
|
$4,282.50
|
|
|
Service Code
|
HCPCS C1897
|
| Hospital Charge Code |
27000065
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$556.72 |
| Max. Negotiated Rate |
$4,111.20 |
| Rate for Payer: Aetna Commercial |
$3,297.52
|
| Rate for Payer: Anthem Medicaid |
$1,472.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,340.35
|
| Rate for Payer: Cash Price |
$2,141.25
|
| Rate for Payer: Cigna Commercial |
$3,554.48
|
| Rate for Payer: First Health Commercial |
$4,068.38
|
| Rate for Payer: Humana Commercial |
$3,640.12
|
| Rate for Payer: Humana KY Medicaid |
$1,472.75
|
| Rate for Payer: Kentucky WC Medicaid |
$1,487.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,511.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,160.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,284.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,502.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,768.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,211.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$856.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$556.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,327.58
|
| Rate for Payer: PHCS Commercial |
$4,111.20
|
| Rate for Payer: United Healthcare All Payer |
$3,768.60
|
|
|
EXTENSION KIT 1*8 40CM
|
Facility
|
IP
|
$4,282.50
|
|
|
Service Code
|
HCPCS C1897
|
| Hospital Charge Code |
27000065
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$556.72 |
| Max. Negotiated Rate |
$4,111.20 |
| Rate for Payer: Aetna Commercial |
$3,297.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,340.35
|
| Rate for Payer: Cash Price |
$2,141.25
|
| Rate for Payer: Cigna Commercial |
$3,554.48
|
| Rate for Payer: First Health Commercial |
$4,068.38
|
| Rate for Payer: Humana Commercial |
$3,640.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,511.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,160.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,284.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,768.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,211.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$856.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$556.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,327.58
|
| Rate for Payer: PHCS Commercial |
$4,111.20
|
| Rate for Payer: United Healthcare All Payer |
$3,768.60
|
|
|
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT
|
Facility
|
IP
|
$35,468.96
|
|
|
Service Code
|
MSDRG 933
|
| Min. Negotiated Rate |
$24,068.22 |
| Max. Negotiated Rate |
$35,468.96 |
| Rate for Payer: Anthem Medicaid |
$24,068.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$25,334.97
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$35,468.96
|
| Rate for Payer: CareSource Just4Me Medicare |
$34,202.21
|
| Rate for Payer: Humana KY Medicaid |
$24,068.22
|
| Rate for Payer: Humana Medicare Advantage |
$25,334.97
|
| Rate for Payer: Kentucky WC Medicaid |
$24,308.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30,401.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$24,549.59
|
|
|
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT
|
Facility
|
IP
|
$308,349.48
|
|
|
Service Code
|
MSDRG 927
|
| Min. Negotiated Rate |
$209,237.15 |
| Max. Negotiated Rate |
$308,349.48 |
| Rate for Payer: Anthem Medicaid |
$209,237.15
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$220,249.63
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$308,349.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$297,337.00
|
| Rate for Payer: Humana KY Medicaid |
$209,237.15
|
| Rate for Payer: Humana Medicare Advantage |
$220,249.63
|
| Rate for Payer: Kentucky WC Medicaid |
$211,329.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$264,299.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$213,421.89
|
|
|
EXTENSIVE EAR CANAL SURGERY
|
Facility
|
OP
|
$2,275.00
|
|
|
Service Code
|
HCPCS 69150
|
| Hospital Charge Code |
76102409
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$295.75 |
| Max. Negotiated Rate |
$7,089.80 |
| Rate for Payer: Aetna Commercial |
$1,751.75
|
| Rate for Payer: Anthem Medicaid |
$782.37
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,064.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,774.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,089.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,836.59
|
| Rate for Payer: Cash Price |
$1,137.50
|
| Rate for Payer: Cash Price |
$1,137.50
|
| Rate for Payer: Cigna Commercial |
$1,888.25
|
| Rate for Payer: First Health Commercial |
$2,161.25
|
| Rate for Payer: Humana Commercial |
$1,933.75
|
| Rate for Payer: Humana KY Medicaid |
$782.37
|
| Rate for Payer: Humana Medicare Advantage |
$5,064.14
|
| Rate for Payer: Kentucky WC Medicaid |
$790.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,865.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,678.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,076.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$798.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,002.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,706.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$455.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$295.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$705.25
|
| Rate for Payer: PHCS Commercial |
$2,184.00
|
| Rate for Payer: United Healthcare All Payer |
$2,002.00
|
|
|
EXTENSIVE EAR CANAL SURGERY
|
Professional
|
Both
|
$2,275.00
|
|
|
Service Code
|
HCPCS 69150
|
| Hospital Charge Code |
76102409
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$692.69 |
| Max. Negotiated Rate |
$2,275.00 |
| Rate for Payer: Aetna Commercial |
$1,515.93
|
| Rate for Payer: Anthem Medicaid |
$692.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,275.00
|
| Rate for Payer: Cash Price |
$1,137.50
|
| Rate for Payer: Cash Price |
$1,137.50
|
| Rate for Payer: Cigna Commercial |
$1,525.50
|
| Rate for Payer: Healthspan PPO |
$1,344.70
|
| Rate for Payer: Humana Medicaid |
$692.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,340.93
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$706.54
|
| Rate for Payer: Molina Healthcare Passport |
$692.69
|
| Rate for Payer: Multiplan PHCS |
$1,365.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,592.50
|
| Rate for Payer: UHCCP Medicaid |
$796.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$699.62
|
|
|
EXTENSIVE EAR CANAL SURGERY
|
Facility
|
IP
|
$2,275.00
|
|
|
Service Code
|
HCPCS 69150
|
| Hospital Charge Code |
76102409
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$295.75 |
| Max. Negotiated Rate |
$2,184.00 |
| Rate for Payer: Aetna Commercial |
$1,751.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,774.50
|
| Rate for Payer: Cash Price |
$1,137.50
|
| Rate for Payer: Cigna Commercial |
$1,888.25
|
| Rate for Payer: First Health Commercial |
$2,161.25
|
| Rate for Payer: Humana Commercial |
$1,933.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,865.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,678.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$682.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,002.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,706.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$455.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$295.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$705.25
|
| Rate for Payer: PHCS Commercial |
$2,184.00
|
| Rate for Payer: United Healthcare All Payer |
$2,002.00
|
|
|
EXTENSIVE EAR CANAL SURGERY(P
|
Professional
|
Both
|
$2,275.00
|
|
|
Service Code
|
HCPCS 69150
|
| Hospital Charge Code |
761P2409
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$692.69 |
| Max. Negotiated Rate |
$2,275.00 |
| Rate for Payer: Aetna Commercial |
$1,515.93
|
| Rate for Payer: Anthem Medicaid |
$692.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,275.00
|
| Rate for Payer: Cash Price |
$1,137.50
|
| Rate for Payer: Cash Price |
$1,137.50
|
| Rate for Payer: Cigna Commercial |
$1,525.50
|
| Rate for Payer: Healthspan PPO |
$1,344.70
|
| Rate for Payer: Humana Medicaid |
$692.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,340.93
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$706.54
|
| Rate for Payer: Molina Healthcare Passport |
$692.69
|
| Rate for Payer: Multiplan PHCS |
$1,365.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,592.50
|
| Rate for Payer: UHCCP Medicaid |
$796.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$699.62
|
|
|
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC
|
Facility
|
IP
|
$29,081.74
|
|
|
Service Code
|
MSDRG 982
|
| Min. Negotiated Rate |
$19,734.04 |
| Max. Negotiated Rate |
$29,081.74 |
| Rate for Payer: Anthem Medicaid |
$19,734.04
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20,772.67
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$29,081.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$28,043.10
|
| Rate for Payer: Humana KY Medicaid |
$19,734.04
|
| Rate for Payer: Humana Medicare Advantage |
$20,772.67
|
| Rate for Payer: Kentucky WC Medicaid |
$19,931.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24,927.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$20,128.72
|
|
|
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC
|
Facility
|
IP
|
$55,454.18
|
|
|
Service Code
|
MSDRG 981
|
| Min. Negotiated Rate |
$37,629.62 |
| Max. Negotiated Rate |
$55,454.18 |
| Rate for Payer: Anthem Medicaid |
$37,629.62
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$39,610.13
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$55,454.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$53,473.68
|
| Rate for Payer: Humana KY Medicaid |
$37,629.62
|
| Rate for Payer: Humana Medicare Advantage |
$39,610.13
|
| Rate for Payer: Kentucky WC Medicaid |
$38,005.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47,532.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$38,382.22
|
|
|
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC
|
Facility
|
IP
|
$19,128.91
|
|
|
Service Code
|
MSDRG 983
|
| Min. Negotiated Rate |
$12,980.33 |
| Max. Negotiated Rate |
$19,128.91 |
| Rate for Payer: Anthem Medicaid |
$12,980.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$13,663.51
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$19,128.91
|
| Rate for Payer: CareSource Just4Me Medicare |
$18,445.74
|
| Rate for Payer: Humana KY Medicaid |
$12,980.33
|
| Rate for Payer: Humana Medicare Advantage |
$13,663.51
|
| Rate for Payer: Kentucky WC Medicaid |
$13,110.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16,396.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,239.94
|
|
|
EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITH INSERTION OF INTRAOCULAR (EG, TRABECULAR MESHWORK, SUPRACILIARY, SUPRACHOROIDAL) ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, ONE OR MORE
|
Facility
|
OP
|
$6,327.54
|
|
|
Service Code
|
CPT 66989
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,519.67 |
| Max. Negotiated Rate |
$6,327.54 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,519.67
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,327.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,101.55
|
| Rate for Payer: Humana Medicare Advantage |
$4,519.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,423.60
|
|
|
EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE; WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION
|
Facility
|
OP
|
$2,821.27
|
|
|
Service Code
|
CPT 66982
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,015.19 |
| Max. Negotiated Rate |
$2,821.27 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,015.19
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,821.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,720.51
|
| Rate for Payer: Humana Medicare Advantage |
$2,015.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,418.23
|
|
