|
AMPUTAT FNGTHMBPRISECJNTPHLNX
|
Professional
|
Both
|
$1,475.00
|
|
|
Service Code
|
HCPCS 26951
|
| Hospital Charge Code |
76100756
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$218.29 |
| Max. Negotiated Rate |
$1,475.00 |
| Rate for Payer: Aetna Commercial |
$859.78
|
| Rate for Payer: Anthem Medicaid |
$218.29
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,475.00
|
| Rate for Payer: Cash Price |
$737.50
|
| Rate for Payer: Cash Price |
$737.50
|
| Rate for Payer: Cigna Commercial |
$1,001.82
|
| Rate for Payer: Healthspan PPO |
$778.78
|
| Rate for Payer: Humana Medicaid |
$218.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$772.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$222.66
|
| Rate for Payer: Molina Healthcare Passport |
$218.29
|
| Rate for Payer: Multiplan PHCS |
$885.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,032.50
|
| Rate for Payer: UHCCP Medicaid |
$516.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$220.47
|
|
|
AMPUTAT FNGTHMBPRISECJNTPHLNX
|
Facility
|
IP
|
$1,475.00
|
|
|
Service Code
|
HCPCS 26951
|
| Hospital Charge Code |
76100756
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$191.75 |
| Max. Negotiated Rate |
$1,416.00 |
| Rate for Payer: Aetna Commercial |
$1,135.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,150.50
|
| Rate for Payer: Cash Price |
$737.50
|
| Rate for Payer: Cigna Commercial |
$1,224.25
|
| Rate for Payer: First Health Commercial |
$1,401.25
|
| Rate for Payer: Humana Commercial |
$1,253.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,209.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,088.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,298.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,106.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$295.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$191.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$457.25
|
| Rate for Payer: PHCS Commercial |
$1,416.00
|
| Rate for Payer: United Healthcare All Payer |
$1,298.00
|
|
|
AMPUTAT FNGTHMBPRISECJNTPHLNX
|
Facility
|
IP
|
$4,088.00
|
|
|
Service Code
|
HCPCS 26951
|
| Hospital Charge Code |
45000149
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$531.44 |
| Max. Negotiated Rate |
$3,924.48 |
| Rate for Payer: Aetna Commercial |
$3,147.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,188.64
|
| Rate for Payer: Cash Price |
$2,044.00
|
| Rate for Payer: Cigna Commercial |
$3,393.04
|
| Rate for Payer: First Health Commercial |
$3,883.60
|
| Rate for Payer: Humana Commercial |
$3,474.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,352.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,016.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,226.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,597.44
|
| Rate for Payer: Ohio Health Group HMO |
$3,066.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$817.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$531.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,267.28
|
| Rate for Payer: PHCS Commercial |
$3,924.48
|
| Rate for Payer: United Healthcare All Payer |
$3,597.44
|
|
|
AMPUTAT FNGTHMBPRISECJNTPHLNX
|
Facility
|
OP
|
$4,088.00
|
|
|
Service Code
|
HCPCS 26951
|
| Hospital Charge Code |
45000149
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$531.44 |
| Max. Negotiated Rate |
$3,924.48 |
| Rate for Payer: Aetna Commercial |
$3,147.76
|
| Rate for Payer: Anthem Medicaid |
$1,405.86
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,188.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Cash Price |
$2,044.00
|
| Rate for Payer: Cash Price |
$2,044.00
|
| Rate for Payer: Cigna Commercial |
$3,393.04
|
| Rate for Payer: First Health Commercial |
$3,883.60
|
| Rate for Payer: Humana Commercial |
$3,474.80
|
| Rate for Payer: Humana KY Medicaid |
$1,405.86
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,420.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,352.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,016.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,434.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,597.44
|
| Rate for Payer: Ohio Health Group HMO |
$3,066.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$817.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$531.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,267.28
|
| Rate for Payer: PHCS Commercial |
$3,924.48
|
| Rate for Payer: United Healthcare All Payer |
$3,597.44
|
|
|
AMPUTAT FNGTHMBPRISECJNTPHLNX
|
Facility
|
OP
|
$1,475.00
|
|
|
Service Code
|
HCPCS 26951
|
| Hospital Charge Code |
76100756
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$191.75 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Aetna Commercial |
$1,135.75
|
| Rate for Payer: Anthem Medicaid |
$507.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,150.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Cash Price |
$737.50
|
| Rate for Payer: Cash Price |
$737.50
|
| Rate for Payer: Cigna Commercial |
$1,224.25
|
| Rate for Payer: First Health Commercial |
$1,401.25
|
| Rate for Payer: Humana Commercial |
$1,253.75
|
| Rate for Payer: Humana KY Medicaid |
$507.25
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Kentucky WC Medicaid |
$512.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,209.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,088.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$517.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,298.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,106.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$295.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$191.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$457.25
|
| Rate for Payer: PHCS Commercial |
$1,416.00
|
| Rate for Payer: United Healthcare All Payer |
$1,298.00
|
|
|
AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE
|
Facility
|
OP
|
$3,918.70
|
|
|
Service Code
|
CPT 26951
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,799.07 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
|
|
AMPUTATION FOLLOW-UP SURGER(P
|
Professional
|
Both
|
$1,160.00
|
|
|
Service Code
|
HCPCS 27884
|
| Hospital Charge Code |
761P0959
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$322.35 |
| Max. Negotiated Rate |
$1,160.00 |
| Rate for Payer: Aetna Commercial |
$870.89
|
| Rate for Payer: Anthem Medicaid |
$322.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,160.00
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cigna Commercial |
$945.18
|
| Rate for Payer: Healthspan PPO |
$788.84
|
| Rate for Payer: Humana Medicaid |
$322.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$744.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$328.80
|
| Rate for Payer: Molina Healthcare Passport |
$322.35
|
| Rate for Payer: Multiplan PHCS |
$696.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$812.00
|
| Rate for Payer: UHCCP Medicaid |
$406.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$325.57
|
|
|
AMPUTATION FOLLOW-UP SURGERY
|
Facility
|
IP
|
$1,160.00
|
|
|
Service Code
|
HCPCS 27884
|
| Hospital Charge Code |
76100959
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$150.80 |
| Max. Negotiated Rate |
$1,113.60 |
| Rate for Payer: Aetna Commercial |
$893.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$904.80
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cigna Commercial |
$962.80
|
| Rate for Payer: First Health Commercial |
$1,102.00
|
| Rate for Payer: Humana Commercial |
$986.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$951.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$856.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$348.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,020.80
|
| Rate for Payer: Ohio Health Group HMO |
$870.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$232.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$150.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$359.60
|
| Rate for Payer: PHCS Commercial |
$1,113.60
|
| Rate for Payer: United Healthcare All Payer |
$1,020.80
|
|
|
AMPUTATION FOLLOW-UP SURGERY
|
Facility
|
OP
|
$1,160.00
|
|
|
Service Code
|
HCPCS 27884
|
| Hospital Charge Code |
76100959
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$150.80 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Aetna Commercial |
$893.20
|
| Rate for Payer: Anthem Medicaid |
$398.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$904.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cigna Commercial |
$962.80
|
| Rate for Payer: First Health Commercial |
$1,102.00
|
| Rate for Payer: Humana Commercial |
$986.00
|
| Rate for Payer: Humana KY Medicaid |
$398.92
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Kentucky WC Medicaid |
$402.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$951.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$856.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$406.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,020.80
|
| Rate for Payer: Ohio Health Group HMO |
$870.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$232.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$150.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$359.60
|
| Rate for Payer: PHCS Commercial |
$1,113.60
|
| Rate for Payer: United Healthcare All Payer |
$1,020.80
|
|
|
AMPUTATION FOLLOW-UP SURGERY
|
Professional
|
Both
|
$1,160.00
|
|
|
Service Code
|
HCPCS 27884
|
| Hospital Charge Code |
76100959
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$322.35 |
| Max. Negotiated Rate |
$1,160.00 |
| Rate for Payer: Aetna Commercial |
$870.89
|
| Rate for Payer: Anthem Medicaid |
$322.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,160.00
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cigna Commercial |
$945.18
|
| Rate for Payer: Healthspan PPO |
$788.84
|
| Rate for Payer: Humana Medicaid |
$322.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$744.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$328.80
|
| Rate for Payer: Molina Healthcare Passport |
$322.35
|
| Rate for Payer: Multiplan PHCS |
$696.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$812.00
|
| Rate for Payer: UHCCP Medicaid |
$406.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$325.57
|
|
|
AMPUTATION FOLLOW-UP SURGERY
|
Professional
|
Both
|
$535.00
|
|
|
Service Code
|
HCPCS 27594
|
| Hospital Charge Code |
76102752
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$187.25 |
| Max. Negotiated Rate |
$811.87 |
| Rate for Payer: Aetna Commercial |
$750.38
|
| Rate for Payer: Anthem Medicaid |
$299.29
|
| Rate for Payer: Buckeye Medicare Advantage |
$535.00
|
| Rate for Payer: Cash Price |
$267.50
|
| Rate for Payer: Cash Price |
$267.50
|
| Rate for Payer: Cigna Commercial |
$811.87
|
| Rate for Payer: Healthspan PPO |
$679.69
|
| Rate for Payer: Humana Medicaid |
$299.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$643.77
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$305.28
|
| Rate for Payer: Molina Healthcare Passport |
$299.29
|
| Rate for Payer: Multiplan PHCS |
$321.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$374.50
|
| Rate for Payer: UHCCP Medicaid |
$187.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$302.28
|
|
|
AMPUTATION - FOOT; TRANSMETA(P
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 28805
|
| Hospital Charge Code |
761P1041
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$420.46 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Aetna Commercial |
$1,125.38
|
| Rate for Payer: Anthem Medicaid |
$420.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,500.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,186.90
|
| Rate for Payer: Healthspan PPO |
$1,019.35
|
| Rate for Payer: Humana Medicaid |
$420.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$957.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$428.87
|
| Rate for Payer: Molina Healthcare Passport |
$420.46
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,050.00
|
| Rate for Payer: UHCCP Medicaid |
$525.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$424.66
|
|
|
AMPUTATION - FOOT; TRANSMETAT
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 28805
|
| Hospital Charge Code |
76101041
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$420.46 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Aetna Commercial |
$1,125.38
|
| Rate for Payer: Anthem Medicaid |
$420.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,500.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,186.90
|
| Rate for Payer: Healthspan PPO |
$1,019.35
|
| Rate for Payer: Humana Medicaid |
$420.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$957.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$428.87
|
| Rate for Payer: Molina Healthcare Passport |
$420.46
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,050.00
|
| Rate for Payer: UHCCP Medicaid |
$525.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$424.66
|
|
|
AMPUTATION - FOOT; TRANSMETAT
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 28805
|
| Hospital Charge Code |
76101041
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$195.00 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Aetna Commercial |
$1,155.00
|
| Rate for Payer: Anthem Medicaid |
$515.85
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,245.00
|
| Rate for Payer: First Health Commercial |
$1,425.00
|
| Rate for Payer: Humana Commercial |
$1,275.00
|
| Rate for Payer: Humana KY Medicaid |
$515.85
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Kentucky WC Medicaid |
$521.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$526.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$195.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$465.00
|
| Rate for Payer: PHCS Commercial |
$1,440.00
|
| Rate for Payer: United Healthcare All Payer |
$1,320.00
|
|
|
AMPUTATION - FOOT; TRANSMETAT
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 28805
|
| Hospital Charge Code |
76101041
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$195.00 |
| Max. Negotiated Rate |
$1,440.00 |
| Rate for Payer: Aetna Commercial |
$1,155.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,245.00
|
| Rate for Payer: First Health Commercial |
$1,425.00
|
| Rate for Payer: Humana Commercial |
$1,275.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$450.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$195.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$465.00
|
| Rate for Payer: PHCS Commercial |
$1,440.00
|
| Rate for Payer: United Healthcare All Payer |
$1,320.00
|
|
|
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC
|
Facility
|
IP
|
$32,862.61
|
|
|
Service Code
|
MSDRG 240
|
| Min. Negotiated Rate |
$22,299.63 |
| Max. Negotiated Rate |
$32,862.61 |
| Rate for Payer: Anthem Medicaid |
$22,299.63
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$23,473.29
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$32,862.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$31,688.94
|
| Rate for Payer: Humana KY Medicaid |
$22,299.63
|
| Rate for Payer: Humana Medicare Advantage |
$23,473.29
|
| Rate for Payer: Kentucky WC Medicaid |
$22,522.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28,167.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$22,745.62
|
|
|
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC
|
Facility
|
IP
|
$56,230.94
|
|
|
Service Code
|
MSDRG 239
|
| Min. Negotiated Rate |
$38,156.71 |
| Max. Negotiated Rate |
$56,230.94 |
| Rate for Payer: Anthem Medicaid |
$38,156.71
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$40,164.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$56,230.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$54,222.70
|
| Rate for Payer: Humana KY Medicaid |
$38,156.71
|
| Rate for Payer: Humana Medicare Advantage |
$40,164.96
|
| Rate for Payer: Kentucky WC Medicaid |
$38,538.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48,197.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$38,919.85
|
|
|
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC
|
Facility
|
IP
|
$16,307.30
|
|
|
Service Code
|
MSDRG 241
|
| Min. Negotiated Rate |
$11,065.67 |
| Max. Negotiated Rate |
$16,307.30 |
| Rate for Payer: Anthem Medicaid |
$11,065.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$11,648.07
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$16,307.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$15,724.89
|
| Rate for Payer: Humana KY Medicaid |
$11,065.67
|
| Rate for Payer: Humana Medicare Advantage |
$11,648.07
|
| Rate for Payer: Kentucky WC Medicaid |
$11,176.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13,977.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,286.98
|
|
|
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC
|
Facility
|
IP
|
$25,089.16
|
|
|
Service Code
|
MSDRG 475
|
| Min. Negotiated Rate |
$17,024.79 |
| Max. Negotiated Rate |
$25,089.16 |
| Rate for Payer: Anthem Medicaid |
$17,024.79
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$17,920.83
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$25,089.16
|
| Rate for Payer: CareSource Just4Me Medicare |
$24,193.12
|
| Rate for Payer: Humana KY Medicaid |
$17,024.79
|
| Rate for Payer: Humana Medicare Advantage |
$17,920.83
|
| Rate for Payer: Kentucky WC Medicaid |
$17,195.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,505.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$17,365.28
|
|
|
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC
|
Facility
|
IP
|
$50,335.04
|
|
|
Service Code
|
MSDRG 474
|
| Min. Negotiated Rate |
$34,155.92 |
| Max. Negotiated Rate |
$50,335.04 |
| Rate for Payer: Anthem Medicaid |
$34,155.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$35,953.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$50,335.04
|
| Rate for Payer: CareSource Just4Me Medicare |
$48,537.36
|
| Rate for Payer: Humana KY Medicaid |
$34,155.92
|
| Rate for Payer: Humana Medicare Advantage |
$35,953.60
|
| Rate for Payer: Kentucky WC Medicaid |
$34,497.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43,144.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$34,839.04
|
|
|
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$13,767.60
|
|
|
Service Code
|
MSDRG 476
|
| Min. Negotiated Rate |
$9,342.30 |
| Max. Negotiated Rate |
$13,767.60 |
| Rate for Payer: Anthem Medicaid |
$9,342.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9,834.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13,767.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$13,275.90
|
| Rate for Payer: Humana KY Medicaid |
$9,342.30
|
| Rate for Payer: Humana Medicare Advantage |
$9,834.00
|
| Rate for Payer: Kentucky WC Medicaid |
$9,435.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,800.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,529.15
|
|
|
AMPUTATION - LEG - THROUGH T
|
Facility
|
IP
|
$1,800.00
|
|
|
Service Code
|
HCPCS 27880
|
| Hospital Charge Code |
76100956
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$234.00 |
| Max. Negotiated Rate |
$1,728.00 |
| Rate for Payer: Aetna Commercial |
$1,386.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,404.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,494.00
|
| Rate for Payer: First Health Commercial |
$1,710.00
|
| Rate for Payer: Humana Commercial |
$1,530.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,476.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,328.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,584.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,350.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$360.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$558.00
|
| Rate for Payer: PHCS Commercial |
$1,728.00
|
| Rate for Payer: United Healthcare All Payer |
$1,584.00
|
|
|
AMPUTATION - LEG - THROUGH T
|
Professional
|
Both
|
$1,800.00
|
|
|
Service Code
|
HCPCS 27880
|
| Hospital Charge Code |
76100956
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$576.79 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,378.67
|
| Rate for Payer: Anthem Medicaid |
$576.79
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,800.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,466.60
|
| Rate for Payer: Healthspan PPO |
$1,248.78
|
| Rate for Payer: Humana Medicaid |
$576.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,192.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$588.33
|
| Rate for Payer: Molina Healthcare Passport |
$576.79
|
| Rate for Payer: Multiplan PHCS |
$1,080.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,260.00
|
| Rate for Payer: UHCCP Medicaid |
$630.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$582.56
|
|
|
AMPUTATION - LEG - THROUGH T
|
Facility
|
OP
|
$1,800.00
|
|
|
Service Code
|
HCPCS 27880
|
| Hospital Charge Code |
76100956
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$234.00 |
| Max. Negotiated Rate |
$1,728.00 |
| Rate for Payer: Aetna Commercial |
$1,386.00
|
| Rate for Payer: Anthem Medicaid |
$619.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,404.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,494.00
|
| Rate for Payer: First Health Commercial |
$1,710.00
|
| Rate for Payer: Humana Commercial |
$1,530.00
|
| Rate for Payer: Humana KY Medicaid |
$619.02
|
| Rate for Payer: Kentucky WC Medicaid |
$625.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,476.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,328.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$631.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,584.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,350.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$360.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$558.00
|
| Rate for Payer: PHCS Commercial |
$1,728.00
|
| Rate for Payer: United Healthcare All Payer |
$1,584.00
|
|
|
AMPUTATION - LEG - THROUGH T(P
|
Professional
|
Both
|
$1,800.00
|
|
|
Service Code
|
HCPCS 27880
|
| Hospital Charge Code |
761P0956
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$576.79 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,378.67
|
| Rate for Payer: Anthem Medicaid |
$576.79
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,800.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,466.60
|
| Rate for Payer: Healthspan PPO |
$1,248.78
|
| Rate for Payer: Humana Medicaid |
$576.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,192.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$588.33
|
| Rate for Payer: Molina Healthcare Passport |
$576.79
|
| Rate for Payer: Multiplan PHCS |
$1,080.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,260.00
|
| Rate for Payer: UHCCP Medicaid |
$630.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$582.56
|
|
