|
AMPUTATION - METATARSAL - WI
|
Facility
|
OP
|
$789.00
|
|
|
Service Code
|
HCPCS 28810
|
| Hospital Charge Code |
76101042
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$102.57 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Anthem POS/PPO/Traditional |
$615.42
|
| Rate for Payer: Aetna Commercial |
$607.53
|
| Rate for Payer: Anthem Medicaid |
$271.34
|
| 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: Cash Price |
$394.50
|
| Rate for Payer: Cash Price |
$394.50
|
| Rate for Payer: Cigna Commercial |
$654.87
|
| Rate for Payer: First Health Commercial |
$749.55
|
| Rate for Payer: Humana Commercial |
$670.65
|
| Rate for Payer: Humana KY Medicaid |
$271.34
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Kentucky WC Medicaid |
$274.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$646.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$582.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$276.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$694.32
|
| Rate for Payer: Ohio Health Group HMO |
$591.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$157.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$244.59
|
| Rate for Payer: PHCS Commercial |
$757.44
|
| Rate for Payer: United Healthcare All Payer |
$694.32
|
|
|
AMPUTATION - METATARSAL - WI
|
Facility
|
IP
|
$789.00
|
|
|
Service Code
|
HCPCS 28810
|
| Hospital Charge Code |
76101042
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$102.57 |
| Max. Negotiated Rate |
$757.44 |
| Rate for Payer: Aetna Commercial |
$607.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$615.42
|
| Rate for Payer: Cash Price |
$394.50
|
| Rate for Payer: Cigna Commercial |
$654.87
|
| Rate for Payer: First Health Commercial |
$749.55
|
| Rate for Payer: Humana Commercial |
$670.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$646.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$582.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$236.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$694.32
|
| Rate for Payer: Ohio Health Group HMO |
$591.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$157.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$244.59
|
| Rate for Payer: PHCS Commercial |
$757.44
|
| Rate for Payer: United Healthcare All Payer |
$694.32
|
|
|
AMPUTATION - METATARSAL - WI
|
Professional
|
Both
|
$789.00
|
|
|
Service Code
|
HCPCS 28810
|
| Hospital Charge Code |
76101042
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$276.15 |
| Max. Negotiated Rate |
$789.00 |
| Rate for Payer: Aetna Commercial |
$661.33
|
| Rate for Payer: Anthem Medicaid |
$285.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$789.00
|
| Rate for Payer: Cash Price |
$394.50
|
| Rate for Payer: Cash Price |
$394.50
|
| Rate for Payer: Cigna Commercial |
$719.83
|
| Rate for Payer: Healthspan PPO |
$599.02
|
| Rate for Payer: Humana Medicaid |
$285.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$556.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$291.08
|
| Rate for Payer: Molina Healthcare Passport |
$285.37
|
| Rate for Payer: Multiplan PHCS |
$473.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$552.30
|
| Rate for Payer: UHCCP Medicaid |
$276.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$288.22
|
|
|
AMPUTATION - METATARSAL - WI(P
|
Professional
|
Both
|
$789.00
|
|
|
Service Code
|
HCPCS 28810
|
| Hospital Charge Code |
761P1042
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$276.15 |
| Max. Negotiated Rate |
$789.00 |
| Rate for Payer: Aetna Commercial |
$661.33
|
| Rate for Payer: Anthem Medicaid |
$285.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$789.00
|
| Rate for Payer: Cash Price |
$394.50
|
| Rate for Payer: Cash Price |
$394.50
|
| Rate for Payer: Cigna Commercial |
$719.83
|
| Rate for Payer: Healthspan PPO |
$599.02
|
| Rate for Payer: Humana Medicaid |
$285.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$556.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$291.08
|
| Rate for Payer: Molina Healthcare Passport |
$285.37
|
| Rate for Payer: Multiplan PHCS |
$473.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$552.30
|
| Rate for Payer: UHCCP Medicaid |
$276.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$288.22
|
|
|
AMPUTATION, METATARSAL, WITH TOE, SINGLE
|
Facility
|
OP
|
$3,918.70
|
|
|
Service Code
|
CPT 28810
|
|
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 OF LOWER LEG
|
Professional
|
Both
|
$2,420.00
|
|
|
Service Code
|
HCPCS 27881
|
| Hospital Charge Code |
76100957
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$655.20 |
| Max. Negotiated Rate |
$2,420.00 |
| Rate for Payer: Aetna Commercial |
$1,334.49
|
| Rate for Payer: Anthem Medicaid |
$655.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,420.00
|
| Rate for Payer: Cash Price |
$1,210.00
|
| Rate for Payer: Cash Price |
$1,210.00
|
| Rate for Payer: Cigna Commercial |
$1,456.90
|
| Rate for Payer: Healthspan PPO |
$1,208.76
|
| Rate for Payer: Humana Medicaid |
$655.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,123.38
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$668.30
|
| Rate for Payer: Molina Healthcare Passport |
$655.20
|
| Rate for Payer: Multiplan PHCS |
$1,452.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,694.00
|
| Rate for Payer: UHCCP Medicaid |
$847.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$661.75
|
|
|
AMPUTATION OF LOWER LEG
|
Facility
|
IP
|
$2,420.00
|
|
|
Service Code
|
HCPCS 27881
|
| Hospital Charge Code |
76100957
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$314.60 |
| Max. Negotiated Rate |
$2,323.20 |
| Rate for Payer: Aetna Commercial |
$1,863.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,887.60
|
| Rate for Payer: Cash Price |
$1,210.00
|
| Rate for Payer: Cigna Commercial |
$2,008.60
|
| Rate for Payer: First Health Commercial |
$2,299.00
|
| Rate for Payer: Humana Commercial |
$2,057.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,984.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,785.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$726.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,129.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,815.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$484.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$314.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$750.20
|
| Rate for Payer: PHCS Commercial |
$2,323.20
|
| Rate for Payer: United Healthcare All Payer |
$2,129.60
|
|
|
AMPUTATION OF LOWER LEG
|
Facility
|
OP
|
$2,420.00
|
|
|
Service Code
|
HCPCS 27881
|
| Hospital Charge Code |
76100957
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$314.60 |
| Max. Negotiated Rate |
$2,323.20 |
| Rate for Payer: Aetna Commercial |
$1,863.40
|
| Rate for Payer: Anthem Medicaid |
$832.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,887.60
|
| Rate for Payer: Cash Price |
$1,210.00
|
| Rate for Payer: Cigna Commercial |
$2,008.60
|
| Rate for Payer: First Health Commercial |
$2,299.00
|
| Rate for Payer: Humana Commercial |
$2,057.00
|
| Rate for Payer: Humana KY Medicaid |
$832.24
|
| Rate for Payer: Kentucky WC Medicaid |
$840.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,984.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,785.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$726.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$848.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,129.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,815.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$484.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$314.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$750.20
|
| Rate for Payer: PHCS Commercial |
$2,323.20
|
| Rate for Payer: United Healthcare All Payer |
$2,129.60
|
|
|
AMPUTATION OF LOWER LEG(P
|
Professional
|
Both
|
$2,420.00
|
|
|
Service Code
|
HCPCS 27881
|
| Hospital Charge Code |
761P0957
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$655.20 |
| Max. Negotiated Rate |
$2,420.00 |
| Rate for Payer: Aetna Commercial |
$1,334.49
|
| Rate for Payer: Anthem Medicaid |
$655.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,420.00
|
| Rate for Payer: Cash Price |
$1,210.00
|
| Rate for Payer: Cash Price |
$1,210.00
|
| Rate for Payer: Cigna Commercial |
$1,456.90
|
| Rate for Payer: Healthspan PPO |
$1,208.76
|
| Rate for Payer: Humana Medicaid |
$655.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,123.38
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$668.30
|
| Rate for Payer: Molina Healthcare Passport |
$655.20
|
| Rate for Payer: Multiplan PHCS |
$1,452.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,694.00
|
| Rate for Payer: UHCCP Medicaid |
$847.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$661.75
|
|
|
AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC
|
Facility
|
IP
|
$23,215.11
|
|
|
Service Code
|
MSDRG 617
|
| Min. Negotiated Rate |
$15,753.11 |
| Max. Negotiated Rate |
$23,215.11 |
| Rate for Payer: Anthem Medicaid |
$15,753.11
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$16,582.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$23,215.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$22,386.00
|
| Rate for Payer: Humana KY Medicaid |
$15,753.11
|
| Rate for Payer: Humana Medicare Advantage |
$16,582.22
|
| Rate for Payer: Kentucky WC Medicaid |
$15,910.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19,898.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$16,068.17
|
|
|
AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC
|
Facility
|
IP
|
$46,298.00
|
|
|
Service Code
|
MSDRG 616
|
| Min. Negotiated Rate |
$31,416.50 |
| Max. Negotiated Rate |
$46,298.00 |
| Rate for Payer: Anthem Medicaid |
$31,416.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$33,070.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$46,298.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$44,644.50
|
| Rate for Payer: Humana KY Medicaid |
$31,416.50
|
| Rate for Payer: Humana Medicare Advantage |
$33,070.00
|
| Rate for Payer: Kentucky WC Medicaid |
$31,730.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39,684.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$32,044.83
|
|
|
AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$13,587.48
|
|
|
Service Code
|
MSDRG 618
|
| Min. Negotiated Rate |
$9,220.07 |
| Max. Negotiated Rate |
$13,587.48 |
| Rate for Payer: Anthem Medicaid |
$9,220.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9,705.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13,587.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$13,102.21
|
| Rate for Payer: Humana KY Medicaid |
$9,220.07
|
| Rate for Payer: Humana Medicare Advantage |
$9,705.34
|
| Rate for Payer: Kentucky WC Medicaid |
$9,312.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,646.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,404.47
|
|
|
AMPUTATION OF MIDFOOT
|
Facility
|
OP
|
$540.00
|
|
|
Service Code
|
HCPCS 28800
|
| Hospital Charge Code |
76102864
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$70.20 |
| Max. Negotiated Rate |
$518.40 |
| Rate for Payer: Aetna Commercial |
$415.80
|
| Rate for Payer: Anthem Medicaid |
$185.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$421.20
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna Commercial |
$448.20
|
| Rate for Payer: First Health Commercial |
$513.00
|
| Rate for Payer: Humana Commercial |
$459.00
|
| Rate for Payer: Humana KY Medicaid |
$185.71
|
| Rate for Payer: Kentucky WC Medicaid |
$187.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$442.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$398.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$189.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$475.20
|
| Rate for Payer: Ohio Health Group HMO |
$405.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$167.40
|
| Rate for Payer: PHCS Commercial |
$518.40
|
| Rate for Payer: United Healthcare All Payer |
$475.20
|
|
|
AMPUTATION OF MIDFOOT
|
Facility
|
IP
|
$540.00
|
|
|
Service Code
|
HCPCS 28800
|
| Hospital Charge Code |
76102864
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$70.20 |
| Max. Negotiated Rate |
$518.40 |
| Rate for Payer: Aetna Commercial |
$415.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$421.20
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna Commercial |
$448.20
|
| Rate for Payer: First Health Commercial |
$513.00
|
| Rate for Payer: Humana Commercial |
$459.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$442.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$398.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$475.20
|
| Rate for Payer: Ohio Health Group HMO |
$405.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$167.40
|
| Rate for Payer: PHCS Commercial |
$518.40
|
| Rate for Payer: United Healthcare All Payer |
$475.20
|
|
|
AMPUTATION OF MIDFOOT
|
Professional
|
Both
|
$540.00
|
|
|
Service Code
|
HCPCS 28800
|
| Hospital Charge Code |
76102864
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$189.00 |
| Max. Negotiated Rate |
$943.24 |
| Rate for Payer: Aetna Commercial |
$860.60
|
| Rate for Payer: Anthem Medicaid |
$423.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$540.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna Commercial |
$943.24
|
| Rate for Payer: Healthspan PPO |
$779.52
|
| Rate for Payer: Humana Medicaid |
$423.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$704.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$432.01
|
| Rate for Payer: Molina Healthcare Passport |
$423.54
|
| Rate for Payer: Multiplan PHCS |
$324.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$378.00
|
| Rate for Payer: UHCCP Medicaid |
$189.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$427.78
|
|
|
AMPUTATION OF TOE
|
Facility
|
IP
|
$728.00
|
|
|
Service Code
|
HCPCS 28820
|
| Hospital Charge Code |
76101043
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$94.64 |
| Max. Negotiated Rate |
$698.88 |
| Rate for Payer: Aetna Commercial |
$560.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$567.84
|
| Rate for Payer: Cash Price |
$364.00
|
| Rate for Payer: Cigna Commercial |
$604.24
|
| Rate for Payer: First Health Commercial |
$691.60
|
| Rate for Payer: Humana Commercial |
$618.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$596.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$537.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$218.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$640.64
|
| Rate for Payer: Ohio Health Group HMO |
$546.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$145.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$94.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$225.68
|
| Rate for Payer: PHCS Commercial |
$698.88
|
| Rate for Payer: United Healthcare All Payer |
$640.64
|
|
|
AMPUTATION OF TOE
|
Professional
|
Both
|
$728.00
|
|
|
Service Code
|
HCPCS 28820
|
| Hospital Charge Code |
76101043
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$141.02 |
| Max. Negotiated Rate |
$728.00 |
| Rate for Payer: Aetna Commercial |
$518.39
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$141.02
|
| Rate for Payer: Anthem Medicaid |
$184.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$728.00
|
| Rate for Payer: Cash Price |
$364.00
|
| Rate for Payer: Cash Price |
$364.00
|
| Rate for Payer: Cigna Commercial |
$565.87
|
| Rate for Payer: Healthspan PPO |
$659.11
|
| Rate for Payer: Humana Medicaid |
$184.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$432.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$188.54
|
| Rate for Payer: Molina Healthcare Passport |
$184.84
|
| Rate for Payer: Multiplan PHCS |
$436.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$509.60
|
| Rate for Payer: UHCCP Medicaid |
$148.07
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$186.69
|
|
|
AMPUTATION OF TOE
|
Facility
|
OP
|
$728.00
|
|
|
Service Code
|
HCPCS 28820
|
| Hospital Charge Code |
76101043
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$94.64 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Aetna Commercial |
$560.56
|
| Rate for Payer: Anthem Medicaid |
$250.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$567.84
|
| 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 |
$364.00
|
| Rate for Payer: Cash Price |
$364.00
|
| Rate for Payer: Cigna Commercial |
$604.24
|
| Rate for Payer: First Health Commercial |
$691.60
|
| Rate for Payer: Humana Commercial |
$618.80
|
| Rate for Payer: Humana KY Medicaid |
$250.36
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Kentucky WC Medicaid |
$252.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$596.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$537.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$255.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$640.64
|
| Rate for Payer: Ohio Health Group HMO |
$546.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$145.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$94.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$225.68
|
| Rate for Payer: PHCS Commercial |
$698.88
|
| Rate for Payer: United Healthcare All Payer |
$640.64
|
|
|
AMPUTATION OF TOE(P
|
Professional
|
Both
|
$728.00
|
|
|
Service Code
|
HCPCS 28820
|
| Hospital Charge Code |
761P1043
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$141.02 |
| Max. Negotiated Rate |
$728.00 |
| Rate for Payer: Aetna Commercial |
$518.39
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$141.02
|
| Rate for Payer: Anthem Medicaid |
$184.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$728.00
|
| Rate for Payer: Cash Price |
$364.00
|
| Rate for Payer: Cash Price |
$364.00
|
| Rate for Payer: Cigna Commercial |
$565.87
|
| Rate for Payer: Healthspan PPO |
$659.11
|
| Rate for Payer: Humana Medicaid |
$184.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$432.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$188.54
|
| Rate for Payer: Molina Healthcare Passport |
$184.84
|
| Rate for Payer: Multiplan PHCS |
$436.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$509.60
|
| Rate for Payer: UHCCP Medicaid |
$148.07
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$186.69
|
|
|
AMPUTATION - THIGH - THROUGH
|
Professional
|
Both
|
$1,900.00
|
|
|
Service Code
|
HCPCS 27590
|
| Hospital Charge Code |
76100879
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$588.56 |
| Max. Negotiated Rate |
$1,900.00 |
| Rate for Payer: Aetna Commercial |
$1,233.51
|
| Rate for Payer: Anthem Medicaid |
$588.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,900.00
|
| Rate for Payer: Cash Price |
$950.00
|
| Rate for Payer: Cash Price |
$950.00
|
| Rate for Payer: Cigna Commercial |
$1,320.72
|
| Rate for Payer: Healthspan PPO |
$1,117.30
|
| Rate for Payer: Humana Medicaid |
$588.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,054.19
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$600.33
|
| Rate for Payer: Molina Healthcare Passport |
$588.56
|
| Rate for Payer: Multiplan PHCS |
$1,140.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,330.00
|
| Rate for Payer: UHCCP Medicaid |
$665.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$594.45
|
|
|
AMPUTATION - THIGH - THROUGH
|
Facility
|
OP
|
$1,900.00
|
|
|
Service Code
|
HCPCS 27590
|
| Hospital Charge Code |
76100879
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$247.00 |
| Max. Negotiated Rate |
$1,824.00 |
| Rate for Payer: Aetna Commercial |
$1,463.00
|
| Rate for Payer: Anthem Medicaid |
$653.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,482.00
|
| Rate for Payer: Cash Price |
$950.00
|
| Rate for Payer: Cigna Commercial |
$1,577.00
|
| Rate for Payer: First Health Commercial |
$1,805.00
|
| Rate for Payer: Humana Commercial |
$1,615.00
|
| Rate for Payer: Humana KY Medicaid |
$653.41
|
| Rate for Payer: Kentucky WC Medicaid |
$660.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,558.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,402.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$570.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$666.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,672.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,425.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$380.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$589.00
|
| Rate for Payer: PHCS Commercial |
$1,824.00
|
| Rate for Payer: United Healthcare All Payer |
$1,672.00
|
|
|
AMPUTATION - THIGH - THROUGH
|
Facility
|
IP
|
$1,900.00
|
|
|
Service Code
|
HCPCS 27590
|
| Hospital Charge Code |
76100879
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$247.00 |
| Max. Negotiated Rate |
$1,824.00 |
| Rate for Payer: Aetna Commercial |
$1,463.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,482.00
|
| Rate for Payer: Cash Price |
$950.00
|
| Rate for Payer: Cigna Commercial |
$1,577.00
|
| Rate for Payer: First Health Commercial |
$1,805.00
|
| Rate for Payer: Humana Commercial |
$1,615.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,558.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,402.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$570.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,672.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,425.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$380.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$589.00
|
| Rate for Payer: PHCS Commercial |
$1,824.00
|
| Rate for Payer: United Healthcare All Payer |
$1,672.00
|
|
|
AMPUTATION - THIGH - THROUGH(P
|
Professional
|
Both
|
$1,900.00
|
|
|
Service Code
|
HCPCS 27590
|
| Hospital Charge Code |
761P0879
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$588.56 |
| Max. Negotiated Rate |
$1,900.00 |
| Rate for Payer: Aetna Commercial |
$1,233.51
|
| Rate for Payer: Anthem Medicaid |
$588.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,900.00
|
| Rate for Payer: Cash Price |
$950.00
|
| Rate for Payer: Cash Price |
$950.00
|
| Rate for Payer: Cigna Commercial |
$1,320.72
|
| Rate for Payer: Healthspan PPO |
$1,117.30
|
| Rate for Payer: Humana Medicaid |
$588.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,054.19
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$600.33
|
| Rate for Payer: Molina Healthcare Passport |
$588.56
|
| Rate for Payer: Multiplan PHCS |
$1,140.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,330.00
|
| Rate for Payer: UHCCP Medicaid |
$665.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$594.45
|
|
|
AMPUTATION - TOE; INTERPHALAN
|
Facility
|
OP
|
$735.00
|
|
|
Service Code
|
HCPCS 28825
|
| Hospital Charge Code |
76101044
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$95.55 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Aetna Commercial |
$565.95
|
| Rate for Payer: Anthem Medicaid |
$252.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$573.30
|
| 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 |
$367.50
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cigna Commercial |
$610.05
|
| Rate for Payer: First Health Commercial |
$698.25
|
| Rate for Payer: Humana Commercial |
$624.75
|
| Rate for Payer: Humana KY Medicaid |
$252.77
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Kentucky WC Medicaid |
$255.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$602.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$542.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$257.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$646.80
|
| Rate for Payer: Ohio Health Group HMO |
$551.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$95.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$227.85
|
| Rate for Payer: PHCS Commercial |
$705.60
|
| Rate for Payer: United Healthcare All Payer |
$646.80
|
|
|
AMPUTATION - TOE; INTERPHALAN
|
Professional
|
Both
|
$735.00
|
|
|
Service Code
|
HCPCS 28825
|
| Hospital Charge Code |
76101044
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$138.00 |
| Max. Negotiated Rate |
$735.00 |
| Rate for Payer: Aetna Commercial |
$584.73
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$138.00
|
| Rate for Payer: Anthem Medicaid |
$166.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$735.00
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cigna Commercial |
$466.89
|
| Rate for Payer: Healthspan PPO |
$710.95
|
| Rate for Payer: Humana Medicaid |
$166.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$506.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$169.50
|
| Rate for Payer: Molina Healthcare Passport |
$166.18
|
| Rate for Payer: Multiplan PHCS |
$441.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$514.50
|
| Rate for Payer: UHCCP Medicaid |
$144.90
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$167.84
|
|
