|
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: Ambetter Exchange |
$479.24
|
| Rate for Payer: Anthem Medicaid |
$299.29
|
| Rate for Payer: Buckeye Individual/Medicaid |
$479.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$479.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$575.09
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$479.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$479.24
|
| 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 |
$623.01
|
| Rate for Payer: UHCCP Medicaid |
$187.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$302.28
|
| Rate for Payer: Wellcare Medicare Advantage |
$479.24
|
|
|
AMPUTATION FOLLOW-UP SURGERY
|
Facility
|
OP
|
$1,160.00
|
|
|
Service Code
|
HCPCS 27884
|
| Hospital Charge Code |
76100959
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$398.92 |
| Max. Negotiated Rate |
$4,197.13 |
| Rate for Payer: Aetna Commercial |
$893.20
|
| Rate for Payer: Anthem Medicaid |
$398.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,997.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$904.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| 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 |
$2,997.95
|
| 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 |
$3,597.54
|
| 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 |
$928.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,009.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$800.40
|
| Rate for Payer: PHCS Commercial |
$1,113.60
|
| Rate for Payer: United Healthcare All Payer |
$1,020.80
|
|
|
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 |
$1,186.90 |
| Rate for Payer: Aetna Commercial |
$1,125.38
|
| Rate for Payer: Ambetter Exchange |
$669.70
|
| Rate for Payer: Anthem Medicaid |
$420.46
|
| Rate for Payer: Buckeye Individual/Medicaid |
$669.70
|
| Rate for Payer: Buckeye Medicare Advantage |
$669.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$803.64
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$669.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$669.70
|
| 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 |
$870.61
|
| Rate for Payer: UHCCP Medicaid |
$525.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$424.66
|
| Rate for Payer: Wellcare Medicare Advantage |
$669.70
|
|
|
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 |
$1,186.90 |
| Rate for Payer: Aetna Commercial |
$1,125.38
|
| Rate for Payer: Ambetter Exchange |
$669.70
|
| Rate for Payer: Anthem Medicaid |
$420.46
|
| Rate for Payer: Buckeye Individual/Medicaid |
$669.70
|
| Rate for Payer: Buckeye Medicare Advantage |
$669.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$803.64
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$669.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$669.70
|
| 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 |
$870.61
|
| Rate for Payer: UHCCP Medicaid |
$525.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$424.66
|
| Rate for Payer: Wellcare Medicare Advantage |
$669.70
|
|
|
AMPUTATION - FOOT; TRANSMETAT
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 28805
|
| Hospital Charge Code |
76101041
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$450.00 |
| 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 |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,305.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,035.00
|
| Rate for Payer: PHCS Commercial |
$1,440.00
|
| Rate for Payer: United Healthcare All Payer |
$1,320.00
|
|
|
AMPUTATION - FOOT; TRANSMETAT
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 28805
|
| Hospital Charge Code |
76101041
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$515.85 |
| Max. Negotiated Rate |
$4,197.13 |
| Rate for Payer: Aetna Commercial |
$1,155.00
|
| Rate for Payer: Anthem Medicaid |
$515.85
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,997.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| 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 |
$2,997.95
|
| 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 |
$3,597.54
|
| 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 |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,305.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,035.00
|
| Rate for Payer: PHCS Commercial |
$1,440.00
|
| Rate for Payer: United Healthcare All Payer |
$1,320.00
|
|
|
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 |
$1,466.60 |
| Rate for Payer: Aetna Commercial |
$1,378.67
|
| Rate for Payer: Ambetter Exchange |
$851.21
|
| Rate for Payer: Anthem Medicaid |
$576.79
|
| Rate for Payer: Buckeye Individual/Medicaid |
$851.21
|
| Rate for Payer: Buckeye Medicare Advantage |
$851.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,021.45
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$851.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$851.21
|
| 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 |
$1,106.57
|
| Rate for Payer: UHCCP Medicaid |
$630.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$582.56
|
| Rate for Payer: Wellcare Medicare Advantage |
$851.21
|
|
|
AMPUTATION - LEG - THROUGH T
|
Facility
|
IP
|
$1,800.00
|
|
|
Service Code
|
HCPCS 27880
|
| Hospital Charge Code |
76100956
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$540.00 |
| 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 |
$1,440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,566.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,242.00
|
| Rate for Payer: PHCS Commercial |
$1,728.00
|
| Rate for Payer: United Healthcare All Payer |
$1,584.00
|
|
|
AMPUTATION - LEG - THROUGH T
|
Facility
|
OP
|
$1,800.00
|
|
|
Service Code
|
HCPCS 27880
|
| Hospital Charge Code |
76100956
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$540.00 |
| 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 |
$1,440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,566.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,242.00
|
| 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 |
$1,466.60 |
| Rate for Payer: Aetna Commercial |
$1,378.67
|
| Rate for Payer: Ambetter Exchange |
$851.21
|
| Rate for Payer: Anthem Medicaid |
$576.79
|
| Rate for Payer: Buckeye Individual/Medicaid |
$851.21
|
| Rate for Payer: Buckeye Medicare Advantage |
$851.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,021.45
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$851.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$851.21
|
| 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 |
$1,106.57
|
| Rate for Payer: UHCCP Medicaid |
$630.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$582.56
|
| Rate for Payer: Wellcare Medicare Advantage |
$851.21
|
|
|
AMPUTATION - METATARSAL - WI
|
Facility
|
OP
|
$789.00
|
|
|
Service Code
|
HCPCS 28810
|
| Hospital Charge Code |
76101042
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$271.34 |
| Max. Negotiated Rate |
$4,197.13 |
| Rate for Payer: Aetna Commercial |
$607.53
|
| Rate for Payer: Anthem Medicaid |
$271.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,997.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$615.42
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| 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 |
$2,997.95
|
| 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 |
$3,597.54
|
| 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 |
$631.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$686.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$544.41
|
| 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 |
$236.70 |
| 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 |
$631.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$686.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$544.41
|
| 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 |
$719.83 |
| Rate for Payer: Aetna Commercial |
$661.33
|
| Rate for Payer: Ambetter Exchange |
$399.42
|
| Rate for Payer: Anthem Medicaid |
$285.37
|
| Rate for Payer: Buckeye Individual/Medicaid |
$399.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$399.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$479.30
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$399.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$399.42
|
| 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 |
$519.25
|
| Rate for Payer: UHCCP Medicaid |
$276.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$288.22
|
| Rate for Payer: Wellcare Medicare Advantage |
$399.42
|
|
|
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 |
$719.83 |
| Rate for Payer: Aetna Commercial |
$661.33
|
| Rate for Payer: Ambetter Exchange |
$399.42
|
| Rate for Payer: Anthem Medicaid |
$285.37
|
| Rate for Payer: Buckeye Individual/Medicaid |
$399.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$399.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$479.30
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$399.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$399.42
|
| 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 |
$519.25
|
| Rate for Payer: UHCCP Medicaid |
$276.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$288.22
|
| Rate for Payer: Wellcare Medicare Advantage |
$399.42
|
|
|
AMPUTATION, METATARSAL, WITH TOE, SINGLE
|
Facility
|
OP
|
$4,197.13
|
|
|
Service Code
|
CPT 28810
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,997.95 |
| Max. Negotiated Rate |
$4,197.13 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,997.95
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| Rate for Payer: Humana Medicare Advantage |
$2,997.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,597.54
|
|
|
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 |
$1,456.90 |
| Rate for Payer: Aetna Commercial |
$1,334.49
|
| Rate for Payer: Ambetter Exchange |
$784.56
|
| Rate for Payer: Anthem Medicaid |
$655.20
|
| Rate for Payer: Buckeye Individual/Medicaid |
$784.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$784.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$941.47
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$784.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$784.56
|
| 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 |
$1,019.93
|
| Rate for Payer: UHCCP Medicaid |
$847.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$661.75
|
| Rate for Payer: Wellcare Medicare Advantage |
$784.56
|
|
|
AMPUTATION OF LOWER LEG
|
Facility
|
OP
|
$2,420.00
|
|
|
Service Code
|
HCPCS 27881
|
| Hospital Charge Code |
76100957
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$726.00 |
| 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 |
$1,936.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,105.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,669.80
|
| Rate for Payer: PHCS Commercial |
$2,323.20
|
| Rate for Payer: United Healthcare All Payer |
$2,129.60
|
|
|
AMPUTATION OF LOWER LEG
|
Facility
|
IP
|
$2,420.00
|
|
|
Service Code
|
HCPCS 27881
|
| Hospital Charge Code |
76100957
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$726.00 |
| 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 |
$1,936.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,105.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,669.80
|
| 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 |
$1,456.90 |
| Rate for Payer: Aetna Commercial |
$1,334.49
|
| Rate for Payer: Ambetter Exchange |
$784.56
|
| Rate for Payer: Anthem Medicaid |
$655.20
|
| Rate for Payer: Buckeye Individual/Medicaid |
$784.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$784.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$941.47
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$784.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$784.56
|
| 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 |
$1,019.93
|
| Rate for Payer: UHCCP Medicaid |
$847.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$661.75
|
| Rate for Payer: Wellcare Medicare Advantage |
$784.56
|
|
|
AMPUTATION OF MIDFOOT
|
Facility
|
OP
|
$540.00
|
|
|
Service Code
|
HCPCS 28800
|
| Hospital Charge Code |
76102864
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$162.00 |
| 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 |
$432.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$469.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$372.60
|
| 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: Ambetter Exchange |
$500.36
|
| Rate for Payer: Anthem Medicaid |
$423.54
|
| Rate for Payer: Buckeye Individual/Medicaid |
$500.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$500.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$600.43
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$500.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$500.36
|
| 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 |
$650.47
|
| Rate for Payer: UHCCP Medicaid |
$189.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$427.78
|
| Rate for Payer: Wellcare Medicare Advantage |
$500.36
|
|
|
AMPUTATION OF MIDFOOT
|
Facility
|
IP
|
$540.00
|
|
|
Service Code
|
HCPCS 28800
|
| Hospital Charge Code |
76102864
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$162.00 |
| 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 |
$432.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$469.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$372.60
|
| Rate for Payer: PHCS Commercial |
$518.40
|
| Rate for Payer: United Healthcare All Payer |
$475.20
|
|
|
AMPUTATION OF TOE
|
Facility
|
OP
|
$728.00
|
|
|
Service Code
|
HCPCS 28820
|
| Hospital Charge Code |
76101043
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$250.36 |
| Max. Negotiated Rate |
$4,197.13 |
| Rate for Payer: Aetna Commercial |
$560.56
|
| Rate for Payer: Anthem Medicaid |
$250.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,997.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$567.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| 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 |
$2,997.95
|
| 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 |
$3,597.54
|
| 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 |
$582.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$633.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$502.32
|
| Rate for Payer: PHCS Commercial |
$698.88
|
| Rate for Payer: United Healthcare All Payer |
$640.64
|
|
|
AMPUTATION OF TOE
|
Facility
|
IP
|
$728.00
|
|
|
Service Code
|
HCPCS 28820
|
| Hospital Charge Code |
76101043
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$218.40 |
| 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 |
$582.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$633.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$502.32
|
| 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 |
$659.11 |
| Rate for Payer: Aetna Commercial |
$518.39
|
| Rate for Payer: Ambetter Exchange |
$168.75
|
| 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 Individual/Medicaid |
$168.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$168.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$202.50
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$168.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$168.75
|
| 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 |
$219.38
|
| Rate for Payer: UHCCP Medicaid |
$148.07
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$186.69
|
| Rate for Payer: Wellcare Medicare Advantage |
$168.75
|
|
