|
LAYER CLOSURE OF WOUNDS OF SCA
|
Facility
|
OP
|
$920.00
|
|
|
Service Code
|
HCPCS 12032
|
| Hospital Charge Code |
76100135
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$316.39 |
| Max. Negotiated Rate |
$883.20 |
| Rate for Payer: Aetna Commercial |
$708.40
|
| Rate for Payer: Anthem Medicaid |
$316.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$717.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$460.00
|
| Rate for Payer: Cash Price |
$460.00
|
| Rate for Payer: Cigna Commercial |
$763.60
|
| Rate for Payer: First Health Commercial |
$874.00
|
| Rate for Payer: Humana Commercial |
$782.00
|
| Rate for Payer: Humana KY Medicaid |
$316.39
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$319.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$754.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$678.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$322.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$809.60
|
| Rate for Payer: Ohio Health Group HMO |
$690.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$736.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$800.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$634.80
|
| Rate for Payer: PHCS Commercial |
$883.20
|
| Rate for Payer: United Healthcare All Payer |
$809.60
|
|
|
LAYER CLOSURE OF WOUNDS OF SCA
|
Professional
|
Both
|
$920.00
|
|
|
Service Code
|
HCPCS 12032
|
| Hospital Charge Code |
76100135
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$95.52 |
| Max. Negotiated Rate |
$552.00 |
| Rate for Payer: Aetna Commercial |
$272.89
|
| Rate for Payer: Ambetter Exchange |
$177.84
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$95.52
|
| Rate for Payer: Anthem Medicaid |
$101.60
|
| Rate for Payer: Buckeye Individual/Medicaid |
$177.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$177.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$213.41
|
| Rate for Payer: Cash Price |
$460.00
|
| Rate for Payer: Cash Price |
$460.00
|
| Rate for Payer: Cigna Commercial |
$379.66
|
| Rate for Payer: Healthspan PPO |
$331.61
|
| Rate for Payer: Humana Medicaid |
$101.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$241.97
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$177.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$177.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.63
|
| Rate for Payer: Molina Healthcare Passport |
$101.60
|
| Rate for Payer: Multiplan PHCS |
$552.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$231.19
|
| Rate for Payer: UHCCP Medicaid |
$100.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.62
|
| Rate for Payer: Wellcare Medicare Advantage |
$177.84
|
|
|
LAYER CLOSURE OF WOUNDS OF SCA
|
Facility
|
OP
|
$742.00
|
|
|
Service Code
|
HCPCS 12036
|
| Hospital Charge Code |
45000059
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$255.17 |
| Max. Negotiated Rate |
$791.84 |
| Rate for Payer: Aetna Commercial |
$571.34
|
| Rate for Payer: Anthem Medicaid |
$255.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$578.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$371.00
|
| Rate for Payer: Cash Price |
$371.00
|
| Rate for Payer: Cigna Commercial |
$615.86
|
| Rate for Payer: First Health Commercial |
$704.90
|
| Rate for Payer: Humana Commercial |
$630.70
|
| Rate for Payer: Humana KY Medicaid |
$255.17
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$257.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$608.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$547.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$260.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$652.96
|
| Rate for Payer: Ohio Health Group HMO |
$556.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$593.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$645.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$511.98
|
| Rate for Payer: PHCS Commercial |
$712.32
|
| Rate for Payer: United Healthcare All Payer |
$652.96
|
|
|
LAYER CLOSURE OF WOUNDS OF SCA
|
Facility
|
OP
|
$531.00
|
|
|
Service Code
|
HCPCS 12032
|
| Hospital Charge Code |
761T0135
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$182.61 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Aetna Commercial |
$408.87
|
| Rate for Payer: Anthem Medicaid |
$182.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cigna Commercial |
$440.73
|
| Rate for Payer: First Health Commercial |
$504.45
|
| Rate for Payer: Humana Commercial |
$451.35
|
| Rate for Payer: Humana KY Medicaid |
$182.61
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$184.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$435.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$186.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$467.28
|
| Rate for Payer: Ohio Health Group HMO |
$398.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$366.39
|
| Rate for Payer: PHCS Commercial |
$509.76
|
| Rate for Payer: United Healthcare All Payer |
$467.28
|
|
|
LAYER CLOSURE OF WOUND(T
|
Facility
|
OP
|
$531.00
|
|
|
Service Code
|
HCPCS 12053
|
| Hospital Charge Code |
761T0145
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$182.61 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Aetna Commercial |
$408.87
|
| Rate for Payer: Anthem Medicaid |
$182.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cigna Commercial |
$440.73
|
| Rate for Payer: First Health Commercial |
$504.45
|
| Rate for Payer: Humana Commercial |
$451.35
|
| Rate for Payer: Humana KY Medicaid |
$182.61
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$184.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$435.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$186.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$467.28
|
| Rate for Payer: Ohio Health Group HMO |
$398.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$366.39
|
| Rate for Payer: PHCS Commercial |
$509.76
|
| Rate for Payer: United Healthcare All Payer |
$467.28
|
|
|
LAYER CLOSURE OF WOUND(T
|
Facility
|
IP
|
$531.00
|
|
|
Service Code
|
HCPCS 12053
|
| Hospital Charge Code |
761T0145
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$159.30 |
| Max. Negotiated Rate |
$509.76 |
| Rate for Payer: Aetna Commercial |
$408.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.18
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cigna Commercial |
$440.73
|
| Rate for Payer: First Health Commercial |
$504.45
|
| Rate for Payer: Humana Commercial |
$451.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$435.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$467.28
|
| Rate for Payer: Ohio Health Group HMO |
$398.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$366.39
|
| Rate for Payer: PHCS Commercial |
$509.76
|
| Rate for Payer: United Healthcare All Payer |
$467.28
|
|
|
LAYER CLOSURE WOUND
|
Facility
|
IP
|
$2,423.00
|
|
|
Service Code
|
HCPCS 12037
|
| Hospital Charge Code |
45000060
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$726.90 |
| Max. Negotiated Rate |
$2,326.08 |
| Rate for Payer: Aetna Commercial |
$1,865.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,889.94
|
| Rate for Payer: Cash Price |
$1,211.50
|
| Rate for Payer: Cigna Commercial |
$2,011.09
|
| Rate for Payer: First Health Commercial |
$2,301.85
|
| Rate for Payer: Humana Commercial |
$2,059.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,986.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,788.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$726.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,132.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,817.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,938.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,108.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,671.87
|
| Rate for Payer: PHCS Commercial |
$2,326.08
|
| Rate for Payer: United Healthcare All Payer |
$2,132.24
|
|
|
LAYER CLOSURE WOUND
|
Facility
|
OP
|
$1,326.00
|
|
|
Service Code
|
HCPCS 12035
|
| Hospital Charge Code |
45000058
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$369.16 |
| Max. Negotiated Rate |
$1,272.96 |
| Rate for Payer: Aetna Commercial |
$1,021.02
|
| Rate for Payer: Anthem Medicaid |
$456.01
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,034.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$663.00
|
| Rate for Payer: Cash Price |
$663.00
|
| Rate for Payer: Cigna Commercial |
$1,100.58
|
| Rate for Payer: First Health Commercial |
$1,259.70
|
| Rate for Payer: Humana Commercial |
$1,127.10
|
| Rate for Payer: Humana KY Medicaid |
$456.01
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$460.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,087.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$978.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$465.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,166.88
|
| Rate for Payer: Ohio Health Group HMO |
$994.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,060.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,153.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$914.94
|
| Rate for Payer: PHCS Commercial |
$1,272.96
|
| Rate for Payer: United Healthcare All Payer |
$1,166.88
|
|
|
LAYER CLOSURE WOUND
|
Facility
|
IP
|
$1,956.00
|
|
|
Service Code
|
HCPCS 12035
|
| Hospital Charge Code |
76100137
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$586.80 |
| Max. Negotiated Rate |
$1,877.76 |
| Rate for Payer: Aetna Commercial |
$1,506.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,525.68
|
| Rate for Payer: Cash Price |
$978.00
|
| Rate for Payer: Cigna Commercial |
$1,623.48
|
| Rate for Payer: First Health Commercial |
$1,858.20
|
| Rate for Payer: Humana Commercial |
$1,662.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,603.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,443.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$586.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,721.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,467.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,564.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,701.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,349.64
|
| Rate for Payer: PHCS Commercial |
$1,877.76
|
| Rate for Payer: United Healthcare All Payer |
$1,721.28
|
|
|
LAYER CLOSURE WOUND
|
Facility
|
OP
|
$1,956.00
|
|
|
Service Code
|
HCPCS 12035
|
| Hospital Charge Code |
76100137
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$369.16 |
| Max. Negotiated Rate |
$1,877.76 |
| Rate for Payer: Aetna Commercial |
$1,506.12
|
| Rate for Payer: Anthem Medicaid |
$672.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,525.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$978.00
|
| Rate for Payer: Cash Price |
$978.00
|
| Rate for Payer: Cigna Commercial |
$1,623.48
|
| Rate for Payer: First Health Commercial |
$1,858.20
|
| Rate for Payer: Humana Commercial |
$1,662.60
|
| Rate for Payer: Humana KY Medicaid |
$672.67
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$679.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,603.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,443.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$686.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,721.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,467.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,564.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,701.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,349.64
|
| Rate for Payer: PHCS Commercial |
$1,877.76
|
| Rate for Payer: United Healthcare All Payer |
$1,721.28
|
|
|
LAYER CLOSURE WOUND
|
Facility
|
OP
|
$2,423.00
|
|
|
Service Code
|
HCPCS 12037
|
| Hospital Charge Code |
45000060
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$833.27 |
| Max. Negotiated Rate |
$2,366.24 |
| Rate for Payer: Aetna Commercial |
$1,865.71
|
| Rate for Payer: Anthem Medicaid |
$833.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,889.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Cash Price |
$1,211.50
|
| Rate for Payer: Cash Price |
$1,211.50
|
| Rate for Payer: Cigna Commercial |
$2,011.09
|
| Rate for Payer: First Health Commercial |
$2,301.85
|
| Rate for Payer: Humana Commercial |
$2,059.55
|
| Rate for Payer: Humana KY Medicaid |
$833.27
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$841.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,986.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,788.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$849.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,132.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,817.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,938.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,108.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,671.87
|
| Rate for Payer: PHCS Commercial |
$2,326.08
|
| Rate for Payer: United Healthcare All Payer |
$2,132.24
|
|
|
LAYER CLOSURE WOUND
|
Facility
|
IP
|
$1,326.00
|
|
|
Service Code
|
HCPCS 12035
|
| Hospital Charge Code |
45000058
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$397.80 |
| Max. Negotiated Rate |
$1,272.96 |
| Rate for Payer: Aetna Commercial |
$1,021.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,034.28
|
| Rate for Payer: Cash Price |
$663.00
|
| Rate for Payer: Cigna Commercial |
$1,100.58
|
| Rate for Payer: First Health Commercial |
$1,259.70
|
| Rate for Payer: Humana Commercial |
$1,127.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,087.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$978.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$397.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,166.88
|
| Rate for Payer: Ohio Health Group HMO |
$994.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,060.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,153.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$914.94
|
| Rate for Payer: PHCS Commercial |
$1,272.96
|
| Rate for Payer: United Healthcare All Payer |
$1,166.88
|
|
|
LAYER CLOSURE WOUND
|
Professional
|
Both
|
$1,956.00
|
|
|
Service Code
|
HCPCS 12035
|
| Hospital Charge Code |
76100137
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$122.68 |
| Max. Negotiated Rate |
$1,173.60 |
| Rate for Payer: Aetna Commercial |
$341.97
|
| Rate for Payer: Ambetter Exchange |
$227.68
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$122.68
|
| Rate for Payer: Anthem Medicaid |
$156.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$227.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$227.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$273.22
|
| Rate for Payer: Cash Price |
$978.00
|
| Rate for Payer: Cash Price |
$978.00
|
| Rate for Payer: Cigna Commercial |
$322.55
|
| Rate for Payer: Healthspan PPO |
$405.24
|
| Rate for Payer: Humana Medicaid |
$156.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$294.99
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$227.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$227.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$159.40
|
| Rate for Payer: Molina Healthcare Passport |
$156.27
|
| Rate for Payer: Multiplan PHCS |
$1,173.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$295.98
|
| Rate for Payer: UHCCP Medicaid |
$128.81
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$157.83
|
| Rate for Payer: Wellcare Medicare Advantage |
$227.68
|
|
|
LAYER CLOSURE WOUND 7.6-12.5CM
|
Facility
|
OP
|
$981.00
|
|
|
Service Code
|
HCPCS 12054
|
| Hospital Charge Code |
76100146
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$337.37 |
| Max. Negotiated Rate |
$941.76 |
| Rate for Payer: Aetna Commercial |
$755.37
|
| Rate for Payer: Anthem Medicaid |
$337.37
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$765.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$490.50
|
| Rate for Payer: Cash Price |
$490.50
|
| Rate for Payer: Cigna Commercial |
$814.23
|
| Rate for Payer: First Health Commercial |
$931.95
|
| Rate for Payer: Humana Commercial |
$833.85
|
| Rate for Payer: Humana KY Medicaid |
$337.37
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$340.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$804.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$723.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$344.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$863.28
|
| Rate for Payer: Ohio Health Group HMO |
$735.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$784.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$853.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$676.89
|
| Rate for Payer: PHCS Commercial |
$941.76
|
| Rate for Payer: United Healthcare All Payer |
$863.28
|
|
|
LAYER CLOSURE WOUND 7.6-12.5CM
|
Facility
|
IP
|
$981.00
|
|
|
Service Code
|
HCPCS 12054
|
| Hospital Charge Code |
76100146
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$294.30 |
| Max. Negotiated Rate |
$941.76 |
| Rate for Payer: Aetna Commercial |
$755.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$765.18
|
| Rate for Payer: Cash Price |
$490.50
|
| Rate for Payer: Cigna Commercial |
$814.23
|
| Rate for Payer: First Health Commercial |
$931.95
|
| Rate for Payer: Humana Commercial |
$833.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$804.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$723.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$294.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$863.28
|
| Rate for Payer: Ohio Health Group HMO |
$735.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$784.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$853.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$676.89
|
| Rate for Payer: PHCS Commercial |
$941.76
|
| Rate for Payer: United Healthcare All Payer |
$863.28
|
|
|
LAYER CLOSURE WOUND 7.6-12.5CM
|
Professional
|
Both
|
$981.00
|
|
|
Service Code
|
HCPCS 12054
|
| Hospital Charge Code |
76100146
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$110.92 |
| Max. Negotiated Rate |
$588.60 |
| Rate for Payer: Aetna Commercial |
$327.13
|
| Rate for Payer: Ambetter Exchange |
$207.46
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$110.92
|
| Rate for Payer: Anthem Medicaid |
$175.87
|
| Rate for Payer: Buckeye Individual/Medicaid |
$207.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$207.46
|
| Rate for Payer: CareSource Just4Me Medicare |
$248.95
|
| Rate for Payer: Cash Price |
$490.50
|
| Rate for Payer: Cash Price |
$490.50
|
| Rate for Payer: Cigna Commercial |
$297.15
|
| Rate for Payer: Healthspan PPO |
$386.96
|
| Rate for Payer: Humana Medicaid |
$175.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$284.70
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$207.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$179.39
|
| Rate for Payer: Molina Healthcare Passport |
$175.87
|
| Rate for Payer: Multiplan PHCS |
$588.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$269.70
|
| Rate for Payer: UHCCP Medicaid |
$116.47
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$177.63
|
| Rate for Payer: Wellcare Medicare Advantage |
$207.46
|
|
|
LAYER CLOSURE WOUND 7.6-12.5CM
|
Facility
|
IP
|
$531.00
|
|
|
Service Code
|
HCPCS 12054
|
| Hospital Charge Code |
761T0146
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$159.30 |
| Max. Negotiated Rate |
$509.76 |
| Rate for Payer: Aetna Commercial |
$408.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.18
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cigna Commercial |
$440.73
|
| Rate for Payer: First Health Commercial |
$504.45
|
| Rate for Payer: Humana Commercial |
$451.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$435.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$467.28
|
| Rate for Payer: Ohio Health Group HMO |
$398.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$366.39
|
| Rate for Payer: PHCS Commercial |
$509.76
|
| Rate for Payer: United Healthcare All Payer |
$467.28
|
|
|
LAYER CLOSURE WOUND 7.6-12.5CM
|
Facility
|
IP
|
$531.00
|
|
|
Service Code
|
HCPCS 12054
|
| Hospital Charge Code |
45000068
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$159.30 |
| Max. Negotiated Rate |
$509.76 |
| Rate for Payer: Aetna Commercial |
$408.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.18
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cigna Commercial |
$440.73
|
| Rate for Payer: First Health Commercial |
$504.45
|
| Rate for Payer: Humana Commercial |
$451.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$435.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$467.28
|
| Rate for Payer: Ohio Health Group HMO |
$398.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$366.39
|
| Rate for Payer: PHCS Commercial |
$509.76
|
| Rate for Payer: United Healthcare All Payer |
$467.28
|
|
|
LAYER CLOSURE WOUND 7.6-12.5CM
|
Facility
|
OP
|
$531.00
|
|
|
Service Code
|
HCPCS 12054
|
| Hospital Charge Code |
45000068
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$182.61 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Aetna Commercial |
$408.87
|
| Rate for Payer: Anthem Medicaid |
$182.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cigna Commercial |
$440.73
|
| Rate for Payer: First Health Commercial |
$504.45
|
| Rate for Payer: Humana Commercial |
$451.35
|
| Rate for Payer: Humana KY Medicaid |
$182.61
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$184.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$435.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$186.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$467.28
|
| Rate for Payer: Ohio Health Group HMO |
$398.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$366.39
|
| Rate for Payer: PHCS Commercial |
$509.76
|
| Rate for Payer: United Healthcare All Payer |
$467.28
|
|
|
LAYER CLOSURE WOUND 7.6-12.5CM
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 12054
|
| Hospital Charge Code |
761P0146
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$110.92 |
| Max. Negotiated Rate |
$386.96 |
| Rate for Payer: Aetna Commercial |
$327.13
|
| Rate for Payer: Ambetter Exchange |
$207.46
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$110.92
|
| Rate for Payer: Anthem Medicaid |
$175.87
|
| Rate for Payer: Buckeye Individual/Medicaid |
$207.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$207.46
|
| Rate for Payer: CareSource Just4Me Medicare |
$248.95
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$297.15
|
| Rate for Payer: Healthspan PPO |
$386.96
|
| Rate for Payer: Humana Medicaid |
$175.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$284.70
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$207.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$179.39
|
| Rate for Payer: Molina Healthcare Passport |
$175.87
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$269.70
|
| Rate for Payer: UHCCP Medicaid |
$116.47
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$177.63
|
| Rate for Payer: Wellcare Medicare Advantage |
$207.46
|
|
|
LAYER CLOSURE WOUND 7.6-12.5CM
|
Facility
|
OP
|
$531.00
|
|
|
Service Code
|
HCPCS 12054
|
| Hospital Charge Code |
761T0146
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$182.61 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Aetna Commercial |
$408.87
|
| Rate for Payer: Anthem Medicaid |
$182.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cigna Commercial |
$440.73
|
| Rate for Payer: First Health Commercial |
$504.45
|
| Rate for Payer: Humana Commercial |
$451.35
|
| Rate for Payer: Humana KY Medicaid |
$182.61
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$184.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$435.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$186.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$467.28
|
| Rate for Payer: Ohio Health Group HMO |
$398.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$366.39
|
| Rate for Payer: PHCS Commercial |
$509.76
|
| Rate for Payer: United Healthcare All Payer |
$467.28
|
|
|
LAYER CLOSURE WOUND(P
|
Professional
|
Both
|
$630.00
|
|
|
Service Code
|
HCPCS 12035
|
| Hospital Charge Code |
761P0137
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$122.68 |
| Max. Negotiated Rate |
$405.24 |
| Rate for Payer: Aetna Commercial |
$341.97
|
| Rate for Payer: Ambetter Exchange |
$227.68
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$122.68
|
| Rate for Payer: Anthem Medicaid |
$156.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$227.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$227.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$273.22
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cigna Commercial |
$322.55
|
| Rate for Payer: Healthspan PPO |
$405.24
|
| Rate for Payer: Humana Medicaid |
$156.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$294.99
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$227.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$227.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$159.40
|
| Rate for Payer: Molina Healthcare Passport |
$156.27
|
| Rate for Payer: Multiplan PHCS |
$378.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$295.98
|
| Rate for Payer: UHCCP Medicaid |
$128.81
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$157.83
|
| Rate for Payer: Wellcare Medicare Advantage |
$227.68
|
|
|
LAYER CLOSURE WOUND(T
|
Facility
|
IP
|
$1,326.00
|
|
|
Service Code
|
HCPCS 12035
|
| Hospital Charge Code |
761T0137
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$397.80 |
| Max. Negotiated Rate |
$1,272.96 |
| Rate for Payer: Aetna Commercial |
$1,021.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,034.28
|
| Rate for Payer: Cash Price |
$663.00
|
| Rate for Payer: Cigna Commercial |
$1,100.58
|
| Rate for Payer: First Health Commercial |
$1,259.70
|
| Rate for Payer: Humana Commercial |
$1,127.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,087.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$978.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$397.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,166.88
|
| Rate for Payer: Ohio Health Group HMO |
$994.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,060.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,153.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$914.94
|
| Rate for Payer: PHCS Commercial |
$1,272.96
|
| Rate for Payer: United Healthcare All Payer |
$1,166.88
|
|
|
LAYER CLOSURE WOUND(T
|
Facility
|
OP
|
$1,326.00
|
|
|
Service Code
|
HCPCS 12035
|
| Hospital Charge Code |
761T0137
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$369.16 |
| Max. Negotiated Rate |
$1,272.96 |
| Rate for Payer: Aetna Commercial |
$1,021.02
|
| Rate for Payer: Anthem Medicaid |
$456.01
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,034.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$663.00
|
| Rate for Payer: Cash Price |
$663.00
|
| Rate for Payer: Cigna Commercial |
$1,100.58
|
| Rate for Payer: First Health Commercial |
$1,259.70
|
| Rate for Payer: Humana Commercial |
$1,127.10
|
| Rate for Payer: Humana KY Medicaid |
$456.01
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$460.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,087.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$978.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$465.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,166.88
|
| Rate for Payer: Ohio Health Group HMO |
$994.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,060.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,153.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$914.94
|
| Rate for Payer: PHCS Commercial |
$1,272.96
|
| Rate for Payer: United Healthcare All Payer |
$1,166.88
|
|
|
LAYERED CLOSURE EXCPT HNDS/FET
|
Facility
|
IP
|
$531.00
|
|
|
Service Code
|
HCPCS 12031
|
| Hospital Charge Code |
45000055
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$159.30 |
| Max. Negotiated Rate |
$509.76 |
| Rate for Payer: Aetna Commercial |
$408.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.18
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cigna Commercial |
$440.73
|
| Rate for Payer: First Health Commercial |
$504.45
|
| Rate for Payer: Humana Commercial |
$451.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$435.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$467.28
|
| Rate for Payer: Ohio Health Group HMO |
$398.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$366.39
|
| Rate for Payer: PHCS Commercial |
$509.76
|
| Rate for Payer: United Healthcare All Payer |
$467.28
|
|
