|
SCREW VALOR 5MM L 90MM
|
Facility
|
IP
|
$2,003.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$600.90 |
| Max. Negotiated Rate |
$1,922.88 |
| Rate for Payer: Aetna Commercial |
$1,542.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,562.34
|
| Rate for Payer: Cash Price |
$1,001.50
|
| Rate for Payer: Cigna Commercial |
$1,662.49
|
| Rate for Payer: First Health Commercial |
$1,902.85
|
| Rate for Payer: Humana Commercial |
$1,702.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,642.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,478.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$600.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,762.64
|
| Rate for Payer: Ohio Health Group HMO |
$1,502.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,602.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,742.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,382.07
|
| Rate for Payer: PHCS Commercial |
$1,922.88
|
| Rate for Payer: United Healthcare All Payer |
$1,762.64
|
|
|
SCROTAL 0^ ANG CYLINDER SET 16
|
Facility
|
IP
|
$76,608.60
|
|
|
Service Code
|
HCPCS C1813
|
| Hospital Charge Code |
27000110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,982.58 |
| Max. Negotiated Rate |
$73,544.26 |
| Rate for Payer: Aetna Commercial |
$58,988.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59,754.71
|
| Rate for Payer: Cash Price |
$38,304.30
|
| Rate for Payer: Cigna Commercial |
$63,585.14
|
| Rate for Payer: First Health Commercial |
$72,778.17
|
| Rate for Payer: Humana Commercial |
$65,117.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62,819.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56,537.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,982.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$67,415.57
|
| Rate for Payer: Ohio Health Group HMO |
$57,456.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61,286.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66,649.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52,859.93
|
| Rate for Payer: PHCS Commercial |
$73,544.26
|
| Rate for Payer: United Healthcare All Payer |
$67,415.57
|
|
|
SCROTAL 0^ ANG CYLINDER SET 16
|
Facility
|
OP
|
$76,608.60
|
|
|
Service Code
|
HCPCS C1813
|
| Hospital Charge Code |
27000110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,982.58 |
| Max. Negotiated Rate |
$73,544.26 |
| Rate for Payer: Aetna Commercial |
$58,988.62
|
| Rate for Payer: Anthem Medicaid |
$26,345.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59,754.71
|
| Rate for Payer: Cash Price |
$38,304.30
|
| Rate for Payer: Cigna Commercial |
$63,585.14
|
| Rate for Payer: First Health Commercial |
$72,778.17
|
| Rate for Payer: Humana Commercial |
$65,117.31
|
| Rate for Payer: Humana KY Medicaid |
$26,345.70
|
| Rate for Payer: Kentucky WC Medicaid |
$26,613.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62,819.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56,537.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,982.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$26,874.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$67,415.57
|
| Rate for Payer: Ohio Health Group HMO |
$57,456.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61,286.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66,649.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52,859.93
|
| Rate for Payer: PHCS Commercial |
$73,544.26
|
| Rate for Payer: United Healthcare All Payer |
$67,415.57
|
|
|
SCULPTRA FILLER
|
Professional
|
Both
|
$750.00
|
|
| Hospital Charge Code |
22200783
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$262.50 |
| Max. Negotiated Rate |
$525.00 |
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Multiplan PHCS |
$450.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$525.00
|
| Rate for Payer: UHCCP Medicaid |
$262.50
|
|
|
SDS MEDICAL CARE ROOM RATE
|
Facility
|
IP
|
$1,790.00
|
|
| Hospital Charge Code |
11000015
|
|
Hospital Revenue Code
|
110
|
| Min. Negotiated Rate |
$537.00 |
| Max. Negotiated Rate |
$1,718.40 |
| Rate for Payer: Aetna Commercial |
$1,378.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,396.20
|
| Rate for Payer: Cash Price |
$895.00
|
| Rate for Payer: Cigna Commercial |
$1,485.70
|
| Rate for Payer: First Health Commercial |
$1,700.50
|
| Rate for Payer: Humana Commercial |
$1,521.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,467.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,321.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$537.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,575.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,342.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,432.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,557.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,235.10
|
| Rate for Payer: PHCS Commercial |
$1,718.40
|
| Rate for Payer: United Healthcare All Payer |
$1,575.20
|
|
|
SDS UNIT ADDITION 1/2 HR
|
Facility
|
OP
|
$75.00
|
|
| Hospital Charge Code |
71000005
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna Commercial |
$57.75
|
| Rate for Payer: Anthem Medicaid |
$25.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$62.25
|
| Rate for Payer: First Health Commercial |
$71.25
|
| Rate for Payer: Humana Commercial |
$63.75
|
| Rate for Payer: Humana KY Medicaid |
$25.79
|
| Rate for Payer: Kentucky WC Medicaid |
$26.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.00
|
| Rate for Payer: Ohio Health Group HMO |
$56.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.75
|
| Rate for Payer: PHCS Commercial |
$72.00
|
| Rate for Payer: United Healthcare All Payer |
$66.00
|
|
|
SDS UNIT ADDITION 1/2 HR
|
Facility
|
IP
|
$75.00
|
|
| Hospital Charge Code |
71000005
|
|
Hospital Revenue Code
|
710
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna Commercial |
$57.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$62.25
|
| Rate for Payer: First Health Commercial |
$71.25
|
| Rate for Payer: Humana Commercial |
$63.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.00
|
| Rate for Payer: Ohio Health Group HMO |
$56.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.75
|
| Rate for Payer: PHCS Commercial |
$72.00
|
| Rate for Payer: United Healthcare All Payer |
$66.00
|
|
|
SEC. ART M-THROMECT ADD-ON
|
Facility
|
OP
|
$2,100.00
|
|
|
Service Code
|
HCPCS 37186
|
| Hospital Charge Code |
76101527
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$630.00 |
| Max. Negotiated Rate |
$2,016.00 |
| Rate for Payer: Aetna Commercial |
$1,617.00
|
| Rate for Payer: Anthem Medicaid |
$722.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,638.00
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cigna Commercial |
$1,743.00
|
| Rate for Payer: First Health Commercial |
$1,995.00
|
| Rate for Payer: Humana Commercial |
$1,785.00
|
| Rate for Payer: Humana KY Medicaid |
$722.19
|
| Rate for Payer: Kentucky WC Medicaid |
$729.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,722.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,549.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$630.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$736.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,848.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,575.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,680.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,827.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,449.00
|
| Rate for Payer: PHCS Commercial |
$2,016.00
|
| Rate for Payer: United Healthcare All Payer |
$1,848.00
|
|
|
SEC. ART M-THROMECT ADD-ON
|
Professional
|
Both
|
$2,100.00
|
|
|
Service Code
|
HCPCS 37186
|
| Hospital Charge Code |
76101527
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$188.24 |
| Max. Negotiated Rate |
$1,884.39 |
| Rate for Payer: Aetna Commercial |
$410.66
|
| Rate for Payer: Ambetter Exchange |
$229.18
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$188.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$229.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$229.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$275.02
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cigna Commercial |
$367.92
|
| Rate for Payer: Healthspan PPO |
$1,884.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$342.89
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$229.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$229.18
|
| Rate for Payer: Multiplan PHCS |
$1,260.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$297.93
|
| Rate for Payer: UHCCP Medicaid |
$197.65
|
| Rate for Payer: Wellcare Medicare Advantage |
$229.18
|
|
|
SEC. ART M-THROMECT ADD-ON
|
Facility
|
IP
|
$2,100.00
|
|
|
Service Code
|
HCPCS 37186
|
| Hospital Charge Code |
76101527
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$630.00 |
| Max. Negotiated Rate |
$2,016.00 |
| Rate for Payer: Aetna Commercial |
$1,617.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,638.00
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cigna Commercial |
$1,743.00
|
| Rate for Payer: First Health Commercial |
$1,995.00
|
| Rate for Payer: Humana Commercial |
$1,785.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,722.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,549.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$630.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,848.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,575.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,680.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,827.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,449.00
|
| Rate for Payer: PHCS Commercial |
$2,016.00
|
| Rate for Payer: United Healthcare All Payer |
$1,848.00
|
|
|
SEC. ART M-THROMECT ADD-ON(P
|
Professional
|
Both
|
$2,100.00
|
|
|
Service Code
|
HCPCS 37186
|
| Hospital Charge Code |
761P1527
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$188.24 |
| Max. Negotiated Rate |
$1,884.39 |
| Rate for Payer: Aetna Commercial |
$410.66
|
| Rate for Payer: Ambetter Exchange |
$229.18
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$188.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$229.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$229.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$275.02
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cigna Commercial |
$367.92
|
| Rate for Payer: Healthspan PPO |
$1,884.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$342.89
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$229.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$229.18
|
| Rate for Payer: Multiplan PHCS |
$1,260.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$297.93
|
| Rate for Payer: UHCCP Medicaid |
$197.65
|
| Rate for Payer: Wellcare Medicare Advantage |
$229.18
|
|
|
SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED
|
Facility
|
OP
|
$2,366.24
|
|
|
Service Code
|
CPT 13160
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,690.17 |
| Max. Negotiated Rate |
$2,366.24 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
|
|
SECONDARY CLOSURE OF WOUND
|
Professional
|
Both
|
$7,679.50
|
|
|
Service Code
|
HCPCS 13160
|
| Hospital Charge Code |
76100161
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$383.05 |
| Max. Negotiated Rate |
$4,607.70 |
| Rate for Payer: Aetna Commercial |
$1,177.96
|
| Rate for Payer: Ambetter Exchange |
$753.55
|
| Rate for Payer: Anthem Medicaid |
$383.05
|
| Rate for Payer: Buckeye Individual/Medicaid |
$753.55
|
| Rate for Payer: Buckeye Medicare Advantage |
$753.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$904.26
|
| Rate for Payer: Cash Price |
$3,839.75
|
| Rate for Payer: Cash Price |
$3,839.75
|
| Rate for Payer: Cigna Commercial |
$1,110.34
|
| Rate for Payer: Healthspan PPO |
$941.89
|
| Rate for Payer: Humana Medicaid |
$383.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,010.20
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$753.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$753.55
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$390.71
|
| Rate for Payer: Molina Healthcare Passport |
$383.05
|
| Rate for Payer: Multiplan PHCS |
$4,607.70
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$979.62
|
| Rate for Payer: UHCCP Medicaid |
$2,687.82
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$386.88
|
| Rate for Payer: Wellcare Medicare Advantage |
$753.55
|
|
|
SECONDARY CLOSURE OF WOUND
|
Facility
|
OP
|
$7,679.50
|
|
|
Service Code
|
HCPCS 13160
|
| Hospital Charge Code |
76100161
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,690.17 |
| Max. Negotiated Rate |
$7,372.32 |
| Rate for Payer: Aetna Commercial |
$5,913.22
|
| Rate for Payer: Anthem Medicaid |
$2,640.98
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,990.01
|
| 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 |
$3,839.75
|
| Rate for Payer: Cash Price |
$3,839.75
|
| Rate for Payer: Cigna Commercial |
$6,373.98
|
| Rate for Payer: First Health Commercial |
$7,295.52
|
| Rate for Payer: Humana Commercial |
$6,527.57
|
| Rate for Payer: Humana KY Medicaid |
$2,640.98
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$2,667.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,297.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,667.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,693.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,757.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,759.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,143.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,681.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,298.85
|
| Rate for Payer: PHCS Commercial |
$7,372.32
|
| Rate for Payer: United Healthcare All Payer |
$6,757.96
|
|
|
SECONDARY CLOSURE OF WOUND
|
Facility
|
IP
|
$7,679.50
|
|
|
Service Code
|
HCPCS 13160
|
| Hospital Charge Code |
76100161
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,303.85 |
| Max. Negotiated Rate |
$7,372.32 |
| Rate for Payer: Aetna Commercial |
$5,913.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,990.01
|
| Rate for Payer: Cash Price |
$3,839.75
|
| Rate for Payer: Cigna Commercial |
$6,373.98
|
| Rate for Payer: First Health Commercial |
$7,295.52
|
| Rate for Payer: Humana Commercial |
$6,527.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,297.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,667.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,303.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,757.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,759.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,143.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,681.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,298.85
|
| Rate for Payer: PHCS Commercial |
$7,372.32
|
| Rate for Payer: United Healthcare All Payer |
$6,757.96
|
|
|
SECONDARY CLOSURE OF WOUND(P
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 13160
|
| Hospital Charge Code |
761P0161
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$383.05 |
| Max. Negotiated Rate |
$1,177.96 |
| Rate for Payer: Aetna Commercial |
$1,177.96
|
| Rate for Payer: Ambetter Exchange |
$753.55
|
| Rate for Payer: Anthem Medicaid |
$383.05
|
| Rate for Payer: Buckeye Individual/Medicaid |
$753.55
|
| Rate for Payer: Buckeye Medicare Advantage |
$753.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$904.26
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,110.34
|
| Rate for Payer: Healthspan PPO |
$941.89
|
| Rate for Payer: Humana Medicaid |
$383.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,010.20
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$753.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$753.55
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$390.71
|
| Rate for Payer: Molina Healthcare Passport |
$383.05
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$979.62
|
| Rate for Payer: UHCCP Medicaid |
$525.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$386.88
|
| Rate for Payer: Wellcare Medicare Advantage |
$753.55
|
|
|
SECONDARY CLOSURE OF WOUND(T
|
Facility
|
OP
|
$6,179.50
|
|
|
Service Code
|
HCPCS 13160
|
| Hospital Charge Code |
761T0161
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,690.17 |
| Max. Negotiated Rate |
$5,932.32 |
| Rate for Payer: Aetna Commercial |
$4,758.22
|
| Rate for Payer: Anthem Medicaid |
$2,125.13
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,820.01
|
| 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 |
$3,089.75
|
| Rate for Payer: Cash Price |
$3,089.75
|
| Rate for Payer: Cigna Commercial |
$5,128.98
|
| Rate for Payer: First Health Commercial |
$5,870.52
|
| Rate for Payer: Humana Commercial |
$5,252.57
|
| Rate for Payer: Humana KY Medicaid |
$2,125.13
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$2,146.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,067.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,560.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,167.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,437.96
|
| Rate for Payer: Ohio Health Group HMO |
$4,634.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,943.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,376.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,263.85
|
| Rate for Payer: PHCS Commercial |
$5,932.32
|
| Rate for Payer: United Healthcare All Payer |
$5,437.96
|
|
|
SECONDARY CLOSURE OF WOUND(T
|
Facility
|
IP
|
$6,179.50
|
|
|
Service Code
|
HCPCS 13160
|
| Hospital Charge Code |
761T0161
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,853.85 |
| Max. Negotiated Rate |
$5,932.32 |
| Rate for Payer: Aetna Commercial |
$4,758.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,820.01
|
| Rate for Payer: Cash Price |
$3,089.75
|
| Rate for Payer: Cigna Commercial |
$5,128.98
|
| Rate for Payer: First Health Commercial |
$5,870.52
|
| Rate for Payer: Humana Commercial |
$5,252.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,067.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,560.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,853.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,437.96
|
| Rate for Payer: Ohio Health Group HMO |
$4,634.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,943.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,376.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,263.85
|
| Rate for Payer: PHCS Commercial |
$5,932.32
|
| Rate for Payer: United Healthcare All Payer |
$5,437.96
|
|
|
SECOND LOOK PROCEDURE
|
Facility
|
OP
|
$2,800.00
|
|
|
Service Code
|
HCPCS 58960
|
| Hospital Charge Code |
76102266
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$840.00 |
| Max. Negotiated Rate |
$2,688.00 |
| Rate for Payer: Aetna Commercial |
$2,156.00
|
| Rate for Payer: Anthem Medicaid |
$962.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,184.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,324.00
|
| Rate for Payer: First Health Commercial |
$2,660.00
|
| Rate for Payer: Humana Commercial |
$2,380.00
|
| Rate for Payer: Humana KY Medicaid |
$962.92
|
| Rate for Payer: Kentucky WC Medicaid |
$972.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,296.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,066.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$840.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$982.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,464.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,100.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,436.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,932.00
|
| Rate for Payer: PHCS Commercial |
$2,688.00
|
| Rate for Payer: United Healthcare All Payer |
$2,464.00
|
|
|
SECOND LOOK PROCEDURE
|
Professional
|
Both
|
$2,800.00
|
|
|
Service Code
|
HCPCS 58960
|
| Hospital Charge Code |
76102266
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$717.37 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,397.29
|
| Rate for Payer: Ambetter Exchange |
$944.36
|
| Rate for Payer: Anthem Medicaid |
$717.37
|
| Rate for Payer: Buckeye Individual/Medicaid |
$944.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$944.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,133.23
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$1,360.02
|
| Rate for Payer: Healthspan PPO |
$1,352.92
|
| Rate for Payer: Humana Medicaid |
$717.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,203.63
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$944.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$944.36
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$731.72
|
| Rate for Payer: Molina Healthcare Passport |
$717.37
|
| Rate for Payer: Multiplan PHCS |
$1,680.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,227.67
|
| Rate for Payer: UHCCP Medicaid |
$980.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$724.54
|
| Rate for Payer: Wellcare Medicare Advantage |
$944.36
|
|
|
SECOND LOOK PROCEDURE
|
Facility
|
IP
|
$2,800.00
|
|
|
Service Code
|
HCPCS 58960
|
| Hospital Charge Code |
76102266
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$840.00 |
| Max. Negotiated Rate |
$2,688.00 |
| Rate for Payer: Aetna Commercial |
$2,156.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,184.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,324.00
|
| Rate for Payer: First Health Commercial |
$2,660.00
|
| Rate for Payer: Humana Commercial |
$2,380.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,296.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,066.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$840.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,464.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,100.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,436.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,932.00
|
| Rate for Payer: PHCS Commercial |
$2,688.00
|
| Rate for Payer: United Healthcare All Payer |
$2,464.00
|
|
|
SECOND LOOK PROCEDURE(P
|
Professional
|
Both
|
$2,800.00
|
|
|
Service Code
|
HCPCS 58960
|
| Hospital Charge Code |
761P2266
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$717.37 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,397.29
|
| Rate for Payer: Ambetter Exchange |
$944.36
|
| Rate for Payer: Anthem Medicaid |
$717.37
|
| Rate for Payer: Buckeye Individual/Medicaid |
$944.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$944.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,133.23
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$1,360.02
|
| Rate for Payer: Healthspan PPO |
$1,352.92
|
| Rate for Payer: Humana Medicaid |
$717.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,203.63
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$944.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$944.36
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$731.72
|
| Rate for Payer: Molina Healthcare Passport |
$717.37
|
| Rate for Payer: Multiplan PHCS |
$1,680.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,227.67
|
| Rate for Payer: UHCCP Medicaid |
$980.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$724.54
|
| Rate for Payer: Wellcare Medicare Advantage |
$944.36
|
|
|
SECURFIT HASTEM #10 132^35*160
|
Facility
|
IP
|
$14,106.59
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,231.98 |
| Max. Negotiated Rate |
$13,542.33 |
| Rate for Payer: Aetna Commercial |
$10,862.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,003.14
|
| Rate for Payer: Cash Price |
$7,053.30
|
| Rate for Payer: Cigna Commercial |
$11,708.47
|
| Rate for Payer: First Health Commercial |
$13,401.26
|
| Rate for Payer: Humana Commercial |
$11,990.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,567.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,410.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,231.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,413.80
|
| Rate for Payer: Ohio Health Group HMO |
$10,579.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,285.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,272.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,733.55
|
| Rate for Payer: PHCS Commercial |
$13,542.33
|
| Rate for Payer: United Healthcare All Payer |
$12,413.80
|
|
|
SECURFIT HASTEM #10 132^35*160
|
Facility
|
OP
|
$14,106.59
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,231.98 |
| Max. Negotiated Rate |
$13,542.33 |
| Rate for Payer: Aetna Commercial |
$10,862.07
|
| Rate for Payer: Anthem Medicaid |
$4,851.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,003.14
|
| Rate for Payer: Cash Price |
$7,053.30
|
| Rate for Payer: Cigna Commercial |
$11,708.47
|
| Rate for Payer: First Health Commercial |
$13,401.26
|
| Rate for Payer: Humana Commercial |
$11,990.60
|
| Rate for Payer: Humana KY Medicaid |
$4,851.26
|
| Rate for Payer: Kentucky WC Medicaid |
$4,900.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,567.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,410.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,231.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,948.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,413.80
|
| Rate for Payer: Ohio Health Group HMO |
$10,579.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,285.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,272.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,733.55
|
| Rate for Payer: PHCS Commercial |
$13,542.33
|
| Rate for Payer: United Healthcare All Payer |
$12,413.80
|
|
|
SECURFIT HASTEM #11 132^40*170
|
Facility
|
IP
|
$20,487.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,146.25 |
| Max. Negotiated Rate |
$19,668.00 |
| Rate for Payer: Aetna Commercial |
$15,775.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,980.25
|
| Rate for Payer: Cash Price |
$10,243.75
|
| Rate for Payer: Cigna Commercial |
$17,004.62
|
| Rate for Payer: First Health Commercial |
$19,463.12
|
| Rate for Payer: Humana Commercial |
$17,414.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,799.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,119.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,146.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,029.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,365.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,390.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,824.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,136.38
|
| Rate for Payer: PHCS Commercial |
$19,668.00
|
| Rate for Payer: United Healthcare All Payer |
$18,029.00
|
|
