|
WOUND EXPLORATION ABDOMEN(T
|
Facility
|
IP
|
$5,560.25
|
|
|
Service Code
|
HCPCS 20102
|
| Hospital Charge Code |
761T0324
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$722.83 |
| Max. Negotiated Rate |
$5,337.84 |
| Rate for Payer: Aetna Commercial |
$4,281.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,337.00
|
| Rate for Payer: Cash Price |
$2,780.12
|
| Rate for Payer: Cigna Commercial |
$4,615.01
|
| Rate for Payer: First Health Commercial |
$5,282.24
|
| Rate for Payer: Humana Commercial |
$4,726.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,559.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,103.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,893.02
|
| Rate for Payer: Ohio Health Group HMO |
$4,170.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,112.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$722.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,723.68
|
| Rate for Payer: PHCS Commercial |
$5,337.84
|
| Rate for Payer: United Healthcare All Payer |
$4,893.02
|
|
|
WOUND EXPLORATION ABDOMEN(T
|
Facility
|
OP
|
$5,560.25
|
|
|
Service Code
|
HCPCS 20102
|
| Hospital Charge Code |
761T0324
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$722.83 |
| Max. Negotiated Rate |
$5,337.84 |
| Rate for Payer: Aetna Commercial |
$4,281.39
|
| Rate for Payer: Anthem Medicaid |
$1,912.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,337.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$2,780.12
|
| Rate for Payer: Cash Price |
$2,780.12
|
| Rate for Payer: Cigna Commercial |
$4,615.01
|
| Rate for Payer: First Health Commercial |
$5,282.24
|
| Rate for Payer: Humana Commercial |
$4,726.21
|
| Rate for Payer: Humana KY Medicaid |
$1,912.17
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,931.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,559.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,103.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,950.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,893.02
|
| Rate for Payer: Ohio Health Group HMO |
$4,170.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,112.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$722.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,723.68
|
| Rate for Payer: PHCS Commercial |
$5,337.84
|
| Rate for Payer: United Healthcare All Payer |
$4,893.02
|
|
|
WOUND MATRIX THIN 4*10
|
Facility
|
OP
|
$27,455.55
|
|
|
Service Code
|
HCPCS Q4108
|
| Hospital Charge Code |
27000118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,569.22 |
| Max. Negotiated Rate |
$26,357.33 |
| Rate for Payer: Aetna Commercial |
$21,140.77
|
| Rate for Payer: Anthem Medicaid |
$9,441.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21,415.33
|
| Rate for Payer: Cash Price |
$13,727.77
|
| Rate for Payer: Cigna Commercial |
$22,788.11
|
| Rate for Payer: First Health Commercial |
$26,082.77
|
| Rate for Payer: Humana Commercial |
$23,337.22
|
| Rate for Payer: Humana KY Medicaid |
$9,441.96
|
| Rate for Payer: Kentucky WC Medicaid |
$9,538.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,513.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,262.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,236.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,631.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$24,160.88
|
| Rate for Payer: Ohio Health Group HMO |
$20,591.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,491.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,569.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,511.22
|
| Rate for Payer: PHCS Commercial |
$26,357.33
|
| Rate for Payer: United Healthcare All Payer |
$24,160.88
|
|
|
WOUND MATRIX THIN 4*10
|
Facility
|
IP
|
$27,455.55
|
|
|
Service Code
|
HCPCS Q4108
|
| Hospital Charge Code |
27000118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,569.22 |
| Max. Negotiated Rate |
$26,357.33 |
| Rate for Payer: Aetna Commercial |
$21,140.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21,415.33
|
| Rate for Payer: Cash Price |
$13,727.77
|
| Rate for Payer: Cigna Commercial |
$22,788.11
|
| Rate for Payer: First Health Commercial |
$26,082.77
|
| Rate for Payer: Humana Commercial |
$23,337.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,513.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,262.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,236.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$24,160.88
|
| Rate for Payer: Ohio Health Group HMO |
$20,591.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,491.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,569.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,511.22
|
| Rate for Payer: PHCS Commercial |
$26,357.33
|
| Rate for Payer: United Healthcare All Payer |
$24,160.88
|
|
|
WOUND MATRIX THIN 4*5(125SQ CM
|
Facility
|
OP
|
$11,716.17
|
|
|
Service Code
|
HCPCS Q4108
|
| Hospital Charge Code |
27000118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,523.10 |
| Max. Negotiated Rate |
$11,247.52 |
| Rate for Payer: Aetna Commercial |
$9,021.45
|
| Rate for Payer: Anthem Medicaid |
$4,029.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,138.61
|
| Rate for Payer: Cash Price |
$5,858.08
|
| Rate for Payer: Cigna Commercial |
$9,724.42
|
| Rate for Payer: First Health Commercial |
$11,130.36
|
| Rate for Payer: Humana Commercial |
$9,958.74
|
| Rate for Payer: Humana KY Medicaid |
$4,029.19
|
| Rate for Payer: Kentucky WC Medicaid |
$4,070.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,607.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,646.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,514.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,110.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,310.23
|
| Rate for Payer: Ohio Health Group HMO |
$8,787.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,343.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,523.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,632.01
|
| Rate for Payer: PHCS Commercial |
$11,247.52
|
| Rate for Payer: United Healthcare All Payer |
$10,310.23
|
|
|
WOUND MATRIX THIN 4*5(125SQ CM
|
Facility
|
IP
|
$11,716.17
|
|
|
Service Code
|
HCPCS Q4108
|
| Hospital Charge Code |
27000118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,523.10 |
| Max. Negotiated Rate |
$11,247.52 |
| Rate for Payer: Aetna Commercial |
$9,021.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,138.61
|
| Rate for Payer: Cash Price |
$5,858.08
|
| Rate for Payer: Cigna Commercial |
$9,724.42
|
| Rate for Payer: First Health Commercial |
$11,130.36
|
| Rate for Payer: Humana Commercial |
$9,958.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,607.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,646.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,514.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,310.23
|
| Rate for Payer: Ohio Health Group HMO |
$8,787.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,343.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,523.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,632.01
|
| Rate for Payer: PHCS Commercial |
$11,247.52
|
| Rate for Payer: United Healthcare All Payer |
$10,310.23
|
|
|
WOUND PREP ADDL 100 CM
|
Facility
|
OP
|
$1,849.25
|
|
|
Service Code
|
HCPCS 15003
|
| Hospital Charge Code |
76100172
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$240.40 |
| Max. Negotiated Rate |
$1,775.28 |
| Rate for Payer: Aetna Commercial |
$1,423.92
|
| Rate for Payer: Anthem Medicaid |
$635.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,442.42
|
| Rate for Payer: Cash Price |
$924.62
|
| Rate for Payer: Cigna Commercial |
$1,534.88
|
| Rate for Payer: First Health Commercial |
$1,756.79
|
| Rate for Payer: Humana Commercial |
$1,571.86
|
| Rate for Payer: Humana KY Medicaid |
$635.96
|
| Rate for Payer: Kentucky WC Medicaid |
$642.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,516.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,364.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$554.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$648.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,627.34
|
| Rate for Payer: Ohio Health Group HMO |
$1,386.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$369.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$240.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$573.27
|
| Rate for Payer: PHCS Commercial |
$1,775.28
|
| Rate for Payer: United Healthcare All Payer |
$1,627.34
|
|
|
WOUND PREP ADDL 100 CM
|
Professional
|
Both
|
$1,849.25
|
|
|
Service Code
|
HCPCS 15003
|
| Hospital Charge Code |
76100172
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$23.19 |
| Max. Negotiated Rate |
$1,849.25 |
| Rate for Payer: Aetna Commercial |
$69.00
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$23.19
|
| Rate for Payer: Anthem Medicaid |
$32.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,849.25
|
| Rate for Payer: Cash Price |
$924.62
|
| Rate for Payer: Cash Price |
$924.62
|
| Rate for Payer: Cigna Commercial |
$64.19
|
| Rate for Payer: Healthspan PPO |
$81.70
|
| Rate for Payer: Humana Medicaid |
$32.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$57.74
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$33.59
|
| Rate for Payer: Molina Healthcare Passport |
$32.93
|
| Rate for Payer: Multiplan PHCS |
$1,109.55
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,294.48
|
| Rate for Payer: UHCCP Medicaid |
$24.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$33.26
|
|
|
WOUND PREP ADDL 100 CM
|
Facility
|
IP
|
$1,849.25
|
|
|
Service Code
|
HCPCS 15003
|
| Hospital Charge Code |
76100172
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$240.40 |
| Max. Negotiated Rate |
$1,775.28 |
| Rate for Payer: Aetna Commercial |
$1,423.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,442.42
|
| Rate for Payer: Cash Price |
$924.62
|
| Rate for Payer: Cigna Commercial |
$1,534.88
|
| Rate for Payer: First Health Commercial |
$1,756.79
|
| Rate for Payer: Humana Commercial |
$1,571.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,516.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,364.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$554.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,627.34
|
| Rate for Payer: Ohio Health Group HMO |
$1,386.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$369.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$240.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$573.27
|
| Rate for Payer: PHCS Commercial |
$1,775.28
|
| Rate for Payer: United Healthcare All Payer |
$1,627.34
|
|
|
WOUND PREP ADDL 100 CM(P
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 15003
|
| Hospital Charge Code |
761P0172
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$23.19 |
| Max. Negotiated Rate |
$125.00 |
| Rate for Payer: Aetna Commercial |
$69.00
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$23.19
|
| Rate for Payer: Anthem Medicaid |
$32.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$125.00
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$64.19
|
| Rate for Payer: Healthspan PPO |
$81.70
|
| Rate for Payer: Humana Medicaid |
$32.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$57.74
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$33.59
|
| Rate for Payer: Molina Healthcare Passport |
$32.93
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.50
|
| Rate for Payer: UHCCP Medicaid |
$24.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$33.26
|
|
|
WOUND PREP ADDL 100 CM(T
|
Facility
|
IP
|
$1,724.25
|
|
|
Service Code
|
HCPCS 15003
|
| Hospital Charge Code |
761T0172
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$224.15 |
| Max. Negotiated Rate |
$1,655.28 |
| Rate for Payer: Aetna Commercial |
$1,327.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,344.92
|
| Rate for Payer: Cash Price |
$862.12
|
| Rate for Payer: Cigna Commercial |
$1,431.13
|
| Rate for Payer: First Health Commercial |
$1,638.04
|
| Rate for Payer: Humana Commercial |
$1,465.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,413.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,272.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$517.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,517.34
|
| Rate for Payer: Ohio Health Group HMO |
$1,293.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$344.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$224.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$534.52
|
| Rate for Payer: PHCS Commercial |
$1,655.28
|
| Rate for Payer: United Healthcare All Payer |
$1,517.34
|
|
|
WOUND PREP ADDL 100 CM(T
|
Facility
|
OP
|
$1,724.25
|
|
|
Service Code
|
HCPCS 15003
|
| Hospital Charge Code |
761T0172
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$224.15 |
| Max. Negotiated Rate |
$1,655.28 |
| Rate for Payer: Aetna Commercial |
$1,327.67
|
| Rate for Payer: Anthem Medicaid |
$592.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,344.92
|
| Rate for Payer: Cash Price |
$862.12
|
| Rate for Payer: Cigna Commercial |
$1,431.13
|
| Rate for Payer: First Health Commercial |
$1,638.04
|
| Rate for Payer: Humana Commercial |
$1,465.61
|
| Rate for Payer: Humana KY Medicaid |
$592.97
|
| Rate for Payer: Kentucky WC Medicaid |
$599.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,413.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,272.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$517.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$604.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,517.34
|
| Rate for Payer: Ohio Health Group HMO |
$1,293.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$344.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$224.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$534.52
|
| Rate for Payer: PHCS Commercial |
$1,655.28
|
| Rate for Payer: United Healthcare All Payer |
$1,517.34
|
|
|
WOUND PREP F/N/HF/G
|
Professional
|
Both
|
$3,323.94
|
|
|
Service Code
|
HCPCS 15004
|
| Hospital Charge Code |
76100173
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$132.72 |
| Max. Negotiated Rate |
$3,323.94 |
| Rate for Payer: Aetna Commercial |
$423.06
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$132.72
|
| Rate for Payer: Anthem Medicaid |
$197.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,323.94
|
| Rate for Payer: Cash Price |
$1,661.97
|
| Rate for Payer: Cash Price |
$1,661.97
|
| Rate for Payer: Cigna Commercial |
$387.02
|
| Rate for Payer: Healthspan PPO |
$456.40
|
| Rate for Payer: Humana Medicaid |
$197.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$343.22
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$201.54
|
| Rate for Payer: Molina Healthcare Passport |
$197.59
|
| Rate for Payer: Multiplan PHCS |
$1,994.36
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,326.76
|
| Rate for Payer: UHCCP Medicaid |
$139.36
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$199.57
|
|
|
WOUND PREP F/N/HF/G
|
Facility
|
OP
|
$3,323.94
|
|
|
Service Code
|
HCPCS 15004
|
| Hospital Charge Code |
76100173
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$432.11 |
| Max. Negotiated Rate |
$3,190.98 |
| Rate for Payer: Aetna Commercial |
$2,559.43
|
| Rate for Payer: Anthem Medicaid |
$1,143.10
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,592.67
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$1,661.97
|
| Rate for Payer: Cash Price |
$1,661.97
|
| Rate for Payer: Cigna Commercial |
$2,758.87
|
| Rate for Payer: First Health Commercial |
$3,157.74
|
| Rate for Payer: Humana Commercial |
$2,825.35
|
| Rate for Payer: Humana KY Medicaid |
$1,143.10
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,154.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,725.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,453.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,166.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,925.07
|
| Rate for Payer: Ohio Health Group HMO |
$2,492.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$664.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$432.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,030.42
|
| Rate for Payer: PHCS Commercial |
$3,190.98
|
| Rate for Payer: United Healthcare All Payer |
$2,925.07
|
|
|
WOUND PREP F/N/HF/G
|
Facility
|
IP
|
$3,323.94
|
|
|
Service Code
|
HCPCS 15004
|
| Hospital Charge Code |
76100173
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$432.11 |
| Max. Negotiated Rate |
$3,190.98 |
| Rate for Payer: Aetna Commercial |
$2,559.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,592.67
|
| Rate for Payer: Cash Price |
$1,661.97
|
| Rate for Payer: Cigna Commercial |
$2,758.87
|
| Rate for Payer: First Health Commercial |
$3,157.74
|
| Rate for Payer: Humana Commercial |
$2,825.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,725.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,453.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$997.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,925.07
|
| Rate for Payer: Ohio Health Group HMO |
$2,492.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$664.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$432.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,030.42
|
| Rate for Payer: PHCS Commercial |
$3,190.98
|
| Rate for Payer: United Healthcare All Payer |
$2,925.07
|
|
|
WOUND PREP F/N/HF/G(P
|
Professional
|
Both
|
$680.00
|
|
|
Service Code
|
HCPCS 15004
|
| Hospital Charge Code |
761P0173
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$132.72 |
| Max. Negotiated Rate |
$680.00 |
| Rate for Payer: Aetna Commercial |
$423.06
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$132.72
|
| Rate for Payer: Anthem Medicaid |
$197.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$680.00
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Cigna Commercial |
$387.02
|
| Rate for Payer: Healthspan PPO |
$456.40
|
| Rate for Payer: Humana Medicaid |
$197.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$343.22
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$201.54
|
| Rate for Payer: Molina Healthcare Passport |
$197.59
|
| Rate for Payer: Multiplan PHCS |
$408.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$476.00
|
| Rate for Payer: UHCCP Medicaid |
$139.36
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$199.57
|
|
|
WOUND PREP F/N/HF/G(T
|
Facility
|
IP
|
$2,643.94
|
|
|
Service Code
|
HCPCS 15004
|
| Hospital Charge Code |
761T0173
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$343.71 |
| Max. Negotiated Rate |
$2,538.18 |
| Rate for Payer: Aetna Commercial |
$2,035.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,062.27
|
| Rate for Payer: Cash Price |
$1,321.97
|
| Rate for Payer: Cigna Commercial |
$2,194.47
|
| Rate for Payer: First Health Commercial |
$2,511.74
|
| Rate for Payer: Humana Commercial |
$2,247.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,168.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,951.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$793.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,326.67
|
| Rate for Payer: Ohio Health Group HMO |
$1,982.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$528.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$343.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$819.62
|
| Rate for Payer: PHCS Commercial |
$2,538.18
|
| Rate for Payer: United Healthcare All Payer |
$2,326.67
|
|
|
WOUND PREP F/N/HF/G(T
|
Facility
|
OP
|
$2,643.94
|
|
|
Service Code
|
HCPCS 15004
|
| Hospital Charge Code |
761T0173
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$343.71 |
| Max. Negotiated Rate |
$2,538.18 |
| Rate for Payer: Aetna Commercial |
$2,035.83
|
| Rate for Payer: Anthem Medicaid |
$909.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,062.27
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$1,321.97
|
| Rate for Payer: Cash Price |
$1,321.97
|
| Rate for Payer: Cigna Commercial |
$2,194.47
|
| Rate for Payer: First Health Commercial |
$2,511.74
|
| Rate for Payer: Humana Commercial |
$2,247.35
|
| Rate for Payer: Humana KY Medicaid |
$909.25
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$918.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,168.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,951.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$927.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,326.67
|
| Rate for Payer: Ohio Health Group HMO |
$1,982.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$528.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$343.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$819.62
|
| Rate for Payer: PHCS Commercial |
$2,538.18
|
| Rate for Payer: United Healthcare All Payer |
$2,326.67
|
|
|
WOUND PREP TRK/ARM/LEG
|
Facility
|
IP
|
$4,093.50
|
|
|
Service Code
|
HCPCS 15002
|
| Hospital Charge Code |
76100171
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$532.16 |
| Max. Negotiated Rate |
$3,929.76 |
| Rate for Payer: Aetna Commercial |
$3,152.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,192.93
|
| Rate for Payer: Cash Price |
$2,046.75
|
| Rate for Payer: Cigna Commercial |
$3,397.60
|
| Rate for Payer: First Health Commercial |
$3,888.82
|
| Rate for Payer: Humana Commercial |
$3,479.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,356.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,021.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,228.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,602.28
|
| Rate for Payer: Ohio Health Group HMO |
$3,070.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$818.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$532.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,268.98
|
| Rate for Payer: PHCS Commercial |
$3,929.76
|
| Rate for Payer: United Healthcare All Payer |
$3,602.28
|
|
|
WOUND PREP TRK/ARM/LEG
|
Professional
|
Both
|
$4,093.50
|
|
|
Service Code
|
HCPCS 15002
|
| Hospital Charge Code |
76100171
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$111.61 |
| Max. Negotiated Rate |
$4,093.50 |
| Rate for Payer: Aetna Commercial |
$338.19
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$111.61
|
| Rate for Payer: Anthem Medicaid |
$159.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,093.50
|
| Rate for Payer: Cash Price |
$2,046.75
|
| Rate for Payer: Cash Price |
$2,046.75
|
| Rate for Payer: Cigna Commercial |
$312.40
|
| Rate for Payer: Healthspan PPO |
$375.26
|
| Rate for Payer: Humana Medicaid |
$159.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$284.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$162.58
|
| Rate for Payer: Molina Healthcare Passport |
$159.39
|
| Rate for Payer: Multiplan PHCS |
$2,456.10
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,865.45
|
| Rate for Payer: UHCCP Medicaid |
$117.19
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$160.98
|
|
|
WOUND PREP TRK/ARM/LEG
|
Facility
|
OP
|
$4,093.50
|
|
|
Service Code
|
HCPCS 15002
|
| Hospital Charge Code |
76100171
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$532.16 |
| Max. Negotiated Rate |
$3,929.76 |
| Rate for Payer: Aetna Commercial |
$3,152.00
|
| Rate for Payer: Anthem Medicaid |
$1,407.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,192.93
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$2,046.75
|
| Rate for Payer: Cash Price |
$2,046.75
|
| Rate for Payer: Cigna Commercial |
$3,397.60
|
| Rate for Payer: First Health Commercial |
$3,888.82
|
| Rate for Payer: Humana Commercial |
$3,479.48
|
| Rate for Payer: Humana KY Medicaid |
$1,407.75
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,422.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,356.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,021.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,436.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,602.28
|
| Rate for Payer: Ohio Health Group HMO |
$3,070.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$818.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$532.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,268.98
|
| Rate for Payer: PHCS Commercial |
$3,929.76
|
| Rate for Payer: United Healthcare All Payer |
$3,602.28
|
|
|
WOUND PREP TRK/ARM/LEG(P
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 15002
|
| Hospital Charge Code |
761P0171
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$111.61 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial |
$338.19
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$111.61
|
| Rate for Payer: Anthem Medicaid |
$159.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$600.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$312.40
|
| Rate for Payer: Healthspan PPO |
$375.26
|
| Rate for Payer: Humana Medicaid |
$159.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$284.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$162.58
|
| Rate for Payer: Molina Healthcare Passport |
$159.39
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$117.19
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$160.98
|
|
|
WOUND PREP TRK/ARM/LEG(T
|
Facility
|
OP
|
$3,493.50
|
|
|
Service Code
|
HCPCS 15002
|
| Hospital Charge Code |
761T0171
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$454.16 |
| Max. Negotiated Rate |
$3,353.76 |
| Rate for Payer: Aetna Commercial |
$2,690.00
|
| Rate for Payer: Anthem Medicaid |
$1,201.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,724.93
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$1,746.75
|
| Rate for Payer: Cash Price |
$1,746.75
|
| Rate for Payer: Cigna Commercial |
$2,899.60
|
| Rate for Payer: First Health Commercial |
$3,318.82
|
| Rate for Payer: Humana Commercial |
$2,969.48
|
| Rate for Payer: Humana KY Medicaid |
$1,201.41
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,213.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,864.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,578.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,225.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,074.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,620.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$698.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$454.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,082.98
|
| Rate for Payer: PHCS Commercial |
$3,353.76
|
| Rate for Payer: United Healthcare All Payer |
$3,074.28
|
|
|
WOUND PREP TRK/ARM/LEG(T
|
Facility
|
IP
|
$3,493.50
|
|
|
Service Code
|
HCPCS 15002
|
| Hospital Charge Code |
761T0171
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$454.16 |
| Max. Negotiated Rate |
$3,353.76 |
| Rate for Payer: Aetna Commercial |
$2,690.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,724.93
|
| Rate for Payer: Cash Price |
$1,746.75
|
| Rate for Payer: Cigna Commercial |
$2,899.60
|
| Rate for Payer: First Health Commercial |
$3,318.82
|
| Rate for Payer: Humana Commercial |
$2,969.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,864.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,578.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,048.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,074.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,620.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$698.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$454.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,082.98
|
| Rate for Payer: PHCS Commercial |
$3,353.76
|
| Rate for Payer: United Healthcare All Payer |
$3,074.28
|
|
|
WRINKLE/TEXTURE REPAIR 1.7 OZ
|
Professional
|
Both
|
$145.00
|
|
| Hospital Charge Code |
22200164
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$50.75 |
| Max. Negotiated Rate |
$145.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$145.00
|
| Rate for Payer: Cash Price |
$72.50
|
| Rate for Payer: Multiplan PHCS |
$87.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$101.50
|
| Rate for Payer: UHCCP Medicaid |
$50.75
|
|
