|
WOUND EXPLORATION ABDOMEN(T
|
Facility
|
IP
|
$5,561.00
|
|
|
Service Code
|
HCPCS 20102
|
| Hospital Charge Code |
761T0324
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,668.30 |
| Max. Negotiated Rate |
$5,338.56 |
| Rate for Payer: Aetna Commercial |
$4,281.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,337.58
|
| Rate for Payer: Cash Price |
$2,780.50
|
| Rate for Payer: Cigna Commercial |
$4,615.63
|
| Rate for Payer: First Health Commercial |
$5,282.95
|
| Rate for Payer: Humana Commercial |
$4,726.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,560.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,104.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,893.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,170.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,448.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,838.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,837.09
|
| Rate for Payer: PHCS Commercial |
$5,338.56
|
| Rate for Payer: United Healthcare All Payer |
$4,893.68
|
|
|
WOUND EXPLORATION ABDOMEN(T
|
Facility
|
OP
|
$5,561.00
|
|
|
Service Code
|
HCPCS 20102
|
| Hospital Charge Code |
761T0324
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,690.17 |
| Max. Negotiated Rate |
$5,338.56 |
| Rate for Payer: Aetna Commercial |
$4,281.97
|
| Rate for Payer: Anthem Medicaid |
$1,912.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,337.58
|
| 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 |
$2,780.50
|
| Rate for Payer: Cash Price |
$2,780.50
|
| Rate for Payer: Cigna Commercial |
$4,615.63
|
| Rate for Payer: First Health Commercial |
$5,282.95
|
| Rate for Payer: Humana Commercial |
$4,726.85
|
| Rate for Payer: Humana KY Medicaid |
$1,912.43
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,931.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,560.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,104.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,950.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,893.68
|
| Rate for Payer: Ohio Health Group HMO |
$4,170.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,448.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,838.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,837.09
|
| Rate for Payer: PHCS Commercial |
$5,338.56
|
| Rate for Payer: United Healthcare All Payer |
$4,893.68
|
|
|
WOUND MATRIX THIN 4*10
|
Facility
|
OP
|
$28,276.25
|
|
|
Service Code
|
HCPCS Q4108
|
| Hospital Charge Code |
27000118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,482.88 |
| Max. Negotiated Rate |
$27,145.20 |
| Rate for Payer: Aetna Commercial |
$21,772.71
|
| Rate for Payer: Anthem Medicaid |
$9,724.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,055.47
|
| Rate for Payer: Cash Price |
$14,138.12
|
| Rate for Payer: Cigna Commercial |
$23,469.29
|
| Rate for Payer: First Health Commercial |
$26,862.44
|
| Rate for Payer: Humana Commercial |
$24,034.81
|
| Rate for Payer: Humana KY Medicaid |
$9,724.20
|
| Rate for Payer: Kentucky WC Medicaid |
$9,823.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,186.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,867.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,482.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,919.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$24,883.10
|
| Rate for Payer: Ohio Health Group HMO |
$21,207.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,621.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,600.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,510.61
|
| Rate for Payer: PHCS Commercial |
$27,145.20
|
| Rate for Payer: United Healthcare All Payer |
$24,883.10
|
|
|
WOUND MATRIX THIN 4*10
|
Facility
|
IP
|
$28,276.25
|
|
|
Service Code
|
HCPCS Q4108
|
| Hospital Charge Code |
27000118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,482.88 |
| Max. Negotiated Rate |
$27,145.20 |
| Rate for Payer: Aetna Commercial |
$21,772.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,055.47
|
| Rate for Payer: Cash Price |
$14,138.12
|
| Rate for Payer: Cigna Commercial |
$23,469.29
|
| Rate for Payer: First Health Commercial |
$26,862.44
|
| Rate for Payer: Humana Commercial |
$24,034.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,186.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,867.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,482.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$24,883.10
|
| Rate for Payer: Ohio Health Group HMO |
$21,207.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,621.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,600.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,510.61
|
| Rate for Payer: PHCS Commercial |
$27,145.20
|
| Rate for Payer: United Healthcare All Payer |
$24,883.10
|
|
|
WOUND MATRIX THIN 4*5(125SQ CM
|
Facility
|
OP
|
$11,962.29
|
|
|
Service Code
|
HCPCS Q4108
|
| Hospital Charge Code |
27000118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,588.69 |
| Max. Negotiated Rate |
$11,483.80 |
| Rate for Payer: Aetna Commercial |
$9,210.96
|
| Rate for Payer: Anthem Medicaid |
$4,113.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,330.59
|
| Rate for Payer: Cash Price |
$5,981.14
|
| Rate for Payer: Cigna Commercial |
$9,928.70
|
| Rate for Payer: First Health Commercial |
$11,364.18
|
| Rate for Payer: Humana Commercial |
$10,167.95
|
| Rate for Payer: Humana KY Medicaid |
$4,113.83
|
| Rate for Payer: Kentucky WC Medicaid |
$4,155.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,809.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,828.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,588.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,196.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,526.82
|
| Rate for Payer: Ohio Health Group HMO |
$8,971.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,569.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,407.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,253.98
|
| Rate for Payer: PHCS Commercial |
$11,483.80
|
| Rate for Payer: United Healthcare All Payer |
$10,526.82
|
|
|
WOUND MATRIX THIN 4*5(125SQ CM
|
Facility
|
IP
|
$11,962.29
|
|
|
Service Code
|
HCPCS Q4108
|
| Hospital Charge Code |
27000118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,588.69 |
| Max. Negotiated Rate |
$11,483.80 |
| Rate for Payer: Aetna Commercial |
$9,210.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,330.59
|
| Rate for Payer: Cash Price |
$5,981.14
|
| Rate for Payer: Cigna Commercial |
$9,928.70
|
| Rate for Payer: First Health Commercial |
$11,364.18
|
| Rate for Payer: Humana Commercial |
$10,167.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,809.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,828.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,588.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,526.82
|
| Rate for Payer: Ohio Health Group HMO |
$8,971.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,569.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,407.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,253.98
|
| Rate for Payer: PHCS Commercial |
$11,483.80
|
| Rate for Payer: United Healthcare All Payer |
$10,526.82
|
|
|
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 |
$554.77 |
| Max. Negotiated Rate |
$1,775.28 |
| Rate for Payer: Aetna Commercial |
$1,423.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,442.41
|
| 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 |
$554.77
|
| 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 |
$1,479.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,608.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,275.98
|
| Rate for Payer: PHCS Commercial |
$1,775.28
|
| Rate for Payer: United Healthcare All Payer |
$1,627.34
|
|
|
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 |
$554.77 |
| 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 |
$1,442.41
|
| 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 |
$554.77
|
| 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 |
$1,479.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,608.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,275.98
|
| 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 |
$1,109.55 |
| Rate for Payer: Aetna Commercial |
$69.00
|
| Rate for Payer: Ambetter Exchange |
$42.17
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$23.19
|
| Rate for Payer: Anthem Medicaid |
$49.17
|
| Rate for Payer: Buckeye Individual/Medicaid |
$42.17
|
| Rate for Payer: Buckeye Medicare Advantage |
$42.17
|
| Rate for Payer: CareSource Just4Me Medicare |
$50.60
|
| 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 |
$49.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$57.74
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$42.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.17
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$50.15
|
| Rate for Payer: Molina Healthcare Passport |
$49.17
|
| Rate for Payer: Multiplan PHCS |
$1,109.55
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$54.82
|
| Rate for Payer: UHCCP Medicaid |
$24.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$49.66
|
| Rate for Payer: Wellcare Medicare Advantage |
$42.17
|
|
|
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 |
$81.70 |
| Rate for Payer: Aetna Commercial |
$69.00
|
| Rate for Payer: Ambetter Exchange |
$42.17
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$23.19
|
| Rate for Payer: Anthem Medicaid |
$49.17
|
| Rate for Payer: Buckeye Individual/Medicaid |
$42.17
|
| Rate for Payer: Buckeye Medicare Advantage |
$42.17
|
| Rate for Payer: CareSource Just4Me Medicare |
$50.60
|
| 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 |
$49.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$57.74
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$42.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.17
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$50.15
|
| Rate for Payer: Molina Healthcare Passport |
$49.17
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$54.82
|
| Rate for Payer: UHCCP Medicaid |
$24.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$49.66
|
| Rate for Payer: Wellcare Medicare Advantage |
$42.17
|
|
|
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 |
$517.27 |
| 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 |
$1,344.91
|
| 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 |
$517.27
|
| 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 |
$1,379.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,500.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,189.73
|
| 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
|
IP
|
$1,724.25
|
|
|
Service Code
|
HCPCS 15003
|
| Hospital Charge Code |
761T0172
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$517.27 |
| Max. Negotiated Rate |
$1,655.28 |
| Rate for Payer: Aetna Commercial |
$1,327.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,344.91
|
| 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 |
$517.27
|
| 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 |
$1,379.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,500.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,189.73
|
| 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 |
$1,994.36 |
| Rate for Payer: Aetna Commercial |
$423.06
|
| Rate for Payer: Ambetter Exchange |
$245.81
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$132.72
|
| Rate for Payer: Anthem Medicaid |
$268.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$245.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$245.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$294.97
|
| 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 |
$268.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$343.22
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$245.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$245.81
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$273.99
|
| Rate for Payer: Molina Healthcare Passport |
$268.62
|
| Rate for Payer: Multiplan PHCS |
$1,994.36
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$319.55
|
| Rate for Payer: UHCCP Medicaid |
$139.36
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$271.31
|
| Rate for Payer: Wellcare Medicare Advantage |
$245.81
|
|
|
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 |
$565.60 |
| 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 |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,592.67
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| 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 |
$565.60
|
| 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 |
$678.72
|
| 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 |
$2,492.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,659.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,891.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,293.52
|
| 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 |
$997.18 |
| 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 |
$2,492.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,659.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,891.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,293.52
|
| 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 |
$456.40 |
| Rate for Payer: Aetna Commercial |
$423.06
|
| Rate for Payer: Ambetter Exchange |
$245.81
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$132.72
|
| Rate for Payer: Anthem Medicaid |
$268.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$245.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$245.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$294.97
|
| 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 |
$268.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$343.22
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$245.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$245.81
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$273.99
|
| Rate for Payer: Molina Healthcare Passport |
$268.62
|
| Rate for Payer: Multiplan PHCS |
$408.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$319.55
|
| Rate for Payer: UHCCP Medicaid |
$139.36
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$271.31
|
| Rate for Payer: Wellcare Medicare Advantage |
$245.81
|
|
|
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 |
$565.60 |
| 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 |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,062.27
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| 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 |
$565.60
|
| 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 |
$678.72
|
| 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 |
$1,982.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,115.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,300.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,824.32
|
| 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
|
IP
|
$2,643.94
|
|
|
Service Code
|
HCPCS 15004
|
| Hospital Charge Code |
761T0173
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$793.18 |
| 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 |
$1,982.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,115.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,300.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,824.32
|
| Rate for Payer: PHCS Commercial |
$2,538.18
|
| Rate for Payer: United Healthcare All Payer |
$2,326.67
|
|
|
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 |
$1,407.75 |
| Max. Negotiated Rate |
$3,929.76 |
| Rate for Payer: Aetna Commercial |
$3,151.99
|
| Rate for Payer: Anthem Medicaid |
$1,407.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,192.93
|
| 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 |
$2,046.75
|
| Rate for Payer: Cash Price |
$2,046.75
|
| Rate for Payer: Cigna Commercial |
$3,397.61
|
| Rate for Payer: First Health Commercial |
$3,888.82
|
| Rate for Payer: Humana Commercial |
$3,479.47
|
| Rate for Payer: Humana KY Medicaid |
$1,407.75
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| 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 |
$2,028.20
|
| 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 |
$3,274.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,561.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,824.51
|
| Rate for Payer: PHCS Commercial |
$3,929.76
|
| Rate for Payer: United Healthcare All Payer |
$3,602.28
|
|
|
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 |
$1,228.05 |
| Max. Negotiated Rate |
$3,929.76 |
| Rate for Payer: Aetna Commercial |
$3,151.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,192.93
|
| Rate for Payer: Cash Price |
$2,046.75
|
| Rate for Payer: Cigna Commercial |
$3,397.61
|
| Rate for Payer: First Health Commercial |
$3,888.82
|
| Rate for Payer: Humana Commercial |
$3,479.47
|
| 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 |
$3,274.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,561.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,824.51
|
| 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 |
$2,456.10 |
| Rate for Payer: Aetna Commercial |
$338.19
|
| Rate for Payer: Ambetter Exchange |
$207.56
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$111.61
|
| Rate for Payer: Anthem Medicaid |
$222.05
|
| Rate for Payer: Buckeye Individual/Medicaid |
$207.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$207.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$249.07
|
| 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 |
$222.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$284.82
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$207.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.56
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$226.49
|
| Rate for Payer: Molina Healthcare Passport |
$222.05
|
| Rate for Payer: Multiplan PHCS |
$2,456.10
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$269.83
|
| Rate for Payer: UHCCP Medicaid |
$117.19
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$224.27
|
| Rate for Payer: Wellcare Medicare Advantage |
$207.56
|
|
|
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 |
$375.26 |
| Rate for Payer: Aetna Commercial |
$338.19
|
| Rate for Payer: Ambetter Exchange |
$207.56
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$111.61
|
| Rate for Payer: Anthem Medicaid |
$222.05
|
| Rate for Payer: Buckeye Individual/Medicaid |
$207.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$207.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$249.07
|
| 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 |
$222.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$284.82
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$207.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.56
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$226.49
|
| Rate for Payer: Molina Healthcare Passport |
$222.05
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$269.83
|
| Rate for Payer: UHCCP Medicaid |
$117.19
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$224.27
|
| Rate for Payer: Wellcare Medicare Advantage |
$207.56
|
|
|
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 |
$1,048.05 |
| Max. Negotiated Rate |
$3,353.76 |
| Rate for Payer: Aetna Commercial |
$2,689.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,724.93
|
| Rate for Payer: Cash Price |
$1,746.75
|
| Rate for Payer: Cigna Commercial |
$2,899.61
|
| Rate for Payer: First Health Commercial |
$3,318.82
|
| Rate for Payer: Humana Commercial |
$2,969.47
|
| 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 |
$2,794.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,039.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,410.51
|
| 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
|
OP
|
$3,493.50
|
|
|
Service Code
|
HCPCS 15002
|
| Hospital Charge Code |
761T0171
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,201.41 |
| Max. Negotiated Rate |
$3,353.76 |
| Rate for Payer: Aetna Commercial |
$2,689.99
|
| Rate for Payer: Anthem Medicaid |
$1,201.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,724.93
|
| 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 |
$1,746.75
|
| Rate for Payer: Cash Price |
$1,746.75
|
| Rate for Payer: Cigna Commercial |
$2,899.61
|
| Rate for Payer: First Health Commercial |
$3,318.82
|
| Rate for Payer: Humana Commercial |
$2,969.47
|
| Rate for Payer: Humana KY Medicaid |
$1,201.41
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| 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 |
$2,028.20
|
| 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 |
$2,794.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,039.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,410.51
|
| 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 |
$101.50 |
| 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
|
|
