|
COMPLEX DRAINAGE - WOUND
|
Professional
|
Both
|
$4,112.00
|
|
|
Service Code
|
HCPCS 10180
|
| Hospital Charge Code |
76100016
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$91.02 |
| Max. Negotiated Rate |
$4,112.00 |
| Rate for Payer: Aetna Commercial |
$255.51
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$91.02
|
| Rate for Payer: Anthem Medicaid |
$97.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,112.00
|
| Rate for Payer: Cash Price |
$2,056.00
|
| Rate for Payer: Cash Price |
$2,056.00
|
| Rate for Payer: Cigna Commercial |
$247.26
|
| Rate for Payer: Healthspan PPO |
$260.36
|
| Rate for Payer: Humana Medicaid |
$97.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$219.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$99.03
|
| Rate for Payer: Molina Healthcare Passport |
$97.09
|
| Rate for Payer: Multiplan PHCS |
$2,467.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,878.40
|
| Rate for Payer: UHCCP Medicaid |
$95.57
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$98.06
|
|
|
COMPLEX DRAINAGE - WOUND(P
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 10180
|
| Hospital Charge Code |
761P0016
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$91.02 |
| Max. Negotiated Rate |
$500.00 |
| Rate for Payer: Aetna Commercial |
$255.51
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$91.02
|
| Rate for Payer: Anthem Medicaid |
$97.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$500.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$247.26
|
| Rate for Payer: Healthspan PPO |
$260.36
|
| Rate for Payer: Humana Medicaid |
$97.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$219.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$99.03
|
| Rate for Payer: Molina Healthcare Passport |
$97.09
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$350.00
|
| Rate for Payer: UHCCP Medicaid |
$95.57
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$98.06
|
|
|
COMPLEX DRAINAGE - WOUND(T
|
Facility
|
IP
|
$3,612.00
|
|
|
Service Code
|
HCPCS 10180
|
| Hospital Charge Code |
761T0016
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$469.56 |
| Max. Negotiated Rate |
$3,467.52 |
| Rate for Payer: Aetna Commercial |
$2,781.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,817.36
|
| Rate for Payer: Cash Price |
$1,806.00
|
| Rate for Payer: Cigna Commercial |
$2,997.96
|
| Rate for Payer: First Health Commercial |
$3,431.40
|
| Rate for Payer: Humana Commercial |
$3,070.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,961.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,665.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,083.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,178.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,709.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$722.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$469.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,119.72
|
| Rate for Payer: PHCS Commercial |
$3,467.52
|
| Rate for Payer: United Healthcare All Payer |
$3,178.56
|
|
|
COMPLEX DRAINAGE - WOUND(T
|
Facility
|
OP
|
$3,612.00
|
|
|
Service Code
|
HCPCS 10180
|
| Hospital Charge Code |
761T0016
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$469.56 |
| Max. Negotiated Rate |
$3,467.52 |
| Rate for Payer: Aetna Commercial |
$2,781.24
|
| Rate for Payer: Anthem Medicaid |
$1,242.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,817.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,440.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,317.21
|
| Rate for Payer: Cash Price |
$1,806.00
|
| Rate for Payer: Cash Price |
$1,806.00
|
| Rate for Payer: Cigna Commercial |
$2,997.96
|
| Rate for Payer: First Health Commercial |
$3,431.40
|
| Rate for Payer: Humana Commercial |
$3,070.20
|
| Rate for Payer: Humana KY Medicaid |
$1,242.17
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$1,254.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,961.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,665.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,267.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,178.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,709.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$722.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$469.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,119.72
|
| Rate for Payer: PHCS Commercial |
$3,467.52
|
| Rate for Payer: United Healthcare All Payer |
$3,178.56
|
|
|
COMPLEX E/M VISIT ADD ON
|
Facility
|
OP
|
$220.00
|
|
|
Service Code
|
HCPCS G2211
|
| Hospital Charge Code |
51000307
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$28.60 |
| Max. Negotiated Rate |
$211.20 |
| Rate for Payer: Aetna Commercial |
$169.40
|
| Rate for Payer: Anthem Medicaid |
$75.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$171.60
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cigna Commercial |
$182.60
|
| Rate for Payer: First Health Commercial |
$209.00
|
| Rate for Payer: Humana Commercial |
$187.00
|
| Rate for Payer: Humana KY Medicaid |
$75.66
|
| Rate for Payer: Kentucky WC Medicaid |
$76.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$180.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$162.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$66.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$77.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$193.60
|
| Rate for Payer: Ohio Health Group HMO |
$165.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$68.20
|
| Rate for Payer: PHCS Commercial |
$211.20
|
| Rate for Payer: United Healthcare All Payer |
$193.60
|
|
|
COMPLEX E/M VISIT ADD ON
|
Facility
|
IP
|
$220.00
|
|
|
Service Code
|
HCPCS G2211
|
| Hospital Charge Code |
51000307
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$28.60 |
| Max. Negotiated Rate |
$211.20 |
| Rate for Payer: Aetna Commercial |
$169.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$171.60
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cigna Commercial |
$182.60
|
| Rate for Payer: First Health Commercial |
$209.00
|
| Rate for Payer: Humana Commercial |
$187.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$180.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$162.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$66.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$193.60
|
| Rate for Payer: Ohio Health Group HMO |
$165.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$68.20
|
| Rate for Payer: PHCS Commercial |
$211.20
|
| Rate for Payer: United Healthcare All Payer |
$193.60
|
|
|
COMPLEX E/M VISIT ADD ON
|
Professional
|
Both
|
$220.00
|
|
|
Service Code
|
HCPCS G2211
|
| Hospital Charge Code |
51000307
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$77.00 |
| Max. Negotiated Rate |
$220.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$220.00
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Multiplan PHCS |
$132.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$154.00
|
| Rate for Payer: UHCCP Medicaid |
$77.00
|
|
|
COMPLEXION RENEW PADS 60CT GBL
|
Professional
|
Both
|
$51.00
|
|
| Hospital Charge Code |
22200143
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$51.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$51.00
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Multiplan PHCS |
$30.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$35.70
|
| Rate for Payer: UHCCP Medicaid |
$17.85
|
|
|
COMPLEX RPR TRUNK 1.1-2.5
|
Facility
|
OP
|
$2,494.00
|
|
|
Service Code
|
HCPCS 13100
|
| Hospital Charge Code |
76100149
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$324.22 |
| Max. Negotiated Rate |
$2,394.24 |
| Rate for Payer: Aetna Commercial |
$1,920.38
|
| Rate for Payer: Anthem Medicaid |
$857.69
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,945.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$1,247.00
|
| Rate for Payer: Cash Price |
$1,247.00
|
| Rate for Payer: Cigna Commercial |
$2,070.02
|
| Rate for Payer: First Health Commercial |
$2,369.30
|
| Rate for Payer: Humana Commercial |
$2,119.90
|
| Rate for Payer: Humana KY Medicaid |
$857.69
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$866.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,045.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,840.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$874.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,194.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,870.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$498.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$324.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$773.14
|
| Rate for Payer: PHCS Commercial |
$2,394.24
|
| Rate for Payer: United Healthcare All Payer |
$2,194.72
|
|
|
COMPLEX RPR TRUNK 1.1-2.5
|
Facility
|
IP
|
$2,494.00
|
|
|
Service Code
|
HCPCS 13100
|
| Hospital Charge Code |
76100149
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$324.22 |
| Max. Negotiated Rate |
$2,394.24 |
| Rate for Payer: Aetna Commercial |
$1,920.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,945.32
|
| Rate for Payer: Cash Price |
$1,247.00
|
| Rate for Payer: Cigna Commercial |
$2,070.02
|
| Rate for Payer: First Health Commercial |
$2,369.30
|
| Rate for Payer: Humana Commercial |
$2,119.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,045.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,840.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$748.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,194.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,870.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$498.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$324.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$773.14
|
| Rate for Payer: PHCS Commercial |
$2,394.24
|
| Rate for Payer: United Healthcare All Payer |
$2,194.72
|
|
|
COMPLEX RPR TRUNK 1.1-2.5
|
Professional
|
Both
|
$2,494.00
|
|
|
Service Code
|
HCPCS 13100
|
| Hospital Charge Code |
76100149
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$101.23 |
| Max. Negotiated Rate |
$2,494.00 |
| Rate for Payer: Aetna Commercial |
$334.67
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$101.23
|
| Rate for Payer: Anthem Medicaid |
$108.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,494.00
|
| Rate for Payer: Cash Price |
$1,247.00
|
| Rate for Payer: Cash Price |
$1,247.00
|
| Rate for Payer: Cigna Commercial |
$410.07
|
| Rate for Payer: Healthspan PPO |
$348.04
|
| Rate for Payer: Humana Medicaid |
$108.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$292.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$110.70
|
| Rate for Payer: Molina Healthcare Passport |
$108.53
|
| Rate for Payer: Multiplan PHCS |
$1,496.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,745.80
|
| Rate for Payer: UHCCP Medicaid |
$106.29
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$109.62
|
|
|
COMPLEX RPR TRUNK 1.1-2.5(P
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 13100
|
| Hospital Charge Code |
761P0149
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$101.23 |
| Max. Negotiated Rate |
$450.00 |
| Rate for Payer: Aetna Commercial |
$334.67
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$101.23
|
| Rate for Payer: Anthem Medicaid |
$108.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$450.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$410.07
|
| Rate for Payer: Healthspan PPO |
$348.04
|
| Rate for Payer: Humana Medicaid |
$108.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$292.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$110.70
|
| Rate for Payer: Molina Healthcare Passport |
$108.53
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$315.00
|
| Rate for Payer: UHCCP Medicaid |
$106.29
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$109.62
|
|
|
COMPLEX RPR TRUNK 1.1-2.5(T
|
Facility
|
OP
|
$2,044.00
|
|
|
Service Code
|
HCPCS 13100
|
| Hospital Charge Code |
761T0149
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$265.72 |
| Max. Negotiated Rate |
$1,962.24 |
| Rate for Payer: Aetna Commercial |
$1,573.88
|
| Rate for Payer: Anthem Medicaid |
$702.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,594.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$1,022.00
|
| Rate for Payer: Cash Price |
$1,022.00
|
| Rate for Payer: Cigna Commercial |
$1,696.52
|
| Rate for Payer: First Health Commercial |
$1,941.80
|
| Rate for Payer: Humana Commercial |
$1,737.40
|
| Rate for Payer: Humana KY Medicaid |
$702.93
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$710.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,676.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,508.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$717.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,798.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,533.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$408.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$265.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$633.64
|
| Rate for Payer: PHCS Commercial |
$1,962.24
|
| Rate for Payer: United Healthcare All Payer |
$1,798.72
|
|
|
COMPLEX RPR TRUNK 1.1-2.5(T
|
Facility
|
IP
|
$2,044.00
|
|
|
Service Code
|
HCPCS 13100
|
| Hospital Charge Code |
761T0149
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$265.72 |
| Max. Negotiated Rate |
$1,962.24 |
| Rate for Payer: Aetna Commercial |
$1,573.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,594.32
|
| Rate for Payer: Cash Price |
$1,022.00
|
| Rate for Payer: Cigna Commercial |
$1,696.52
|
| Rate for Payer: First Health Commercial |
$1,941.80
|
| Rate for Payer: Humana Commercial |
$1,737.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,676.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,508.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$613.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,798.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,533.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$408.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$265.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$633.64
|
| Rate for Payer: PHCS Commercial |
$1,962.24
|
| Rate for Payer: United Healthcare All Payer |
$1,798.72
|
|
|
COMPLICATED PEPTIC ULCER WITH CC
|
Facility
|
IP
|
$12,552.16
|
|
|
Service Code
|
MSDRG 381
|
| Min. Negotiated Rate |
$8,517.54 |
| Max. Negotiated Rate |
$12,552.16 |
| Rate for Payer: Anthem Medicaid |
$8,517.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8,965.83
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12,552.16
|
| Rate for Payer: CareSource Just4Me Medicare |
$12,103.87
|
| Rate for Payer: Humana KY Medicaid |
$8,517.54
|
| Rate for Payer: Humana Medicare Advantage |
$8,965.83
|
| Rate for Payer: Kentucky WC Medicaid |
$8,602.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,759.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,687.89
|
|
|
COMPLICATED PEPTIC ULCER WITH MCC
|
Facility
|
IP
|
$22,793.96
|
|
|
Service Code
|
MSDRG 380
|
| Min. Negotiated Rate |
$15,467.33 |
| Max. Negotiated Rate |
$22,793.96 |
| Rate for Payer: Anthem Medicaid |
$15,467.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$16,281.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$22,793.96
|
| Rate for Payer: CareSource Just4Me Medicare |
$21,979.89
|
| Rate for Payer: Humana KY Medicaid |
$15,467.33
|
| Rate for Payer: Humana Medicare Advantage |
$16,281.40
|
| Rate for Payer: Kentucky WC Medicaid |
$15,622.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19,537.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$15,776.68
|
|
|
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC
|
Facility
|
IP
|
$8,856.72
|
|
|
Service Code
|
MSDRG 382
|
| Min. Negotiated Rate |
$6,009.92 |
| Max. Negotiated Rate |
$8,856.72 |
| Rate for Payer: Anthem Medicaid |
$6,009.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,326.23
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,856.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,540.41
|
| Rate for Payer: Humana KY Medicaid |
$6,009.92
|
| Rate for Payer: Humana Medicare Advantage |
$6,326.23
|
| Rate for Payer: Kentucky WC Medicaid |
$6,070.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,591.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,130.12
|
|
|
COMPLICATIONS OF TREATMENT WITH CC
|
Facility
|
IP
|
$12,093.62
|
|
|
Service Code
|
MSDRG 920
|
| Min. Negotiated Rate |
$8,206.38 |
| Max. Negotiated Rate |
$12,093.62 |
| Rate for Payer: Anthem Medicaid |
$8,206.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8,638.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12,093.62
|
| Rate for Payer: CareSource Just4Me Medicare |
$11,661.70
|
| Rate for Payer: Humana KY Medicaid |
$8,206.38
|
| Rate for Payer: Humana Medicare Advantage |
$8,638.30
|
| Rate for Payer: Kentucky WC Medicaid |
$8,288.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,365.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,370.51
|
|
|
COMPLICATIONS OF TREATMENT WITH MCC
|
Facility
|
IP
|
$21,345.70
|
|
|
Service Code
|
MSDRG 919
|
| Min. Negotiated Rate |
$14,484.58 |
| Max. Negotiated Rate |
$21,345.70 |
| Rate for Payer: Anthem Medicaid |
$14,484.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$15,246.93
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$21,345.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$20,583.36
|
| Rate for Payer: Humana KY Medicaid |
$14,484.58
|
| Rate for Payer: Humana Medicare Advantage |
$15,246.93
|
| Rate for Payer: Kentucky WC Medicaid |
$14,629.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18,296.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,774.28
|
|
|
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC
|
Facility
|
IP
|
$8,162.98
|
|
|
Service Code
|
MSDRG 921
|
| Min. Negotiated Rate |
$5,539.16 |
| Max. Negotiated Rate |
$8,162.98 |
| Rate for Payer: Anthem Medicaid |
$5,539.16
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,830.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,162.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,871.44
|
| Rate for Payer: Humana KY Medicaid |
$5,539.16
|
| Rate for Payer: Humana Medicare Advantage |
$5,830.70
|
| Rate for Payer: Kentucky WC Medicaid |
$5,594.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,996.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,649.95
|
|
|
COMPOSITE SKIN GRAFT
|
Facility
|
IP
|
$5,925.46
|
|
|
Service Code
|
HCPCS 15760
|
| Hospital Charge Code |
76100208
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$770.31 |
| Max. Negotiated Rate |
$5,688.44 |
| Rate for Payer: Aetna Commercial |
$4,562.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,621.86
|
| Rate for Payer: Cash Price |
$2,962.73
|
| Rate for Payer: Cigna Commercial |
$4,918.13
|
| Rate for Payer: First Health Commercial |
$5,629.19
|
| Rate for Payer: Humana Commercial |
$5,036.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,858.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,372.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,777.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,214.40
|
| Rate for Payer: Ohio Health Group HMO |
$4,444.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,185.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$770.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,836.89
|
| Rate for Payer: PHCS Commercial |
$5,688.44
|
| Rate for Payer: United Healthcare All Payer |
$5,214.40
|
|
|
COMPOSITE SKIN GRAFT
|
Professional
|
Both
|
$5,925.46
|
|
|
Service Code
|
HCPCS 15760
|
| Hospital Charge Code |
76100208
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$355.06 |
| Max. Negotiated Rate |
$5,925.46 |
| Rate for Payer: Aetna Commercial |
$1,006.84
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$355.06
|
| Rate for Payer: Anthem Medicaid |
$465.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,925.46
|
| Rate for Payer: Cash Price |
$2,962.73
|
| Rate for Payer: Cash Price |
$2,962.73
|
| Rate for Payer: Cigna Commercial |
$959.98
|
| Rate for Payer: Healthspan PPO |
$939.44
|
| Rate for Payer: Humana Medicaid |
$465.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$890.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$474.78
|
| Rate for Payer: Molina Healthcare Passport |
$465.47
|
| Rate for Payer: Multiplan PHCS |
$3,555.28
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,147.82
|
| Rate for Payer: UHCCP Medicaid |
$372.81
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$470.12
|
|
|
COMPOSITE SKIN GRAFT
|
Facility
|
OP
|
$5,925.46
|
|
|
Service Code
|
HCPCS 15760
|
| Hospital Charge Code |
76100208
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$770.31 |
| Max. Negotiated Rate |
$5,688.44 |
| Rate for Payer: Aetna Commercial |
$4,562.60
|
| Rate for Payer: Anthem Medicaid |
$2,037.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,621.86
|
| 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 |
$2,962.73
|
| Rate for Payer: Cash Price |
$2,962.73
|
| Rate for Payer: Cigna Commercial |
$4,918.13
|
| Rate for Payer: First Health Commercial |
$5,629.19
|
| Rate for Payer: Humana Commercial |
$5,036.64
|
| Rate for Payer: Humana KY Medicaid |
$2,037.77
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,058.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,858.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,372.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,078.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,214.40
|
| Rate for Payer: Ohio Health Group HMO |
$4,444.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,185.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$770.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,836.89
|
| Rate for Payer: PHCS Commercial |
$5,688.44
|
| Rate for Payer: United Healthcare All Payer |
$5,214.40
|
|
|
COMPOSITE SKIN GRAFT(P
|
Professional
|
Both
|
$1,400.00
|
|
|
Service Code
|
HCPCS 15760
|
| Hospital Charge Code |
761P0208
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$355.06 |
| Max. Negotiated Rate |
$1,400.00 |
| Rate for Payer: Aetna Commercial |
$1,006.84
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$355.06
|
| Rate for Payer: Anthem Medicaid |
$465.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,400.00
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cigna Commercial |
$959.98
|
| Rate for Payer: Healthspan PPO |
$939.44
|
| Rate for Payer: Humana Medicaid |
$465.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$890.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$474.78
|
| Rate for Payer: Molina Healthcare Passport |
$465.47
|
| Rate for Payer: Multiplan PHCS |
$840.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$980.00
|
| Rate for Payer: UHCCP Medicaid |
$372.81
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$470.12
|
|
|
COMPOSITE SKIN GRAFT(T
|
Facility
|
OP
|
$4,525.46
|
|
|
Service Code
|
HCPCS 15760
|
| Hospital Charge Code |
761T0208
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$588.31 |
| Max. Negotiated Rate |
$4,344.44 |
| Rate for Payer: Aetna Commercial |
$3,484.60
|
| Rate for Payer: Anthem Medicaid |
$1,556.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,529.86
|
| 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 |
$2,262.73
|
| Rate for Payer: Cash Price |
$2,262.73
|
| Rate for Payer: Cigna Commercial |
$3,756.13
|
| Rate for Payer: First Health Commercial |
$4,299.19
|
| Rate for Payer: Humana Commercial |
$3,846.64
|
| Rate for Payer: Humana KY Medicaid |
$1,556.31
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,572.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,710.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,339.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,587.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,982.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,394.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$905.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$588.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,402.89
|
| Rate for Payer: PHCS Commercial |
$4,344.44
|
| Rate for Payer: United Healthcare All Payer |
$3,982.40
|
|
