|
DEBRID SEL GREAT EQ 20 SQCM
|
Facility
|
OP
|
$472.00
|
|
|
Service Code
|
HCPCS 97598
|
| Hospital Charge Code |
76102500
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$61.36 |
| Max. Negotiated Rate |
$453.12 |
| Rate for Payer: Aetna Commercial |
$363.44
|
| Rate for Payer: Anthem Medicaid |
$162.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$368.16
|
| Rate for Payer: Cash Price |
$236.00
|
| Rate for Payer: Cigna Commercial |
$391.76
|
| Rate for Payer: First Health Commercial |
$448.40
|
| Rate for Payer: Humana Commercial |
$401.20
|
| Rate for Payer: Humana KY Medicaid |
$162.32
|
| Rate for Payer: Kentucky WC Medicaid |
$163.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$387.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$348.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$141.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$165.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$415.36
|
| Rate for Payer: Ohio Health Group HMO |
$354.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$94.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$61.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$146.32
|
| Rate for Payer: PHCS Commercial |
$453.12
|
| Rate for Payer: United Healthcare All Payer |
$415.36
|
|
|
DEBRID SEL GREAT EQ 20 SQCM
|
Professional
|
Both
|
$472.00
|
|
|
Service Code
|
HCPCS 97598
|
| Hospital Charge Code |
76102500
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$11.72 |
| Max. Negotiated Rate |
$472.00 |
| Rate for Payer: Aetna Commercial |
$67.41
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$11.72
|
| Rate for Payer: Anthem Medicaid |
$45.19
|
| Rate for Payer: Buckeye Medicare Advantage |
$472.00
|
| Rate for Payer: Cash Price |
$236.00
|
| Rate for Payer: Cash Price |
$236.00
|
| Rate for Payer: Cigna Commercial |
$87.22
|
| Rate for Payer: Humana Medicaid |
$45.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$14.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$46.09
|
| Rate for Payer: Molina Healthcare Passport |
$45.19
|
| Rate for Payer: Multiplan PHCS |
$283.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$330.40
|
| Rate for Payer: UHCCP Medicaid |
$12.31
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$45.64
|
|
|
DEBRID SEL GREAT EQ 20 SQCM
|
Facility
|
IP
|
$472.00
|
|
|
Service Code
|
HCPCS 97598
|
| Hospital Charge Code |
76102500
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$61.36 |
| Max. Negotiated Rate |
$453.12 |
| Rate for Payer: Aetna Commercial |
$363.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$368.16
|
| Rate for Payer: Cash Price |
$236.00
|
| Rate for Payer: Cigna Commercial |
$391.76
|
| Rate for Payer: First Health Commercial |
$448.40
|
| Rate for Payer: Humana Commercial |
$401.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$387.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$348.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$141.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$415.36
|
| Rate for Payer: Ohio Health Group HMO |
$354.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$94.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$61.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$146.32
|
| Rate for Payer: PHCS Commercial |
$453.12
|
| Rate for Payer: United Healthcare All Payer |
$415.36
|
|
|
DEBRID SEL GREAT EQ 20 SQCM(P
|
Professional
|
Both
|
$70.00
|
|
|
Service Code
|
HCPCS 97598
|
| Hospital Charge Code |
761P2500
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$11.72 |
| Max. Negotiated Rate |
$87.22 |
| Rate for Payer: Aetna Commercial |
$67.41
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$11.72
|
| Rate for Payer: Anthem Medicaid |
$45.19
|
| Rate for Payer: Buckeye Medicare Advantage |
$70.00
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Cigna Commercial |
$87.22
|
| Rate for Payer: Humana Medicaid |
$45.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$14.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$46.09
|
| Rate for Payer: Molina Healthcare Passport |
$45.19
|
| Rate for Payer: Multiplan PHCS |
$42.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$49.00
|
| Rate for Payer: UHCCP Medicaid |
$12.31
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$45.64
|
|
|
DEBRID SEL GREAT EQ 20 SQCM(T
|
Facility
|
OP
|
$402.00
|
|
|
Service Code
|
HCPCS 97598
|
| Hospital Charge Code |
761T2500
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$52.26 |
| Max. Negotiated Rate |
$385.92 |
| Rate for Payer: Aetna Commercial |
$309.54
|
| Rate for Payer: Anthem Medicaid |
$138.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$313.56
|
| Rate for Payer: Cash Price |
$201.00
|
| Rate for Payer: Cigna Commercial |
$333.66
|
| Rate for Payer: First Health Commercial |
$381.90
|
| Rate for Payer: Humana Commercial |
$341.70
|
| Rate for Payer: Humana KY Medicaid |
$138.25
|
| Rate for Payer: Kentucky WC Medicaid |
$139.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$329.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$296.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$120.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$141.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$353.76
|
| Rate for Payer: Ohio Health Group HMO |
$301.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.62
|
| Rate for Payer: PHCS Commercial |
$385.92
|
| Rate for Payer: United Healthcare All Payer |
$353.76
|
|
|
DEBRID SEL GREAT EQ 20 SQCM(T
|
Facility
|
IP
|
$402.00
|
|
|
Service Code
|
HCPCS 97598
|
| Hospital Charge Code |
761T2500
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$52.26 |
| Max. Negotiated Rate |
$385.92 |
| Rate for Payer: Aetna Commercial |
$309.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$313.56
|
| Rate for Payer: Cash Price |
$201.00
|
| Rate for Payer: Cigna Commercial |
$333.66
|
| Rate for Payer: First Health Commercial |
$381.90
|
| Rate for Payer: Humana Commercial |
$341.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$329.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$296.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$120.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$353.76
|
| Rate for Payer: Ohio Health Group HMO |
$301.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.62
|
| Rate for Payer: PHCS Commercial |
$385.92
|
| Rate for Payer: United Healthcare All Payer |
$353.76
|
|
|
DEBRID SEL LESS EQ 20SQ CM
|
Facility
|
IP
|
$301.00
|
|
|
Service Code
|
HCPCS 97597
|
| Hospital Charge Code |
42000035
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$39.13 |
| Max. Negotiated Rate |
$288.96 |
| Rate for Payer: Aetna Commercial |
$231.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$234.78
|
| Rate for Payer: Cash Price |
$150.50
|
| Rate for Payer: Cigna Commercial |
$249.83
|
| Rate for Payer: First Health Commercial |
$285.95
|
| Rate for Payer: Humana Commercial |
$255.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$246.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$222.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$90.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$264.88
|
| Rate for Payer: Ohio Health Group HMO |
$225.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$93.31
|
| Rate for Payer: PHCS Commercial |
$288.96
|
| Rate for Payer: United Healthcare All Payer |
$264.88
|
|
|
DEBRID SEL LESS EQ 20SQ CM
|
Facility
|
OP
|
$301.00
|
|
|
Service Code
|
HCPCS 97597
|
| Hospital Charge Code |
42000035
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$39.13 |
| Max. Negotiated Rate |
$288.96 |
| Rate for Payer: Aetna Commercial |
$231.77
|
| Rate for Payer: Anthem Medicaid |
$103.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$234.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$150.50
|
| Rate for Payer: Cash Price |
$150.50
|
| Rate for Payer: Cigna Commercial |
$249.83
|
| Rate for Payer: First Health Commercial |
$285.95
|
| Rate for Payer: Humana Commercial |
$255.85
|
| Rate for Payer: Humana KY Medicaid |
$103.51
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$104.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$246.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$222.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$105.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$264.88
|
| Rate for Payer: Ohio Health Group HMO |
$225.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$93.31
|
| Rate for Payer: PHCS Commercial |
$288.96
|
| Rate for Payer: United Healthcare All Payer |
$264.88
|
|
|
DEBR MUS/FAS 1ST 20 SQ CM OR <
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 11043
|
| Hospital Charge Code |
761P0027
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$78.04 |
| Max. Negotiated Rate |
$500.00 |
| Rate for Payer: Aetna Commercial |
$336.89
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$78.04
|
| Rate for Payer: Anthem Medicaid |
$110.51
|
| 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 |
$323.79
|
| Rate for Payer: Healthspan PPO |
$305.75
|
| Rate for Payer: Humana Medicaid |
$110.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$153.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$112.72
|
| Rate for Payer: Molina Healthcare Passport |
$110.51
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$350.00
|
| Rate for Payer: UHCCP Medicaid |
$81.94
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$111.62
|
|
|
DEBR MUS/FAS 1ST 20 SQ CM OR <
|
Facility
|
IP
|
$2,025.00
|
|
|
Service Code
|
HCPCS 11043
|
| Hospital Charge Code |
761T0027
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$263.25 |
| Max. Negotiated Rate |
$1,944.00 |
| Rate for Payer: Aetna Commercial |
$1,559.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,579.50
|
| Rate for Payer: Cash Price |
$1,012.50
|
| Rate for Payer: Cigna Commercial |
$1,680.75
|
| Rate for Payer: First Health Commercial |
$1,923.75
|
| Rate for Payer: Humana Commercial |
$1,721.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,660.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,494.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$607.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,782.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,518.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$405.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$263.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$627.75
|
| Rate for Payer: PHCS Commercial |
$1,944.00
|
| Rate for Payer: United Healthcare All Payer |
$1,782.00
|
|
|
DEBR MUS/FAS 1ST 20 SQ CM OR <
|
Professional
|
Both
|
$2,525.00
|
|
|
Service Code
|
HCPCS 11043
|
| Hospital Charge Code |
76100027
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$78.04 |
| Max. Negotiated Rate |
$2,525.00 |
| Rate for Payer: Aetna Commercial |
$336.89
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$78.04
|
| Rate for Payer: Anthem Medicaid |
$110.51
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,525.00
|
| Rate for Payer: Cash Price |
$1,262.50
|
| Rate for Payer: Cash Price |
$1,262.50
|
| Rate for Payer: Cigna Commercial |
$323.79
|
| Rate for Payer: Healthspan PPO |
$305.75
|
| Rate for Payer: Humana Medicaid |
$110.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$153.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$112.72
|
| Rate for Payer: Molina Healthcare Passport |
$110.51
|
| Rate for Payer: Multiplan PHCS |
$1,515.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,767.50
|
| Rate for Payer: UHCCP Medicaid |
$81.94
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$111.62
|
|
|
DEBR MUS/FAS 1ST 20 SQ CM OR <
|
Facility
|
IP
|
$2,525.00
|
|
|
Service Code
|
HCPCS 11043
|
| Hospital Charge Code |
76100027
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$328.25 |
| Max. Negotiated Rate |
$2,424.00 |
| Rate for Payer: Aetna Commercial |
$1,944.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,969.50
|
| Rate for Payer: Cash Price |
$1,262.50
|
| Rate for Payer: Cigna Commercial |
$2,095.75
|
| Rate for Payer: First Health Commercial |
$2,398.75
|
| Rate for Payer: Humana Commercial |
$2,146.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,070.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,863.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$757.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,222.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,893.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$505.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$328.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$782.75
|
| Rate for Payer: PHCS Commercial |
$2,424.00
|
| Rate for Payer: United Healthcare All Payer |
$2,222.00
|
|
|
DEBR MUS/FAS 1ST 20 SQ CM OR <
|
Facility
|
OP
|
$2,525.00
|
|
|
Service Code
|
HCPCS 11043
|
| Hospital Charge Code |
76100027
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$328.25 |
| Max. Negotiated Rate |
$2,424.00 |
| Rate for Payer: Aetna Commercial |
$1,944.25
|
| Rate for Payer: Anthem Medicaid |
$868.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,969.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$1,262.50
|
| Rate for Payer: Cash Price |
$1,262.50
|
| Rate for Payer: Cigna Commercial |
$2,095.75
|
| Rate for Payer: First Health Commercial |
$2,398.75
|
| Rate for Payer: Humana Commercial |
$2,146.25
|
| Rate for Payer: Humana KY Medicaid |
$868.35
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$877.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,070.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,863.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$885.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,222.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,893.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$505.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$328.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$782.75
|
| Rate for Payer: PHCS Commercial |
$2,424.00
|
| Rate for Payer: United Healthcare All Payer |
$2,222.00
|
|
|
DEBR MUS/FAS 1ST 20 SQ CM OR <
|
Facility
|
OP
|
$2,025.00
|
|
|
Service Code
|
HCPCS 11043
|
| Hospital Charge Code |
761T0027
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$263.25 |
| Max. Negotiated Rate |
$1,944.00 |
| Rate for Payer: Aetna Commercial |
$1,559.25
|
| Rate for Payer: Anthem Medicaid |
$696.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,579.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$1,012.50
|
| Rate for Payer: Cash Price |
$1,012.50
|
| Rate for Payer: Cigna Commercial |
$1,680.75
|
| Rate for Payer: First Health Commercial |
$1,923.75
|
| Rate for Payer: Humana Commercial |
$1,721.25
|
| Rate for Payer: Humana KY Medicaid |
$696.40
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$703.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,660.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,494.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$710.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,782.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,518.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$405.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$263.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$627.75
|
| Rate for Payer: PHCS Commercial |
$1,944.00
|
| Rate for Payer: United Healthcare All Payer |
$1,782.00
|
|
|
DEBR SQ UP TO EA ADTL 20 SQ CM
|
Professional
|
Both
|
$1,009.00
|
|
|
Service Code
|
HCPCS 11045
|
| Hospital Charge Code |
76100029
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$13.33 |
| Max. Negotiated Rate |
$1,009.00 |
| Rate for Payer: Aetna Commercial |
$29.42
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$13.33
|
| Rate for Payer: Anthem Medicaid |
$15.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,009.00
|
| Rate for Payer: Cash Price |
$504.50
|
| Rate for Payer: Cash Price |
$504.50
|
| Rate for Payer: Cigna Commercial |
$51.57
|
| Rate for Payer: Healthspan PPO |
$29.56
|
| Rate for Payer: Humana Medicaid |
$15.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$22.93
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$16.04
|
| Rate for Payer: Molina Healthcare Passport |
$15.73
|
| Rate for Payer: Multiplan PHCS |
$605.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$706.30
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$15.89
|
|
|
DEBR SQ UP TO EA ADTL 20 SQ CM
|
Facility
|
OP
|
$944.00
|
|
|
Service Code
|
HCPCS 11045
|
| Hospital Charge Code |
761T0029
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$122.72 |
| Max. Negotiated Rate |
$906.24 |
| Rate for Payer: Aetna Commercial |
$726.88
|
| Rate for Payer: Anthem Medicaid |
$324.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$736.32
|
| Rate for Payer: Cash Price |
$472.00
|
| Rate for Payer: Cigna Commercial |
$783.52
|
| Rate for Payer: First Health Commercial |
$896.80
|
| Rate for Payer: Humana Commercial |
$802.40
|
| Rate for Payer: Humana KY Medicaid |
$324.64
|
| Rate for Payer: Kentucky WC Medicaid |
$327.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$774.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$696.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$283.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$331.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$830.72
|
| Rate for Payer: Ohio Health Group HMO |
$708.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$188.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$122.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$292.64
|
| Rate for Payer: PHCS Commercial |
$906.24
|
| Rate for Payer: United Healthcare All Payer |
$830.72
|
|
|
DEBR SQ UP TO EA ADTL 20 SQ CM
|
Facility
|
OP
|
$1,009.00
|
|
|
Service Code
|
HCPCS 11045
|
| Hospital Charge Code |
76100029
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$131.17 |
| Max. Negotiated Rate |
$968.64 |
| Rate for Payer: Aetna Commercial |
$776.93
|
| Rate for Payer: Anthem Medicaid |
$347.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$787.02
|
| Rate for Payer: Cash Price |
$504.50
|
| Rate for Payer: Cigna Commercial |
$837.47
|
| Rate for Payer: First Health Commercial |
$958.55
|
| Rate for Payer: Humana Commercial |
$857.65
|
| Rate for Payer: Humana KY Medicaid |
$347.00
|
| Rate for Payer: Kentucky WC Medicaid |
$350.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$827.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$744.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$302.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$353.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$887.92
|
| Rate for Payer: Ohio Health Group HMO |
$756.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$201.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$131.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$312.79
|
| Rate for Payer: PHCS Commercial |
$968.64
|
| Rate for Payer: United Healthcare All Payer |
$887.92
|
|
|
DEBR SQ UP TO EA ADTL 20 SQ CM
|
Facility
|
IP
|
$944.00
|
|
|
Service Code
|
HCPCS 11045
|
| Hospital Charge Code |
761T0029
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$122.72 |
| Max. Negotiated Rate |
$906.24 |
| Rate for Payer: Aetna Commercial |
$726.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$736.32
|
| Rate for Payer: Cash Price |
$472.00
|
| Rate for Payer: Cigna Commercial |
$783.52
|
| Rate for Payer: First Health Commercial |
$896.80
|
| Rate for Payer: Humana Commercial |
$802.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$774.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$696.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$283.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$830.72
|
| Rate for Payer: Ohio Health Group HMO |
$708.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$188.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$122.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$292.64
|
| Rate for Payer: PHCS Commercial |
$906.24
|
| Rate for Payer: United Healthcare All Payer |
$830.72
|
|
|
DEBR SQ UP TO EA ADTL 20 SQ CM
|
Professional
|
Both
|
$65.00
|
|
|
Service Code
|
HCPCS 11045
|
| Hospital Charge Code |
761P0029
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$13.33 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Aetna Commercial |
$29.42
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$13.33
|
| Rate for Payer: Anthem Medicaid |
$15.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$65.00
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$51.57
|
| Rate for Payer: Healthspan PPO |
$29.56
|
| Rate for Payer: Humana Medicaid |
$15.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$22.93
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$16.04
|
| Rate for Payer: Molina Healthcare Passport |
$15.73
|
| Rate for Payer: Multiplan PHCS |
$39.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$45.50
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$15.89
|
|
|
DEBR SQ UP TO EA ADTL 20 SQ CM
|
Facility
|
IP
|
$1,009.00
|
|
|
Service Code
|
HCPCS 11045
|
| Hospital Charge Code |
76100029
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$131.17 |
| Max. Negotiated Rate |
$968.64 |
| Rate for Payer: Aetna Commercial |
$776.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$787.02
|
| Rate for Payer: Cash Price |
$504.50
|
| Rate for Payer: Cigna Commercial |
$837.47
|
| Rate for Payer: First Health Commercial |
$958.55
|
| Rate for Payer: Humana Commercial |
$857.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$827.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$744.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$302.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$887.92
|
| Rate for Payer: Ohio Health Group HMO |
$756.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$201.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$131.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$312.79
|
| Rate for Payer: PHCS Commercial |
$968.64
|
| Rate for Payer: United Healthcare All Payer |
$887.92
|
|
|
DEB SKIN BONE AT FX SITE
|
Professional
|
Both
|
$5,225.00
|
|
|
Service Code
|
HCPCS 11012
|
| Hospital Charge Code |
76100025
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$211.79 |
| Max. Negotiated Rate |
$5,225.00 |
| Rate for Payer: Aetna Commercial |
$663.27
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$211.79
|
| Rate for Payer: Anthem Medicaid |
$393.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,225.00
|
| Rate for Payer: Cash Price |
$2,612.50
|
| Rate for Payer: Cash Price |
$2,612.50
|
| Rate for Payer: Cigna Commercial |
$632.99
|
| Rate for Payer: Healthspan PPO |
$802.96
|
| Rate for Payer: Humana Medicaid |
$393.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$540.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$401.22
|
| Rate for Payer: Molina Healthcare Passport |
$393.35
|
| Rate for Payer: Multiplan PHCS |
$3,135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,657.50
|
| Rate for Payer: UHCCP Medicaid |
$222.38
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$397.28
|
|
|
DEB SKIN BONE AT FX SITE
|
Facility
|
IP
|
$5,225.00
|
|
|
Service Code
|
HCPCS 11012
|
| Hospital Charge Code |
76100025
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$679.25 |
| Max. Negotiated Rate |
$5,016.00 |
| Rate for Payer: Aetna Commercial |
$4,023.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,075.50
|
| Rate for Payer: Cash Price |
$2,612.50
|
| Rate for Payer: Cigna Commercial |
$4,336.75
|
| Rate for Payer: First Health Commercial |
$4,963.75
|
| Rate for Payer: Humana Commercial |
$4,441.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,284.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,856.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,567.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,598.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,918.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,045.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$679.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,619.75
|
| Rate for Payer: PHCS Commercial |
$5,016.00
|
| Rate for Payer: United Healthcare All Payer |
$4,598.00
|
|
|
DEB SKIN BONE AT FX SITE
|
Facility
|
OP
|
$5,225.00
|
|
|
Service Code
|
HCPCS 11012
|
| Hospital Charge Code |
76100025
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$679.25 |
| Max. Negotiated Rate |
$5,016.00 |
| Rate for Payer: Aetna Commercial |
$4,023.25
|
| Rate for Payer: Anthem Medicaid |
$1,796.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,075.50
|
| 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 |
$2,612.50
|
| Rate for Payer: Cash Price |
$2,612.50
|
| Rate for Payer: Cigna Commercial |
$4,336.75
|
| Rate for Payer: First Health Commercial |
$4,963.75
|
| Rate for Payer: Humana Commercial |
$4,441.25
|
| Rate for Payer: Humana KY Medicaid |
$1,796.88
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$1,815.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,284.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,856.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,832.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,598.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,918.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,045.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$679.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,619.75
|
| Rate for Payer: PHCS Commercial |
$5,016.00
|
| Rate for Payer: United Healthcare All Payer |
$4,598.00
|
|
|
DEB SKIN BONE AT FX SITE(P
|
Professional
|
Both
|
$1,400.00
|
|
|
Service Code
|
HCPCS 11012
|
| Hospital Charge Code |
761P0025
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$211.79 |
| Max. Negotiated Rate |
$1,400.00 |
| Rate for Payer: Aetna Commercial |
$663.27
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$211.79
|
| Rate for Payer: Anthem Medicaid |
$393.35
|
| 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 |
$632.99
|
| Rate for Payer: Healthspan PPO |
$802.96
|
| Rate for Payer: Humana Medicaid |
$393.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$540.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$401.22
|
| Rate for Payer: Molina Healthcare Passport |
$393.35
|
| Rate for Payer: Multiplan PHCS |
$840.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$980.00
|
| Rate for Payer: UHCCP Medicaid |
$222.38
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$397.28
|
|
|
DEB SKIN BONE AT FX SITE(T
|
Facility
|
IP
|
$3,825.00
|
|
|
Service Code
|
HCPCS 11012
|
| Hospital Charge Code |
761T0025
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$497.25 |
| Max. Negotiated Rate |
$3,672.00 |
| Rate for Payer: Aetna Commercial |
$2,945.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,983.50
|
| Rate for Payer: Cash Price |
$1,912.50
|
| Rate for Payer: Cigna Commercial |
$3,174.75
|
| Rate for Payer: First Health Commercial |
$3,633.75
|
| Rate for Payer: Humana Commercial |
$3,251.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,136.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,822.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,147.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,366.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,868.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$765.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$497.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,185.75
|
| Rate for Payer: PHCS Commercial |
$3,672.00
|
| Rate for Payer: United Healthcare All Payer |
$3,366.00
|
|
