|
DEPOPROVERA(MEDRX150MG/1ML)1MG
|
Facility
|
OP
|
$2.10
|
|
|
Service Code
|
HCPCS J1050
|
| Hospital Charge Code |
63600027
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna Commercial |
$1.62
|
| Rate for Payer: Anthem Medicaid |
$0.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.64
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cigna Commercial |
$1.74
|
| Rate for Payer: First Health Commercial |
$2.00
|
| Rate for Payer: Humana Commercial |
$1.78
|
| Rate for Payer: Humana KY Medicaid |
$0.72
|
| Rate for Payer: Kentucky WC Medicaid |
$0.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.85
|
| Rate for Payer: Ohio Health Group HMO |
$1.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.65
|
| Rate for Payer: PHCS Commercial |
$2.02
|
| Rate for Payer: United Healthcare All Payer |
$1.85
|
|
|
DEPOPROVERA(MEDRX150MG/1ML)1MG
|
Facility
|
IP
|
$321.63
|
|
|
Service Code
|
HCPCS J1050
|
| Hospital Charge Code |
25002010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.81 |
| Max. Negotiated Rate |
$308.76 |
| Rate for Payer: Medical Mutual Of Ohio HMO |
$263.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$237.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$283.03
|
| Rate for Payer: Ohio Health Group HMO |
$241.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.71
|
| Rate for Payer: PHCS Commercial |
$308.76
|
| Rate for Payer: United Healthcare All Payer |
$283.03
|
| Rate for Payer: Aetna Commercial |
$247.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$250.87
|
| Rate for Payer: Cash Price |
$160.82
|
| Rate for Payer: Cigna Commercial |
$266.95
|
| Rate for Payer: First Health Commercial |
$305.55
|
| Rate for Payer: Humana Commercial |
$273.39
|
|
|
DEPOPROVERA(MEDRX150MG/1ML)1MG
|
Facility
|
OP
|
$2.10
|
|
|
Service Code
|
HCPCS J1050
|
| Hospital Charge Code |
636T0027
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna Commercial |
$1.62
|
| Rate for Payer: Anthem Medicaid |
$0.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.64
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cigna Commercial |
$1.74
|
| Rate for Payer: First Health Commercial |
$2.00
|
| Rate for Payer: Humana Commercial |
$1.78
|
| Rate for Payer: Humana KY Medicaid |
$0.72
|
| Rate for Payer: Kentucky WC Medicaid |
$0.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.85
|
| Rate for Payer: Ohio Health Group HMO |
$1.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.65
|
| Rate for Payer: PHCS Commercial |
$2.02
|
| Rate for Payer: United Healthcare All Payer |
$1.85
|
|
|
DEPOPROVERA SQ [1MG] 104MG SYR
|
Facility
|
IP
|
$321.63
|
|
|
Service Code
|
HCPCS J1050
|
| Hospital Charge Code |
25002008
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.81 |
| Max. Negotiated Rate |
$308.76 |
| Rate for Payer: Aetna Commercial |
$247.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$250.87
|
| Rate for Payer: Cash Price |
$160.82
|
| Rate for Payer: Cigna Commercial |
$266.95
|
| Rate for Payer: First Health Commercial |
$305.55
|
| Rate for Payer: Humana Commercial |
$273.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$263.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$237.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$283.03
|
| Rate for Payer: Ohio Health Group HMO |
$241.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.71
|
| Rate for Payer: PHCS Commercial |
$308.76
|
| Rate for Payer: United Healthcare All Payer |
$283.03
|
|
|
DEPOPROVERA SQ [1MG] 104MG SYR
|
Facility
|
OP
|
$321.63
|
|
|
Service Code
|
HCPCS J1050
|
| Hospital Charge Code |
25002008
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.81 |
| Max. Negotiated Rate |
$308.76 |
| Rate for Payer: Aetna Commercial |
$247.66
|
| Rate for Payer: Anthem Medicaid |
$110.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$250.87
|
| Rate for Payer: Cash Price |
$160.82
|
| Rate for Payer: Cigna Commercial |
$266.95
|
| Rate for Payer: First Health Commercial |
$305.55
|
| Rate for Payer: Humana Commercial |
$273.39
|
| Rate for Payer: Humana KY Medicaid |
$110.61
|
| Rate for Payer: Kentucky WC Medicaid |
$111.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$263.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$237.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$112.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$283.03
|
| Rate for Payer: Ohio Health Group HMO |
$241.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.71
|
| Rate for Payer: PHCS Commercial |
$308.76
|
| Rate for Payer: United Healthcare All Payer |
$283.03
|
|
|
DEPRESSION SCREEN ANNUAL 15MIN
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
HCPCS G0444
|
| Hospital Charge Code |
51000321
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$5.85 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna Commercial |
$34.65
|
| Rate for Payer: Anthem Medicaid |
$15.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$24.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$34.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$33.49
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$37.35
|
| Rate for Payer: First Health Commercial |
$42.75
|
| Rate for Payer: Humana Commercial |
$38.25
|
| Rate for Payer: Humana KY Medicaid |
$15.48
|
| Rate for Payer: Humana Medicare Advantage |
$24.81
|
| Rate for Payer: Kentucky WC Medicaid |
$15.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$15.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.60
|
| Rate for Payer: Ohio Health Group HMO |
$33.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.95
|
| Rate for Payer: PHCS Commercial |
$43.20
|
| Rate for Payer: United Healthcare All Payer |
$39.60
|
|
|
DEPRESSION SCREEN ANNUAL 15MIN
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
HCPCS G0444
|
| Hospital Charge Code |
51000321
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$5.85 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna Commercial |
$34.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.10
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$37.35
|
| Rate for Payer: First Health Commercial |
$42.75
|
| Rate for Payer: Humana Commercial |
$38.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.60
|
| Rate for Payer: Ohio Health Group HMO |
$33.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.95
|
| Rate for Payer: PHCS Commercial |
$43.20
|
| Rate for Payer: United Healthcare All Payer |
$39.60
|
|
|
DEPRESSION SCREEN ANNUAL 15MIN
|
Professional
|
Both
|
$45.00
|
|
|
Service Code
|
HCPCS G0444
|
| Hospital Charge Code |
51000321
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$10.54 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$45.00
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$10.54
|
| Rate for Payer: Multiplan PHCS |
$27.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$31.50
|
| Rate for Payer: UHCCP Medicaid |
$15.75
|
|
|
DEPRESSIVE NEUROSES
|
Facility
|
IP
|
$10,604.43
|
|
|
Service Code
|
MSDRG 881
|
| Min. Negotiated Rate |
$7,195.86 |
| Max. Negotiated Rate |
$10,604.43 |
| Rate for Payer: Anthem Medicaid |
$7,195.86
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7,574.59
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10,604.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$10,225.70
|
| Rate for Payer: Humana KY Medicaid |
$7,195.86
|
| Rate for Payer: Humana Medicare Advantage |
$7,574.59
|
| Rate for Payer: Kentucky WC Medicaid |
$7,267.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,089.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,339.78
|
|
|
DERIDE INFEC TISS<10% BODSURF
|
Facility
|
IP
|
$1,192.00
|
|
|
Service Code
|
HCPCS 11760
|
| Hospital Charge Code |
76100101
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$154.96 |
| Max. Negotiated Rate |
$1,144.32 |
| Rate for Payer: Aetna Commercial |
$917.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$929.76
|
| Rate for Payer: Cash Price |
$596.00
|
| Rate for Payer: Cigna Commercial |
$989.36
|
| Rate for Payer: First Health Commercial |
$1,132.40
|
| Rate for Payer: Humana Commercial |
$1,013.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$977.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$879.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$357.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,048.96
|
| Rate for Payer: Ohio Health Group HMO |
$894.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$238.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$154.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$369.52
|
| Rate for Payer: PHCS Commercial |
$1,144.32
|
| Rate for Payer: United Healthcare All Payer |
$1,048.96
|
|
|
DERIDE INFEC TISS<10% BODSURF
|
Facility
|
OP
|
$1,192.00
|
|
|
Service Code
|
HCPCS 11760
|
| Hospital Charge Code |
76100101
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$154.96 |
| Max. Negotiated Rate |
$1,144.32 |
| Rate for Payer: Aetna Commercial |
$917.84
|
| Rate for Payer: Anthem Medicaid |
$409.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$929.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$596.00
|
| Rate for Payer: Cash Price |
$596.00
|
| Rate for Payer: Cigna Commercial |
$989.36
|
| Rate for Payer: First Health Commercial |
$1,132.40
|
| Rate for Payer: Humana Commercial |
$1,013.20
|
| Rate for Payer: Humana KY Medicaid |
$409.93
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$414.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$977.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$879.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$418.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,048.96
|
| Rate for Payer: Ohio Health Group HMO |
$894.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$238.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$154.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$369.52
|
| Rate for Payer: PHCS Commercial |
$1,144.32
|
| Rate for Payer: United Healthcare All Payer |
$1,048.96
|
|
|
DERIDE INFEC TISS<10% BODSURF
|
Facility
|
IP
|
$742.00
|
|
|
Service Code
|
HCPCS 11760
|
| Hospital Charge Code |
45000039
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$96.46 |
| Max. Negotiated Rate |
$712.32 |
| Rate for Payer: Aetna Commercial |
$571.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$578.76
|
| Rate for Payer: Cash Price |
$371.00
|
| Rate for Payer: Cigna Commercial |
$615.86
|
| Rate for Payer: First Health Commercial |
$704.90
|
| Rate for Payer: Humana Commercial |
$630.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$608.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$547.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$222.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$652.96
|
| Rate for Payer: Ohio Health Group HMO |
$556.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$148.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$96.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$230.02
|
| Rate for Payer: PHCS Commercial |
$712.32
|
| Rate for Payer: United Healthcare All Payer |
$652.96
|
|
|
DERIDE INFEC TISS<10% BODSURF
|
Facility
|
OP
|
$742.00
|
|
|
Service Code
|
HCPCS 11760
|
| Hospital Charge Code |
45000039
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$96.46 |
| Max. Negotiated Rate |
$760.35 |
| Rate for Payer: Aetna Commercial |
$571.34
|
| Rate for Payer: Anthem Medicaid |
$255.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$578.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$371.00
|
| Rate for Payer: Cash Price |
$371.00
|
| Rate for Payer: Cigna Commercial |
$615.86
|
| Rate for Payer: First Health Commercial |
$704.90
|
| Rate for Payer: Humana Commercial |
$630.70
|
| Rate for Payer: Humana KY Medicaid |
$255.17
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$257.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$608.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$547.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$260.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$652.96
|
| Rate for Payer: Ohio Health Group HMO |
$556.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$148.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$96.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$230.02
|
| Rate for Payer: PHCS Commercial |
$712.32
|
| Rate for Payer: United Healthcare All Payer |
$652.96
|
|
|
DERIDE INFEC TISS<10% BODSURF
|
Professional
|
Both
|
$1,192.00
|
|
|
Service Code
|
HCPCS 11760
|
| Hospital Charge Code |
76100101
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$56.58 |
| Max. Negotiated Rate |
$1,192.00 |
| Rate for Payer: Aetna Commercial |
$188.67
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$56.58
|
| Rate for Payer: Anthem Medicaid |
$59.55
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,192.00
|
| Rate for Payer: Cash Price |
$596.00
|
| Rate for Payer: Cash Price |
$596.00
|
| Rate for Payer: Cigna Commercial |
$190.67
|
| Rate for Payer: Healthspan PPO |
$221.90
|
| Rate for Payer: Humana Medicaid |
$59.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$161.70
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$60.74
|
| Rate for Payer: Molina Healthcare Passport |
$59.55
|
| Rate for Payer: Multiplan PHCS |
$715.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$834.40
|
| Rate for Payer: UHCCP Medicaid |
$59.41
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$60.15
|
|
|
DERIDE INFEC TISS<10% BODSUR(P
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 11760
|
| Hospital Charge Code |
761P0101
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$56.58 |
| Max. Negotiated Rate |
$450.00 |
| Rate for Payer: Aetna Commercial |
$188.67
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$56.58
|
| Rate for Payer: Anthem Medicaid |
$59.55
|
| 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 |
$190.67
|
| Rate for Payer: Healthspan PPO |
$221.90
|
| Rate for Payer: Humana Medicaid |
$59.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$161.70
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$60.74
|
| Rate for Payer: Molina Healthcare Passport |
$59.55
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$315.00
|
| Rate for Payer: UHCCP Medicaid |
$59.41
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$60.15
|
|
|
DERIDE INFEC TISS<10% BODSUR(T
|
Facility
|
IP
|
$742.00
|
|
|
Service Code
|
HCPCS 11760
|
| Hospital Charge Code |
761T0101
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$96.46 |
| Max. Negotiated Rate |
$712.32 |
| Rate for Payer: Aetna Commercial |
$571.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$578.76
|
| Rate for Payer: Cash Price |
$371.00
|
| Rate for Payer: Cigna Commercial |
$615.86
|
| Rate for Payer: First Health Commercial |
$704.90
|
| Rate for Payer: Humana Commercial |
$630.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$608.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$547.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$222.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$652.96
|
| Rate for Payer: Ohio Health Group HMO |
$556.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$148.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$96.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$230.02
|
| Rate for Payer: PHCS Commercial |
$712.32
|
| Rate for Payer: United Healthcare All Payer |
$652.96
|
|
|
DERIDE INFEC TISS<10% BODSUR(T
|
Facility
|
OP
|
$742.00
|
|
|
Service Code
|
HCPCS 11760
|
| Hospital Charge Code |
761T0101
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$96.46 |
| Max. Negotiated Rate |
$760.35 |
| Rate for Payer: Aetna Commercial |
$571.34
|
| Rate for Payer: Anthem Medicaid |
$255.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$578.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$371.00
|
| Rate for Payer: Cash Price |
$371.00
|
| Rate for Payer: Cigna Commercial |
$615.86
|
| Rate for Payer: First Health Commercial |
$704.90
|
| Rate for Payer: Humana Commercial |
$630.70
|
| Rate for Payer: Humana KY Medicaid |
$255.17
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$257.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$608.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$547.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$260.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$652.96
|
| Rate for Payer: Ohio Health Group HMO |
$556.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$148.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$96.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$230.02
|
| Rate for Payer: PHCS Commercial |
$712.32
|
| Rate for Payer: United Healthcare All Payer |
$652.96
|
|
|
DERMABRASION
|
Professional
|
Both
|
$250.00
|
|
| Hospital Charge Code |
22200327
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$87.50 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
|
|
DERMABRASION SEGMENTAL FACE
|
Facility
|
IP
|
$3,825.00
|
|
|
Service Code
|
HCPCS 15781
|
| Hospital Charge Code |
76102765
|
|
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
|
|
|
DERMABRASION SEGMENTAL FACE
|
Facility
|
OP
|
$3,825.00
|
|
|
Service Code
|
HCPCS 15781
|
| Hospital Charge Code |
76102765
|
|
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 Medicaid |
$1,315.42
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$608.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,983.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$851.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$821.37
|
| Rate for Payer: Cash Price |
$1,912.50
|
| 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: Humana KY Medicaid |
$1,315.42
|
| Rate for Payer: Humana Medicare Advantage |
$608.42
|
| Rate for Payer: Kentucky WC Medicaid |
$1,328.80
|
| 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 |
$730.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,341.81
|
| 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
|
|
|
DERMABRASION SEGMENTAL FACE
|
Professional
|
Both
|
$3,825.00
|
|
|
Service Code
|
HCPCS 15781
|
| Hospital Charge Code |
76102765
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$197.07 |
| Max. Negotiated Rate |
$3,825.00 |
| Rate for Payer: Aetna Commercial |
$597.22
|
| Rate for Payer: Anthem Medicaid |
$197.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,825.00
|
| Rate for Payer: Cash Price |
$1,912.50
|
| Rate for Payer: Cash Price |
$1,912.50
|
| Rate for Payer: Cigna Commercial |
$685.52
|
| Rate for Payer: Healthspan PPO |
$584.52
|
| Rate for Payer: Humana Medicaid |
$197.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$533.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$201.01
|
| Rate for Payer: Molina Healthcare Passport |
$197.07
|
| Rate for Payer: Multiplan PHCS |
$2,295.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,677.50
|
| Rate for Payer: UHCCP Medicaid |
$1,338.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$199.04
|
|
|
DERMABRASION SEGMENTAL FACE (P
|
Professional
|
Both
|
$550.00
|
|
|
Service Code
|
HCPCS 15781
|
| Hospital Charge Code |
761P2765
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$192.50 |
| Max. Negotiated Rate |
$685.52 |
| Rate for Payer: Aetna Commercial |
$597.22
|
| Rate for Payer: Anthem Medicaid |
$197.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$550.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$685.52
|
| Rate for Payer: Healthspan PPO |
$584.52
|
| Rate for Payer: Humana Medicaid |
$197.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$533.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$201.01
|
| Rate for Payer: Molina Healthcare Passport |
$197.07
|
| Rate for Payer: Multiplan PHCS |
$330.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$385.00
|
| Rate for Payer: UHCCP Medicaid |
$192.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$199.04
|
|
|
DERMABRASION SEGMENTAL FACE (T
|
Facility
|
OP
|
$3,275.00
|
|
|
Service Code
|
HCPCS 15781
|
| Hospital Charge Code |
761T2765
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$425.75 |
| Max. Negotiated Rate |
$3,144.00 |
| Rate for Payer: Aetna Commercial |
$2,521.75
|
| Rate for Payer: Anthem Medicaid |
$1,126.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$608.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,554.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$851.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$821.37
|
| Rate for Payer: Cash Price |
$1,637.50
|
| Rate for Payer: Cash Price |
$1,637.50
|
| Rate for Payer: Cigna Commercial |
$2,718.25
|
| Rate for Payer: First Health Commercial |
$3,111.25
|
| Rate for Payer: Humana Commercial |
$2,783.75
|
| Rate for Payer: Humana KY Medicaid |
$1,126.27
|
| Rate for Payer: Humana Medicare Advantage |
$608.42
|
| Rate for Payer: Kentucky WC Medicaid |
$1,137.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,685.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,416.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$730.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,148.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,882.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,456.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$425.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,015.25
|
| Rate for Payer: PHCS Commercial |
$3,144.00
|
| Rate for Payer: United Healthcare All Payer |
$2,882.00
|
|
|
DERMABRASION SEGMENTAL FACE (T
|
Facility
|
IP
|
$3,275.00
|
|
|
Service Code
|
HCPCS 15781
|
| Hospital Charge Code |
761T2765
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$425.75 |
| Max. Negotiated Rate |
$3,144.00 |
| Rate for Payer: Aetna Commercial |
$2,521.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,554.50
|
| Rate for Payer: Cash Price |
$1,637.50
|
| Rate for Payer: Cigna Commercial |
$2,718.25
|
| Rate for Payer: First Health Commercial |
$3,111.25
|
| Rate for Payer: Humana Commercial |
$2,783.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,685.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,416.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$982.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,882.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,456.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$425.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,015.25
|
| Rate for Payer: PHCS Commercial |
$3,144.00
|
| Rate for Payer: United Healthcare All Payer |
$2,882.00
|
|
|
DERMABRASION TOTAL FACE
|
Facility
|
IP
|
$4,416.00
|
|
|
Service Code
|
HCPCS 15780
|
| Hospital Charge Code |
76100210
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$574.08 |
| Max. Negotiated Rate |
$4,239.36 |
| Rate for Payer: Aetna Commercial |
$3,400.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,444.48
|
| Rate for Payer: Cash Price |
$2,208.00
|
| Rate for Payer: Cigna Commercial |
$3,665.28
|
| Rate for Payer: First Health Commercial |
$4,195.20
|
| Rate for Payer: Humana Commercial |
$3,753.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,621.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,259.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,324.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,886.08
|
| Rate for Payer: Ohio Health Group HMO |
$3,312.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$883.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$574.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,368.96
|
| Rate for Payer: PHCS Commercial |
$4,239.36
|
| Rate for Payer: United Healthcare All Payer |
$3,886.08
|
|
