|
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 |
$103.51 |
| 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 |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$234.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| 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 |
$183.59
|
| 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 |
$220.31
|
| 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 |
$240.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$207.69
|
| Rate for Payer: PHCS Commercial |
$288.96
|
| Rate for Payer: United Healthcare All Payer |
$264.88
|
|
|
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 |
$90.30 |
| 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 |
$240.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$207.69
|
| Rate for Payer: PHCS Commercial |
$288.96
|
| Rate for Payer: United Healthcare All Payer |
$264.88
|
|
|
DEBR MUS/FAS 1ST 20 SQ CM OR <
|
Facility
|
OP
|
$2,657.00
|
|
|
Service Code
|
HCPCS 11043
|
| Hospital Charge Code |
76100027
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$565.60 |
| Max. Negotiated Rate |
$2,550.72 |
| Rate for Payer: Aetna Commercial |
$2,045.89
|
| Rate for Payer: Anthem Medicaid |
$913.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,072.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$1,328.50
|
| Rate for Payer: Cash Price |
$1,328.50
|
| Rate for Payer: Cigna Commercial |
$2,205.31
|
| Rate for Payer: First Health Commercial |
$2,524.15
|
| Rate for Payer: Humana Commercial |
$2,258.45
|
| Rate for Payer: Humana KY Medicaid |
$913.74
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$923.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,178.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,960.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$932.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,338.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,992.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,125.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,311.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,833.33
|
| Rate for Payer: PHCS Commercial |
$2,550.72
|
| Rate for Payer: United Healthcare All Payer |
$2,338.16
|
|
|
DEBR MUS/FAS 1ST 20 SQ CM OR <
|
Professional
|
Both
|
$2,657.00
|
|
|
Service Code
|
HCPCS 11043
|
| Hospital Charge Code |
76100027
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$78.04 |
| Max. Negotiated Rate |
$1,594.20 |
| Rate for Payer: Aetna Commercial |
$336.89
|
| Rate for Payer: Ambetter Exchange |
$145.57
|
| 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 Individual/Medicaid |
$145.57
|
| Rate for Payer: Buckeye Medicare Advantage |
$145.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$174.68
|
| Rate for Payer: Cash Price |
$1,328.50
|
| Rate for Payer: Cash Price |
$1,328.50
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$145.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$145.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$112.72
|
| Rate for Payer: Molina Healthcare Passport |
$110.51
|
| Rate for Payer: Multiplan PHCS |
$1,594.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$189.24
|
| Rate for Payer: UHCCP Medicaid |
$81.94
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$111.62
|
| Rate for Payer: Wellcare Medicare Advantage |
$145.57
|
|
|
DEBR MUS/FAS 1ST 20 SQ CM OR <
|
Facility
|
IP
|
$2,657.00
|
|
|
Service Code
|
HCPCS 11043
|
| Hospital Charge Code |
76100027
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$797.10 |
| Max. Negotiated Rate |
$2,550.72 |
| Rate for Payer: Aetna Commercial |
$2,045.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,072.46
|
| Rate for Payer: Cash Price |
$1,328.50
|
| Rate for Payer: Cigna Commercial |
$2,205.31
|
| Rate for Payer: First Health Commercial |
$2,524.15
|
| Rate for Payer: Humana Commercial |
$2,258.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,178.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,960.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$797.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,338.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,992.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,125.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,311.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,833.33
|
| Rate for Payer: PHCS Commercial |
$2,550.72
|
| Rate for Payer: United Healthcare All Payer |
$2,338.16
|
|
|
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 |
$336.89 |
| Rate for Payer: Aetna Commercial |
$336.89
|
| Rate for Payer: Ambetter Exchange |
$145.57
|
| 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 Individual/Medicaid |
$145.57
|
| Rate for Payer: Buckeye Medicare Advantage |
$145.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$174.68
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$145.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$145.57
|
| 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 |
$189.24
|
| Rate for Payer: UHCCP Medicaid |
$81.94
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$111.62
|
| Rate for Payer: Wellcare Medicare Advantage |
$145.57
|
|
|
DEBR MUS/FAS 1ST 20 SQ CM OR <
|
Facility
|
OP
|
$2,157.00
|
|
|
Service Code
|
HCPCS 11043
|
| Hospital Charge Code |
761T0027
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$565.60 |
| Max. Negotiated Rate |
$2,070.72 |
| Rate for Payer: Aetna Commercial |
$1,660.89
|
| Rate for Payer: Anthem Medicaid |
$741.79
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,682.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$1,078.50
|
| Rate for Payer: Cash Price |
$1,078.50
|
| Rate for Payer: Cigna Commercial |
$1,790.31
|
| Rate for Payer: First Health Commercial |
$2,049.15
|
| Rate for Payer: Humana Commercial |
$1,833.45
|
| Rate for Payer: Humana KY Medicaid |
$741.79
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$749.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,768.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,591.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$756.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,898.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,617.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,725.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,876.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,488.33
|
| Rate for Payer: PHCS Commercial |
$2,070.72
|
| Rate for Payer: United Healthcare All Payer |
$1,898.16
|
|
|
DEBR MUS/FAS 1ST 20 SQ CM OR <
|
Facility
|
IP
|
$2,157.00
|
|
|
Service Code
|
HCPCS 11043
|
| Hospital Charge Code |
761T0027
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$647.10 |
| Max. Negotiated Rate |
$2,070.72 |
| Rate for Payer: Aetna Commercial |
$1,660.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,682.46
|
| Rate for Payer: Cash Price |
$1,078.50
|
| Rate for Payer: Cigna Commercial |
$1,790.31
|
| Rate for Payer: First Health Commercial |
$2,049.15
|
| Rate for Payer: Humana Commercial |
$1,833.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,768.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,591.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$647.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,898.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,617.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,725.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,876.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,488.33
|
| Rate for Payer: PHCS Commercial |
$2,070.72
|
| Rate for Payer: United Healthcare All Payer |
$1,898.16
|
|
|
DEBR SQ UP TO EA ADTL 20 SQ CM
|
Professional
|
Both
|
$1,070.00
|
|
|
Service Code
|
HCPCS 11045
|
| Hospital Charge Code |
76100029
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$13.33 |
| Max. Negotiated Rate |
$642.00 |
| Rate for Payer: Aetna Commercial |
$29.42
|
| Rate for Payer: Ambetter Exchange |
$23.52
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$13.33
|
| Rate for Payer: Anthem Medicaid |
$27.00
|
| Rate for Payer: Buckeye Individual/Medicaid |
$23.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$23.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$28.22
|
| Rate for Payer: Cash Price |
$535.00
|
| Rate for Payer: Cash Price |
$535.00
|
| Rate for Payer: Cigna Commercial |
$51.57
|
| Rate for Payer: Healthspan PPO |
$29.56
|
| Rate for Payer: Humana Medicaid |
$27.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$22.93
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$23.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$27.54
|
| Rate for Payer: Molina Healthcare Passport |
$27.00
|
| Rate for Payer: Multiplan PHCS |
$642.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$30.58
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$27.27
|
| Rate for Payer: Wellcare Medicare Advantage |
$23.52
|
|
|
DEBR SQ UP TO EA ADTL 20 SQ CM
|
Facility
|
IP
|
$1,070.00
|
|
|
Service Code
|
HCPCS 11045
|
| Hospital Charge Code |
76100029
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$321.00 |
| Max. Negotiated Rate |
$1,027.20 |
| Rate for Payer: Aetna Commercial |
$823.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$834.60
|
| Rate for Payer: Cash Price |
$535.00
|
| Rate for Payer: Cigna Commercial |
$888.10
|
| Rate for Payer: First Health Commercial |
$1,016.50
|
| Rate for Payer: Humana Commercial |
$909.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$877.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$789.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$321.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$941.60
|
| Rate for Payer: Ohio Health Group HMO |
$802.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$856.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$930.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$738.30
|
| Rate for Payer: PHCS Commercial |
$1,027.20
|
| Rate for Payer: United Healthcare All Payer |
$941.60
|
|
|
DEBR SQ UP TO EA ADTL 20 SQ CM
|
Facility
|
IP
|
$1,005.00
|
|
|
Service Code
|
HCPCS 11045
|
| Hospital Charge Code |
761T0029
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$301.50 |
| Max. Negotiated Rate |
$964.80 |
| Rate for Payer: Aetna Commercial |
$773.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$783.90
|
| Rate for Payer: Cash Price |
$502.50
|
| Rate for Payer: Cigna Commercial |
$834.15
|
| Rate for Payer: First Health Commercial |
$954.75
|
| Rate for Payer: Humana Commercial |
$854.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$824.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$741.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$301.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$884.40
|
| Rate for Payer: Ohio Health Group HMO |
$753.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$804.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$874.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$693.45
|
| Rate for Payer: PHCS Commercial |
$964.80
|
| Rate for Payer: United Healthcare All Payer |
$884.40
|
|
|
DEBR SQ UP TO EA ADTL 20 SQ CM
|
Facility
|
OP
|
$1,070.00
|
|
|
Service Code
|
HCPCS 11045
|
| Hospital Charge Code |
76100029
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$321.00 |
| Max. Negotiated Rate |
$1,027.20 |
| Rate for Payer: Aetna Commercial |
$823.90
|
| Rate for Payer: Anthem Medicaid |
$367.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$834.60
|
| Rate for Payer: Cash Price |
$535.00
|
| Rate for Payer: Cigna Commercial |
$888.10
|
| Rate for Payer: First Health Commercial |
$1,016.50
|
| Rate for Payer: Humana Commercial |
$909.50
|
| Rate for Payer: Humana KY Medicaid |
$367.97
|
| Rate for Payer: Kentucky WC Medicaid |
$371.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$877.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$789.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$321.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$375.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$941.60
|
| Rate for Payer: Ohio Health Group HMO |
$802.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$856.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$930.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$738.30
|
| Rate for Payer: PHCS Commercial |
$1,027.20
|
| Rate for Payer: United Healthcare All Payer |
$941.60
|
|
|
DEBR SQ UP TO EA ADTL 20 SQ CM
|
Facility
|
OP
|
$1,005.00
|
|
|
Service Code
|
HCPCS 11045
|
| Hospital Charge Code |
761T0029
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$301.50 |
| Max. Negotiated Rate |
$964.80 |
| Rate for Payer: Aetna Commercial |
$773.85
|
| Rate for Payer: Anthem Medicaid |
$345.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$783.90
|
| Rate for Payer: Cash Price |
$502.50
|
| Rate for Payer: Cigna Commercial |
$834.15
|
| Rate for Payer: First Health Commercial |
$954.75
|
| Rate for Payer: Humana Commercial |
$854.25
|
| Rate for Payer: Humana KY Medicaid |
$345.62
|
| Rate for Payer: Kentucky WC Medicaid |
$349.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$824.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$741.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$301.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$352.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$884.40
|
| Rate for Payer: Ohio Health Group HMO |
$753.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$804.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$874.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$693.45
|
| Rate for Payer: PHCS Commercial |
$964.80
|
| Rate for Payer: United Healthcare All Payer |
$884.40
|
|
|
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 |
$51.57 |
| Rate for Payer: Aetna Commercial |
$29.42
|
| Rate for Payer: Ambetter Exchange |
$23.52
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$13.33
|
| Rate for Payer: Anthem Medicaid |
$27.00
|
| Rate for Payer: Buckeye Individual/Medicaid |
$23.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$23.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$28.22
|
| 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 |
$27.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$22.93
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$23.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$27.54
|
| Rate for Payer: Molina Healthcare Passport |
$27.00
|
| Rate for Payer: Multiplan PHCS |
$39.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$30.58
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$27.27
|
| Rate for Payer: Wellcare Medicare Advantage |
$23.52
|
|
|
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 |
$1,567.50 |
| 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 |
$4,180.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,545.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,605.25
|
| 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 |
$1,796.88 |
| 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 |
$2,644.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,075.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,702.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,570.05
|
| 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 |
$2,644.48
|
| 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 |
$3,173.38
|
| 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 |
$4,180.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,545.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,605.25
|
| Rate for Payer: PHCS Commercial |
$5,016.00
|
| Rate for Payer: United Healthcare All Payer |
$4,598.00
|
|
|
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 |
$3,135.00 |
| Rate for Payer: Aetna Commercial |
$663.27
|
| Rate for Payer: Ambetter Exchange |
$392.41
|
| 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 Individual/Medicaid |
$392.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$392.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$470.89
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$392.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$392.41
|
| 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 |
$510.13
|
| Rate for Payer: UHCCP Medicaid |
$222.38
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$397.28
|
| Rate for Payer: Wellcare Medicare Advantage |
$392.41
|
|
|
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 |
$840.00 |
| Rate for Payer: Aetna Commercial |
$663.27
|
| Rate for Payer: Ambetter Exchange |
$392.41
|
| 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 Individual/Medicaid |
$392.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$392.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$470.89
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$392.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$392.41
|
| 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 |
$510.13
|
| Rate for Payer: UHCCP Medicaid |
$222.38
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$397.28
|
| Rate for Payer: Wellcare Medicare Advantage |
$392.41
|
|
|
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 |
$1,147.50 |
| 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 |
$3,060.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,327.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,639.25
|
| Rate for Payer: PHCS Commercial |
$3,672.00
|
| Rate for Payer: United Healthcare All Payer |
$3,366.00
|
|
|
DEB SKIN BONE AT FX SITE(T
|
Facility
|
OP
|
$3,825.00
|
|
|
Service Code
|
HCPCS 11012
|
| Hospital Charge Code |
761T0025
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,315.42 |
| Max. Negotiated Rate |
$3,702.27 |
| Rate for Payer: Aetna Commercial |
$2,945.25
|
| Rate for Payer: Anthem Medicaid |
$1,315.42
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,644.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,983.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,702.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,570.05
|
| 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 |
$2,644.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1,328.81
|
| 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 |
$3,173.38
|
| 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 |
$3,060.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,327.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,639.25
|
| Rate for Payer: PHCS Commercial |
$3,672.00
|
| Rate for Payer: United Healthcare All Payer |
$3,366.00
|
|
|
DEB SUB MUSC FASC ABD WALL
|
Facility
|
IP
|
$5,755.00
|
|
|
Service Code
|
HCPCS 11005
|
| Hospital Charge Code |
76100020
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,726.50 |
| Max. Negotiated Rate |
$5,524.80 |
| Rate for Payer: Aetna Commercial |
$4,431.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,488.90
|
| Rate for Payer: Cash Price |
$2,877.50
|
| Rate for Payer: Cigna Commercial |
$4,776.65
|
| Rate for Payer: First Health Commercial |
$5,467.25
|
| Rate for Payer: Humana Commercial |
$4,891.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,719.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,247.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,726.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,064.40
|
| Rate for Payer: Ohio Health Group HMO |
$4,316.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,604.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,006.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,970.95
|
| Rate for Payer: PHCS Commercial |
$5,524.80
|
| Rate for Payer: United Healthcare All Payer |
$5,064.40
|
|
|
DEB SUB MUSC FASC ABD WALL
|
Professional
|
Both
|
$5,755.00
|
|
|
Service Code
|
HCPCS 11005
|
| Hospital Charge Code |
76100020
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$574.70 |
| Max. Negotiated Rate |
$3,453.00 |
| Rate for Payer: Aetna Commercial |
$1,127.55
|
| Rate for Payer: Ambetter Exchange |
$732.68
|
| Rate for Payer: Anthem Medicaid |
$574.70
|
| Rate for Payer: Buckeye Individual/Medicaid |
$732.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$732.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$879.22
|
| Rate for Payer: Cash Price |
$2,877.50
|
| Rate for Payer: Cash Price |
$2,877.50
|
| Rate for Payer: Cigna Commercial |
$1,099.09
|
| Rate for Payer: Healthspan PPO |
$901.58
|
| Rate for Payer: Humana Medicaid |
$574.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$997.84
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$732.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$732.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$586.19
|
| Rate for Payer: Molina Healthcare Passport |
$574.70
|
| Rate for Payer: Multiplan PHCS |
$3,453.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$952.48
|
| Rate for Payer: UHCCP Medicaid |
$2,014.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$580.45
|
| Rate for Payer: Wellcare Medicare Advantage |
$732.68
|
|
|
DEB SUB MUSC FASC ABD WALL
|
Facility
|
OP
|
$5,755.00
|
|
|
Service Code
|
HCPCS 11005
|
| Hospital Charge Code |
76100020
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,726.50 |
| Max. Negotiated Rate |
$5,524.80 |
| Rate for Payer: Aetna Commercial |
$4,431.35
|
| Rate for Payer: Anthem Medicaid |
$1,979.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,488.90
|
| Rate for Payer: Cash Price |
$2,877.50
|
| Rate for Payer: Cigna Commercial |
$4,776.65
|
| Rate for Payer: First Health Commercial |
$5,467.25
|
| Rate for Payer: Humana Commercial |
$4,891.75
|
| Rate for Payer: Humana KY Medicaid |
$1,979.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,999.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,719.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,247.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,726.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,018.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,064.40
|
| Rate for Payer: Ohio Health Group HMO |
$4,316.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,604.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,006.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,970.95
|
| Rate for Payer: PHCS Commercial |
$5,524.80
|
| Rate for Payer: United Healthcare All Payer |
$5,064.40
|
|
|
DEB SUB MUSC FASC ABD WALL(P
|
Professional
|
Both
|
$1,331.00
|
|
|
Service Code
|
HCPCS 11005
|
| Hospital Charge Code |
761P0020
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$465.85 |
| Max. Negotiated Rate |
$1,127.55 |
| Rate for Payer: Aetna Commercial |
$1,127.55
|
| Rate for Payer: Ambetter Exchange |
$732.68
|
| Rate for Payer: Anthem Medicaid |
$574.70
|
| Rate for Payer: Buckeye Individual/Medicaid |
$732.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$732.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$879.22
|
| Rate for Payer: Cash Price |
$665.50
|
| Rate for Payer: Cash Price |
$665.50
|
| Rate for Payer: Cigna Commercial |
$1,099.09
|
| Rate for Payer: Healthspan PPO |
$901.58
|
| Rate for Payer: Humana Medicaid |
$574.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$997.84
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$732.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$732.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$586.19
|
| Rate for Payer: Molina Healthcare Passport |
$574.70
|
| Rate for Payer: Multiplan PHCS |
$798.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$952.48
|
| Rate for Payer: UHCCP Medicaid |
$465.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$580.45
|
| Rate for Payer: Wellcare Medicare Advantage |
$732.68
|
|
|
DEB SUB MUSC FASC ABD WALL(T
|
Facility
|
IP
|
$4,424.00
|
|
|
Service Code
|
HCPCS 11005
|
| Hospital Charge Code |
761T0020
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,327.20 |
| Max. Negotiated Rate |
$4,247.04 |
| Rate for Payer: Aetna Commercial |
$3,406.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,450.72
|
| Rate for Payer: Cash Price |
$2,212.00
|
| Rate for Payer: Cigna Commercial |
$3,671.92
|
| Rate for Payer: First Health Commercial |
$4,202.80
|
| Rate for Payer: Humana Commercial |
$3,760.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,627.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,264.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,327.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,893.12
|
| Rate for Payer: Ohio Health Group HMO |
$3,318.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,539.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,848.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,052.56
|
| Rate for Payer: PHCS Commercial |
$4,247.04
|
| Rate for Payer: United Healthcare All Payer |
$3,893.12
|
|
