|
DERIDE INFEC TISS<10% BODSURF
|
Professional
|
Both
|
$1,218.00
|
|
|
Service Code
|
HCPCS 11760
|
| Hospital Charge Code |
76100101
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$56.58 |
| Max. Negotiated Rate |
$730.80 |
| Rate for Payer: Aetna Commercial |
$188.67
|
| Rate for Payer: Ambetter Exchange |
$102.65
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$56.58
|
| Rate for Payer: Anthem Medicaid |
$72.03
|
| Rate for Payer: Buckeye Individual/Medicaid |
$102.65
|
| Rate for Payer: Buckeye Medicare Advantage |
$102.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$123.18
|
| Rate for Payer: Cash Price |
$609.00
|
| Rate for Payer: Cash Price |
$609.00
|
| Rate for Payer: Cigna Commercial |
$190.67
|
| Rate for Payer: Healthspan PPO |
$221.90
|
| Rate for Payer: Humana Medicaid |
$72.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$161.70
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$102.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$102.65
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$73.47
|
| Rate for Payer: Molina Healthcare Passport |
$72.03
|
| Rate for Payer: Multiplan PHCS |
$730.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$133.44
|
| Rate for Payer: UHCCP Medicaid |
$59.41
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.75
|
| Rate for Payer: Wellcare Medicare Advantage |
$102.65
|
|
|
DERIDE INFEC TISS<10% BODSURF
|
Facility
|
IP
|
$1,218.00
|
|
|
Service Code
|
HCPCS 11760
|
| Hospital Charge Code |
76100101
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$365.40 |
| Max. Negotiated Rate |
$1,169.28 |
| Rate for Payer: Aetna Commercial |
$937.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$950.04
|
| Rate for Payer: Cash Price |
$609.00
|
| Rate for Payer: Cigna Commercial |
$1,010.94
|
| Rate for Payer: First Health Commercial |
$1,157.10
|
| Rate for Payer: Humana Commercial |
$1,035.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$998.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$898.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$365.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,071.84
|
| Rate for Payer: Ohio Health Group HMO |
$913.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$974.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,059.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$840.42
|
| Rate for Payer: PHCS Commercial |
$1,169.28
|
| Rate for Payer: United Healthcare All Payer |
$1,071.84
|
|
|
DERIDE INFEC TISS<10% BODSURF
|
Facility
|
OP
|
$768.00
|
|
|
Service Code
|
HCPCS 11760
|
| Hospital Charge Code |
45000039
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$264.12 |
| Max. Negotiated Rate |
$791.84 |
| Rate for Payer: Aetna Commercial |
$591.36
|
| Rate for Payer: Anthem Medicaid |
$264.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$599.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cigna Commercial |
$637.44
|
| Rate for Payer: First Health Commercial |
$729.60
|
| Rate for Payer: Humana Commercial |
$652.80
|
| Rate for Payer: Humana KY Medicaid |
$264.12
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$266.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$629.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$566.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$269.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$675.84
|
| Rate for Payer: Ohio Health Group HMO |
$576.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$614.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$668.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$529.92
|
| Rate for Payer: PHCS Commercial |
$737.28
|
| Rate for Payer: United Healthcare All Payer |
$675.84
|
|
|
DERIDE INFEC TISS<10% BODSURF
|
Facility
|
IP
|
$768.00
|
|
|
Service Code
|
HCPCS 11760
|
| Hospital Charge Code |
45000039
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$230.40 |
| Max. Negotiated Rate |
$737.28 |
| Rate for Payer: Aetna Commercial |
$591.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$599.04
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cigna Commercial |
$637.44
|
| Rate for Payer: First Health Commercial |
$729.60
|
| Rate for Payer: Humana Commercial |
$652.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$629.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$566.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$230.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$675.84
|
| Rate for Payer: Ohio Health Group HMO |
$576.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$614.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$668.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$529.92
|
| Rate for Payer: PHCS Commercial |
$737.28
|
| Rate for Payer: United Healthcare All Payer |
$675.84
|
|
|
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 |
$270.00 |
| Rate for Payer: Aetna Commercial |
$188.67
|
| Rate for Payer: Ambetter Exchange |
$102.65
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$56.58
|
| Rate for Payer: Anthem Medicaid |
$72.03
|
| Rate for Payer: Buckeye Individual/Medicaid |
$102.65
|
| Rate for Payer: Buckeye Medicare Advantage |
$102.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$123.18
|
| 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 |
$72.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$161.70
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$102.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$102.65
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$73.47
|
| Rate for Payer: Molina Healthcare Passport |
$72.03
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$133.44
|
| Rate for Payer: UHCCP Medicaid |
$59.41
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.75
|
| Rate for Payer: Wellcare Medicare Advantage |
$102.65
|
|
|
DERIDE INFEC TISS<10% BODSUR(T
|
Facility
|
IP
|
$768.00
|
|
|
Service Code
|
HCPCS 11760
|
| Hospital Charge Code |
761T0101
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$230.40 |
| Max. Negotiated Rate |
$737.28 |
| Rate for Payer: Aetna Commercial |
$591.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$599.04
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cigna Commercial |
$637.44
|
| Rate for Payer: First Health Commercial |
$729.60
|
| Rate for Payer: Humana Commercial |
$652.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$629.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$566.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$230.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$675.84
|
| Rate for Payer: Ohio Health Group HMO |
$576.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$614.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$668.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$529.92
|
| Rate for Payer: PHCS Commercial |
$737.28
|
| Rate for Payer: United Healthcare All Payer |
$675.84
|
|
|
DERIDE INFEC TISS<10% BODSUR(T
|
Facility
|
OP
|
$768.00
|
|
|
Service Code
|
HCPCS 11760
|
| Hospital Charge Code |
761T0101
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$264.12 |
| Max. Negotiated Rate |
$791.84 |
| Rate for Payer: Aetna Commercial |
$591.36
|
| Rate for Payer: Anthem Medicaid |
$264.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$599.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cigna Commercial |
$637.44
|
| Rate for Payer: First Health Commercial |
$729.60
|
| Rate for Payer: Humana Commercial |
$652.80
|
| Rate for Payer: Humana KY Medicaid |
$264.12
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$266.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$629.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$566.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$269.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$675.84
|
| Rate for Payer: Ohio Health Group HMO |
$576.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$614.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$668.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$529.92
|
| Rate for Payer: PHCS Commercial |
$737.28
|
| Rate for Payer: United Healthcare All Payer |
$675.84
|
|
|
DERMABRASION
|
Professional
|
Both
|
$250.00
|
|
| Hospital Charge Code |
22200327
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$87.50 |
| Max. Negotiated Rate |
$175.00 |
| 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 |
$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
|
|
|
DERMABRASION SEGMENTAL FACE
|
Facility
|
OP
|
$3,825.00
|
|
|
Service Code
|
HCPCS 15781
|
| Hospital Charge Code |
76102765
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$650.10 |
| 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 |
$650.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,983.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$910.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$877.63
|
| 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 |
$650.10
|
| 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 |
$780.12
|
| 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
|
|
|
DERMABRASION SEGMENTAL FACE
|
Professional
|
Both
|
$3,825.00
|
|
|
Service Code
|
HCPCS 15781
|
| Hospital Charge Code |
76102765
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$247.63 |
| Max. Negotiated Rate |
$2,295.00 |
| Rate for Payer: Aetna Commercial |
$597.22
|
| Rate for Payer: Ambetter Exchange |
$391.59
|
| Rate for Payer: Anthem Medicaid |
$247.63
|
| Rate for Payer: Buckeye Individual/Medicaid |
$391.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$391.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$469.91
|
| 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 |
$247.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$533.63
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$391.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$391.59
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$252.58
|
| Rate for Payer: Molina Healthcare Passport |
$247.63
|
| Rate for Payer: Multiplan PHCS |
$2,295.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$509.07
|
| Rate for Payer: UHCCP Medicaid |
$1,338.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$250.11
|
| Rate for Payer: Wellcare Medicare Advantage |
$391.59
|
|
|
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: Ambetter Exchange |
$391.59
|
| Rate for Payer: Anthem Medicaid |
$247.63
|
| Rate for Payer: Buckeye Individual/Medicaid |
$391.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$391.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$469.91
|
| 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 |
$247.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$533.63
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$391.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$391.59
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$252.58
|
| Rate for Payer: Molina Healthcare Passport |
$247.63
|
| Rate for Payer: Multiplan PHCS |
$330.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$509.07
|
| Rate for Payer: UHCCP Medicaid |
$192.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$250.11
|
| Rate for Payer: Wellcare Medicare Advantage |
$391.59
|
|
|
DERMABRASION SEGMENTAL FACE (T
|
Facility
|
IP
|
$3,275.00
|
|
|
Service Code
|
HCPCS 15781
|
| Hospital Charge Code |
761T2765
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$982.50 |
| 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 |
$2,620.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,849.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,259.75
|
| Rate for Payer: PHCS Commercial |
$3,144.00
|
| Rate for Payer: United Healthcare All Payer |
$2,882.00
|
|
|
DERMABRASION SEGMENTAL FACE (T
|
Facility
|
OP
|
$3,275.00
|
|
|
Service Code
|
HCPCS 15781
|
| Hospital Charge Code |
761T2765
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$650.10 |
| 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 |
$650.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,554.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$910.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$877.63
|
| 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 |
$650.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,137.73
|
| 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 |
$780.12
|
| 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 |
$2,620.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,849.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,259.75
|
| 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 |
$1,324.80 |
| 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 |
$3,532.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,841.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,047.04
|
| Rate for Payer: PHCS Commercial |
$4,239.36
|
| Rate for Payer: United Healthcare All Payer |
$3,886.08
|
|
|
DERMABRASION TOTAL FACE
|
Professional
|
Both
|
$4,416.00
|
|
|
Service Code
|
HCPCS 15780
|
| Hospital Charge Code |
76100210
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$241.68 |
| Max. Negotiated Rate |
$2,649.60 |
| Rate for Payer: Aetna Commercial |
$915.73
|
| Rate for Payer: Ambetter Exchange |
$620.36
|
| Rate for Payer: Anthem Medicaid |
$241.68
|
| Rate for Payer: Buckeye Individual/Medicaid |
$620.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$620.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$744.43
|
| Rate for Payer: Cash Price |
$2,208.00
|
| Rate for Payer: Cash Price |
$2,208.00
|
| Rate for Payer: Cigna Commercial |
$1,128.70
|
| Rate for Payer: Healthspan PPO |
$917.52
|
| Rate for Payer: Humana Medicaid |
$241.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$783.55
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$620.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$620.36
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$246.51
|
| Rate for Payer: Molina Healthcare Passport |
$241.68
|
| Rate for Payer: Multiplan PHCS |
$2,649.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$806.47
|
| Rate for Payer: UHCCP Medicaid |
$1,545.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$244.10
|
| Rate for Payer: Wellcare Medicare Advantage |
$620.36
|
|
|
DERMABRASION TOTAL FACE
|
Facility
|
OP
|
$4,416.00
|
|
|
Service Code
|
HCPCS 15780
|
| Hospital Charge Code |
76100210
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,518.66 |
| Max. Negotiated Rate |
$4,239.36 |
| Rate for Payer: Aetna Commercial |
$3,400.32
|
| Rate for Payer: Anthem Medicaid |
$1,518.66
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,644.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,444.48
|
| 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 |
$2,208.00
|
| 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: Humana KY Medicaid |
$1,518.66
|
| Rate for Payer: Humana Medicare Advantage |
$2,644.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1,534.12
|
| 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 |
$3,173.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,549.13
|
| 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 |
$3,532.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,841.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,047.04
|
| Rate for Payer: PHCS Commercial |
$4,239.36
|
| Rate for Payer: United Healthcare All Payer |
$3,886.08
|
|
|
DERMABRASION TOTAL FACE (P
|
Professional
|
Both
|
$1,095.00
|
|
|
Service Code
|
HCPCS 15780
|
| Hospital Charge Code |
761P0210
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$241.68 |
| Max. Negotiated Rate |
$1,128.70 |
| Rate for Payer: Aetna Commercial |
$915.73
|
| Rate for Payer: Ambetter Exchange |
$620.36
|
| Rate for Payer: Anthem Medicaid |
$241.68
|
| Rate for Payer: Buckeye Individual/Medicaid |
$620.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$620.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$744.43
|
| Rate for Payer: Cash Price |
$547.50
|
| Rate for Payer: Cash Price |
$547.50
|
| Rate for Payer: Cigna Commercial |
$1,128.70
|
| Rate for Payer: Healthspan PPO |
$917.52
|
| Rate for Payer: Humana Medicaid |
$241.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$783.55
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$620.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$620.36
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$246.51
|
| Rate for Payer: Molina Healthcare Passport |
$241.68
|
| Rate for Payer: Multiplan PHCS |
$657.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$806.47
|
| Rate for Payer: UHCCP Medicaid |
$383.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$244.10
|
| Rate for Payer: Wellcare Medicare Advantage |
$620.36
|
|
|
DERMABRASION TOTAL FACE (T
|
Facility
|
IP
|
$3,321.00
|
|
|
Service Code
|
HCPCS 15780
|
| Hospital Charge Code |
761T0210
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$996.30 |
| Max. Negotiated Rate |
$3,188.16 |
| Rate for Payer: Aetna Commercial |
$2,557.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,590.38
|
| Rate for Payer: Cash Price |
$1,660.50
|
| Rate for Payer: Cigna Commercial |
$2,756.43
|
| Rate for Payer: First Health Commercial |
$3,154.95
|
| Rate for Payer: Humana Commercial |
$2,822.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,723.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,450.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$996.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,922.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,490.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,656.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,889.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,291.49
|
| Rate for Payer: PHCS Commercial |
$3,188.16
|
| Rate for Payer: United Healthcare All Payer |
$2,922.48
|
|
|
DERMABRASION TOTAL FACE (T
|
Facility
|
OP
|
$3,321.00
|
|
|
Service Code
|
HCPCS 15780
|
| Hospital Charge Code |
761T0210
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,142.09 |
| Max. Negotiated Rate |
$3,702.27 |
| Rate for Payer: Aetna Commercial |
$2,557.17
|
| Rate for Payer: Anthem Medicaid |
$1,142.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,644.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,590.38
|
| 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 |
$1,660.50
|
| Rate for Payer: Cash Price |
$1,660.50
|
| Rate for Payer: Cigna Commercial |
$2,756.43
|
| Rate for Payer: First Health Commercial |
$3,154.95
|
| Rate for Payer: Humana Commercial |
$2,822.85
|
| Rate for Payer: Humana KY Medicaid |
$1,142.09
|
| Rate for Payer: Humana Medicare Advantage |
$2,644.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1,153.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,723.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,450.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,173.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,165.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,922.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,490.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,656.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,889.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,291.49
|
| Rate for Payer: PHCS Commercial |
$3,188.16
|
| Rate for Payer: United Healthcare All Payer |
$2,922.48
|
|
|
DERMAGRAFT 2*3
|
Facility
|
IP
|
$4,107.50
|
|
|
Service Code
|
HCPCS Q4106
|
| Hospital Charge Code |
27000116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,232.25 |
| Max. Negotiated Rate |
$3,943.20 |
| Rate for Payer: Aetna Commercial |
$3,162.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,203.85
|
| Rate for Payer: Cash Price |
$2,053.75
|
| Rate for Payer: Cigna Commercial |
$3,409.22
|
| Rate for Payer: First Health Commercial |
$3,902.12
|
| Rate for Payer: Humana Commercial |
$3,491.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,368.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,031.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,232.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,614.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,080.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,286.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,573.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,834.18
|
| Rate for Payer: PHCS Commercial |
$3,943.20
|
| Rate for Payer: United Healthcare All Payer |
$3,614.60
|
|
|
DERMAGRAFT 2*3
|
Facility
|
OP
|
$4,107.50
|
|
|
Service Code
|
HCPCS Q4106
|
| Hospital Charge Code |
27000116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,232.25 |
| Max. Negotiated Rate |
$3,943.20 |
| Rate for Payer: Aetna Commercial |
$3,162.78
|
| Rate for Payer: Anthem Medicaid |
$1,412.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,203.85
|
| Rate for Payer: Cash Price |
$2,053.75
|
| Rate for Payer: Cigna Commercial |
$3,409.22
|
| Rate for Payer: First Health Commercial |
$3,902.12
|
| Rate for Payer: Humana Commercial |
$3,491.38
|
| Rate for Payer: Humana KY Medicaid |
$1,412.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1,426.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,368.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,031.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,232.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,440.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,614.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,080.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,286.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,573.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,834.18
|
| Rate for Payer: PHCS Commercial |
$3,943.20
|
| Rate for Payer: United Healthcare All Payer |
$3,614.60
|
|
|
DERMAPHOR OINT 15APPL/15GM
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 61924018404
|
| Hospital Charge Code |
25003896
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Anthem Medicaid |
$0.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.02
|
| Rate for Payer: First Health Commercial |
$0.03
|
| Rate for Payer: Humana Commercial |
$0.03
|
| Rate for Payer: Humana KY Medicaid |
$0.01
|
| Rate for Payer: Kentucky WC Medicaid |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.03
|
| Rate for Payer: Ohio Health Group HMO |
$0.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.02
|
| Rate for Payer: PHCS Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Payer |
$0.03
|
|
|
DERMAPHOR OINT 15APPL/15GM
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 61924018404
|
| Hospital Charge Code |
25003896
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.02
|
| Rate for Payer: First Health Commercial |
$0.03
|
| Rate for Payer: Humana Commercial |
$0.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.03
|
| Rate for Payer: Ohio Health Group HMO |
$0.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.02
|
| Rate for Payer: PHCS Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Payer |
$0.03
|
|
|
DERMA SMOOTHE FS OIL
|
Facility
|
OP
|
$4.13
|
|
|
Service Code
|
NDC 68791010204
|
| Hospital Charge Code |
25000539
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.96 |
| Rate for Payer: Aetna Commercial |
$3.18
|
| Rate for Payer: Anthem Medicaid |
$1.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.22
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Cigna Commercial |
$3.43
|
| Rate for Payer: First Health Commercial |
$3.92
|
| Rate for Payer: Humana Commercial |
$3.51
|
| Rate for Payer: Humana KY Medicaid |
$1.42
|
| Rate for Payer: Kentucky WC Medicaid |
$1.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.63
|
| Rate for Payer: Ohio Health Group HMO |
$3.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.85
|
| Rate for Payer: PHCS Commercial |
$3.96
|
| Rate for Payer: United Healthcare All Payer |
$3.63
|
|
