|
DREAMWIRE ST SS .035*450
|
Facility
|
OP
|
$1,978.72
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$593.62 |
| Max. Negotiated Rate |
$1,899.57 |
| Rate for Payer: Aetna Commercial |
$1,523.61
|
| Rate for Payer: Anthem Medicaid |
$680.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,543.40
|
| Rate for Payer: Cash Price |
$989.36
|
| Rate for Payer: Cigna Commercial |
$1,642.34
|
| Rate for Payer: First Health Commercial |
$1,879.78
|
| Rate for Payer: Humana Commercial |
$1,681.91
|
| Rate for Payer: Humana KY Medicaid |
$680.48
|
| Rate for Payer: Kentucky WC Medicaid |
$687.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,622.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,460.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$593.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$694.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,741.27
|
| Rate for Payer: Ohio Health Group HMO |
$1,484.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,582.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,721.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,365.32
|
| Rate for Payer: PHCS Commercial |
$1,899.57
|
| Rate for Payer: United Healthcare All Payer |
$1,741.27
|
|
|
DRES DEBR BURN W/O ANES SM
|
Facility
|
IP
|
$425.00
|
|
|
Service Code
|
HCPCS 16020
|
| Hospital Charge Code |
76100243
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$127.50 |
| Max. Negotiated Rate |
$408.00 |
| Rate for Payer: Aetna Commercial |
$327.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$331.50
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cigna Commercial |
$352.75
|
| Rate for Payer: First Health Commercial |
$403.75
|
| Rate for Payer: Humana Commercial |
$361.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$348.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$313.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$127.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$374.00
|
| Rate for Payer: Ohio Health Group HMO |
$318.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$369.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.25
|
| Rate for Payer: PHCS Commercial |
$408.00
|
| Rate for Payer: United Healthcare All Payer |
$374.00
|
|
|
DRES DEBR BURN W/O ANES SM
|
Professional
|
Both
|
$425.00
|
|
|
Service Code
|
HCPCS 16020
|
| Hospital Charge Code |
76100243
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$32.83 |
| Max. Negotiated Rate |
$255.00 |
| Rate for Payer: Aetna Commercial |
$81.85
|
| Rate for Payer: Ambetter Exchange |
$52.36
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$32.83
|
| Rate for Payer: Anthem Medicaid |
$33.32
|
| Rate for Payer: Buckeye Individual/Medicaid |
$52.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$52.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$62.83
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cigna Commercial |
$115.98
|
| Rate for Payer: Healthspan PPO |
$90.27
|
| Rate for Payer: Humana Medicaid |
$33.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$70.21
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$52.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$52.36
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$33.99
|
| Rate for Payer: Molina Healthcare Passport |
$33.32
|
| Rate for Payer: Multiplan PHCS |
$255.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$68.07
|
| Rate for Payer: UHCCP Medicaid |
$34.47
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$33.65
|
| Rate for Payer: Wellcare Medicare Advantage |
$52.36
|
|
|
DRES DEBR BURN W/O ANES SM
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
HCPCS 16020
|
| Hospital Charge Code |
45000078
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$91.50 |
| Max. Negotiated Rate |
$292.80 |
| Rate for Payer: Aetna Commercial |
$234.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.90
|
| Rate for Payer: Cash Price |
$152.50
|
| Rate for Payer: Cigna Commercial |
$253.15
|
| Rate for Payer: First Health Commercial |
$289.75
|
| Rate for Payer: Humana Commercial |
$259.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$250.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$225.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$91.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$268.40
|
| Rate for Payer: Ohio Health Group HMO |
$228.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$244.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$265.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$210.45
|
| Rate for Payer: PHCS Commercial |
$292.80
|
| Rate for Payer: United Healthcare All Payer |
$268.40
|
|
|
DRES DEBR BURN W/O ANES SM
|
Facility
|
OP
|
$425.00
|
|
|
Service Code
|
HCPCS 16020
|
| Hospital Charge Code |
76100243
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$146.16 |
| Max. Negotiated Rate |
$408.00 |
| Rate for Payer: Aetna Commercial |
$327.25
|
| Rate for Payer: Anthem Medicaid |
$146.16
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$331.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cigna Commercial |
$352.75
|
| Rate for Payer: First Health Commercial |
$403.75
|
| Rate for Payer: Humana Commercial |
$361.25
|
| Rate for Payer: Humana KY Medicaid |
$146.16
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$147.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$348.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$313.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$149.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$374.00
|
| Rate for Payer: Ohio Health Group HMO |
$318.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$369.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.25
|
| Rate for Payer: PHCS Commercial |
$408.00
|
| Rate for Payer: United Healthcare All Payer |
$374.00
|
|
|
DRES DEBR BURN W/O ANES SM
|
Facility
|
OP
|
$305.00
|
|
|
Service Code
|
HCPCS 16020
|
| Hospital Charge Code |
45000078
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$104.89 |
| Max. Negotiated Rate |
$292.80 |
| Rate for Payer: Aetna Commercial |
$234.85
|
| Rate for Payer: Anthem Medicaid |
$104.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$152.50
|
| Rate for Payer: Cash Price |
$152.50
|
| Rate for Payer: Cigna Commercial |
$253.15
|
| Rate for Payer: First Health Commercial |
$289.75
|
| Rate for Payer: Humana Commercial |
$259.25
|
| Rate for Payer: Humana KY Medicaid |
$104.89
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$105.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$250.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$225.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$106.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$268.40
|
| Rate for Payer: Ohio Health Group HMO |
$228.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$244.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$265.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$210.45
|
| Rate for Payer: PHCS Commercial |
$292.80
|
| Rate for Payer: United Healthcare All Payer |
$268.40
|
|
|
DRES DEBR BURN W/O ANES SM(P
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
HCPCS 16020
|
| Hospital Charge Code |
761P0243
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$32.83 |
| Max. Negotiated Rate |
$115.98 |
| Rate for Payer: Aetna Commercial |
$81.85
|
| Rate for Payer: Ambetter Exchange |
$52.36
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$32.83
|
| Rate for Payer: Anthem Medicaid |
$33.32
|
| Rate for Payer: Buckeye Individual/Medicaid |
$52.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$52.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$62.83
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$115.98
|
| Rate for Payer: Healthspan PPO |
$90.27
|
| Rate for Payer: Humana Medicaid |
$33.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$70.21
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$52.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$52.36
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$33.99
|
| Rate for Payer: Molina Healthcare Passport |
$33.32
|
| Rate for Payer: Multiplan PHCS |
$72.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$68.07
|
| Rate for Payer: UHCCP Medicaid |
$34.47
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$33.65
|
| Rate for Payer: Wellcare Medicare Advantage |
$52.36
|
|
|
DRES DEBR BURN W/O ANES SM(T
|
Facility
|
OP
|
$305.00
|
|
|
Service Code
|
HCPCS 16020
|
| Hospital Charge Code |
761T0243
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$104.89 |
| Max. Negotiated Rate |
$292.80 |
| Rate for Payer: Aetna Commercial |
$234.85
|
| Rate for Payer: Anthem Medicaid |
$104.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$152.50
|
| Rate for Payer: Cash Price |
$152.50
|
| Rate for Payer: Cigna Commercial |
$253.15
|
| Rate for Payer: First Health Commercial |
$289.75
|
| Rate for Payer: Humana Commercial |
$259.25
|
| Rate for Payer: Humana KY Medicaid |
$104.89
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$105.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$250.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$225.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$106.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$268.40
|
| Rate for Payer: Ohio Health Group HMO |
$228.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$244.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$265.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$210.45
|
| Rate for Payer: PHCS Commercial |
$292.80
|
| Rate for Payer: United Healthcare All Payer |
$268.40
|
|
|
DRES DEBR BURN W/O ANES SM(T
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
HCPCS 16020
|
| Hospital Charge Code |
761T0243
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$91.50 |
| Max. Negotiated Rate |
$292.80 |
| Rate for Payer: Aetna Commercial |
$234.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.90
|
| Rate for Payer: Cash Price |
$152.50
|
| Rate for Payer: Cigna Commercial |
$253.15
|
| Rate for Payer: First Health Commercial |
$289.75
|
| Rate for Payer: Humana Commercial |
$259.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$250.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$225.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$91.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$268.40
|
| Rate for Payer: Ohio Health Group HMO |
$228.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$244.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$265.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$210.45
|
| Rate for Payer: PHCS Commercial |
$292.80
|
| Rate for Payer: United Healthcare All Payer |
$268.40
|
|
|
DRESSING CHANGE /NOT BURN
|
Facility
|
OP
|
$1,114.00
|
|
|
Service Code
|
HCPCS 15852
|
| Hospital Charge Code |
76100227
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$383.10 |
| Max. Negotiated Rate |
$1,069.44 |
| Rate for Payer: Aetna Commercial |
$857.78
|
| Rate for Payer: Anthem Medicaid |
$383.10
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$868.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$557.00
|
| Rate for Payer: Cash Price |
$557.00
|
| Rate for Payer: Cigna Commercial |
$924.62
|
| Rate for Payer: First Health Commercial |
$1,058.30
|
| Rate for Payer: Humana Commercial |
$946.90
|
| Rate for Payer: Humana KY Medicaid |
$383.10
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$387.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$913.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$822.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$390.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$980.32
|
| Rate for Payer: Ohio Health Group HMO |
$835.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$891.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$969.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$768.66
|
| Rate for Payer: PHCS Commercial |
$1,069.44
|
| Rate for Payer: United Healthcare All Payer |
$980.32
|
|
|
DRESSING CHANGE /NOT BURN
|
Facility
|
IP
|
$764.00
|
|
|
Service Code
|
HCPCS 15852
|
| Hospital Charge Code |
45000076
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$229.20 |
| Max. Negotiated Rate |
$733.44 |
| Rate for Payer: Aetna Commercial |
$588.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$595.92
|
| Rate for Payer: Cash Price |
$382.00
|
| Rate for Payer: Cigna Commercial |
$634.12
|
| Rate for Payer: First Health Commercial |
$725.80
|
| Rate for Payer: Humana Commercial |
$649.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$626.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$563.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$229.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$672.32
|
| Rate for Payer: Ohio Health Group HMO |
$573.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$611.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$664.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$527.16
|
| Rate for Payer: PHCS Commercial |
$733.44
|
| Rate for Payer: United Healthcare All Payer |
$672.32
|
|
|
DRESSING CHANGE /NOT BURN
|
Facility
|
OP
|
$764.00
|
|
|
Service Code
|
HCPCS 15852
|
| Hospital Charge Code |
45000076
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$262.74 |
| Max. Negotiated Rate |
$791.84 |
| Rate for Payer: Aetna Commercial |
$588.28
|
| Rate for Payer: Anthem Medicaid |
$262.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$595.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$382.00
|
| Rate for Payer: Cash Price |
$382.00
|
| Rate for Payer: Cigna Commercial |
$634.12
|
| Rate for Payer: First Health Commercial |
$725.80
|
| Rate for Payer: Humana Commercial |
$649.40
|
| Rate for Payer: Humana KY Medicaid |
$262.74
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$265.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$626.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$563.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$268.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$672.32
|
| Rate for Payer: Ohio Health Group HMO |
$573.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$611.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$664.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$527.16
|
| Rate for Payer: PHCS Commercial |
$733.44
|
| Rate for Payer: United Healthcare All Payer |
$672.32
|
|
|
DRESSING CHANGE /NOT BURN
|
Facility
|
IP
|
$1,114.00
|
|
|
Service Code
|
HCPCS 15852
|
| Hospital Charge Code |
76100227
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$334.20 |
| Max. Negotiated Rate |
$1,069.44 |
| Rate for Payer: Aetna Commercial |
$857.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$868.92
|
| Rate for Payer: Cash Price |
$557.00
|
| Rate for Payer: Cigna Commercial |
$924.62
|
| Rate for Payer: First Health Commercial |
$1,058.30
|
| Rate for Payer: Humana Commercial |
$946.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$913.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$822.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$334.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$980.32
|
| Rate for Payer: Ohio Health Group HMO |
$835.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$891.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$969.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$768.66
|
| Rate for Payer: PHCS Commercial |
$1,069.44
|
| Rate for Payer: United Healthcare All Payer |
$980.32
|
|
|
DRESSING CHANGE /NOT BURN
|
Professional
|
Both
|
$1,114.00
|
|
|
Service Code
|
HCPCS 15852
|
| Hospital Charge Code |
76100227
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$38.74 |
| Max. Negotiated Rate |
$668.40 |
| Rate for Payer: Aetna Commercial |
$71.57
|
| Rate for Payer: Ambetter Exchange |
$42.18
|
| Rate for Payer: Anthem Medicaid |
$38.74
|
| Rate for Payer: Buckeye Individual/Medicaid |
$42.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$42.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$50.62
|
| Rate for Payer: Cash Price |
$557.00
|
| Rate for Payer: Cash Price |
$557.00
|
| Rate for Payer: Cigna Commercial |
$67.65
|
| Rate for Payer: Healthspan PPO |
$57.23
|
| Rate for Payer: Humana Medicaid |
$38.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$59.25
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$42.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$39.51
|
| Rate for Payer: Molina Healthcare Passport |
$38.74
|
| Rate for Payer: Multiplan PHCS |
$668.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$54.83
|
| Rate for Payer: UHCCP Medicaid |
$389.90
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$39.13
|
| Rate for Payer: Wellcare Medicare Advantage |
$42.18
|
|
|
DRESSING CHANGE /NOT BURN(P
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
HCPCS 15852
|
| Hospital Charge Code |
761P0227
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$38.74 |
| Max. Negotiated Rate |
$210.00 |
| Rate for Payer: Aetna Commercial |
$71.57
|
| Rate for Payer: Ambetter Exchange |
$42.18
|
| Rate for Payer: Anthem Medicaid |
$38.74
|
| Rate for Payer: Buckeye Individual/Medicaid |
$42.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$42.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$50.62
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna Commercial |
$67.65
|
| Rate for Payer: Healthspan PPO |
$57.23
|
| Rate for Payer: Humana Medicaid |
$38.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$59.25
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$42.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$39.51
|
| Rate for Payer: Molina Healthcare Passport |
$38.74
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$54.83
|
| Rate for Payer: UHCCP Medicaid |
$122.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$39.13
|
| Rate for Payer: Wellcare Medicare Advantage |
$42.18
|
|
|
DRESSING CHANGE /NOT BURN(T
|
Facility
|
OP
|
$764.00
|
|
|
Service Code
|
HCPCS 15852
|
| Hospital Charge Code |
761T0227
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$262.74 |
| Max. Negotiated Rate |
$791.84 |
| Rate for Payer: Aetna Commercial |
$588.28
|
| Rate for Payer: Anthem Medicaid |
$262.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$595.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$382.00
|
| Rate for Payer: Cash Price |
$382.00
|
| Rate for Payer: Cigna Commercial |
$634.12
|
| Rate for Payer: First Health Commercial |
$725.80
|
| Rate for Payer: Humana Commercial |
$649.40
|
| Rate for Payer: Humana KY Medicaid |
$262.74
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$265.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$626.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$563.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$268.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$672.32
|
| Rate for Payer: Ohio Health Group HMO |
$573.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$611.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$664.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$527.16
|
| Rate for Payer: PHCS Commercial |
$733.44
|
| Rate for Payer: United Healthcare All Payer |
$672.32
|
|
|
DRESSING CHANGE /NOT BURN(T
|
Facility
|
IP
|
$764.00
|
|
|
Service Code
|
HCPCS 15852
|
| Hospital Charge Code |
761T0227
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$229.20 |
| Max. Negotiated Rate |
$733.44 |
| Rate for Payer: Aetna Commercial |
$588.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$595.92
|
| Rate for Payer: Cash Price |
$382.00
|
| Rate for Payer: Cigna Commercial |
$634.12
|
| Rate for Payer: First Health Commercial |
$725.80
|
| Rate for Payer: Humana Commercial |
$649.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$626.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$563.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$229.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$672.32
|
| Rate for Payer: Ohio Health Group HMO |
$573.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$611.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$664.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$527.16
|
| Rate for Payer: PHCS Commercial |
$733.44
|
| Rate for Payer: United Healthcare All Payer |
$672.32
|
|
|
DRESSING VERAFLO LG
|
Facility
|
IP
|
$2,120.80
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$636.24 |
| Max. Negotiated Rate |
$2,035.97 |
| Rate for Payer: Aetna Commercial |
$1,633.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,654.22
|
| Rate for Payer: Cash Price |
$1,060.40
|
| Rate for Payer: Cigna Commercial |
$1,760.26
|
| Rate for Payer: First Health Commercial |
$2,014.76
|
| Rate for Payer: Humana Commercial |
$1,802.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,739.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,565.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$636.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,866.30
|
| Rate for Payer: Ohio Health Group HMO |
$1,590.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,696.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,845.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,463.35
|
| Rate for Payer: PHCS Commercial |
$2,035.97
|
| Rate for Payer: United Healthcare All Payer |
$1,866.30
|
|
|
DRESSING VERAFLO LG
|
Facility
|
OP
|
$2,120.80
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$636.24 |
| Max. Negotiated Rate |
$2,035.97 |
| Rate for Payer: Aetna Commercial |
$1,633.02
|
| Rate for Payer: Anthem Medicaid |
$729.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,654.22
|
| Rate for Payer: Cash Price |
$1,060.40
|
| Rate for Payer: Cigna Commercial |
$1,760.26
|
| Rate for Payer: First Health Commercial |
$2,014.76
|
| Rate for Payer: Humana Commercial |
$1,802.68
|
| Rate for Payer: Humana KY Medicaid |
$729.34
|
| Rate for Payer: Kentucky WC Medicaid |
$736.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,739.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,565.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$636.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$743.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,866.30
|
| Rate for Payer: Ohio Health Group HMO |
$1,590.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,696.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,845.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,463.35
|
| Rate for Payer: PHCS Commercial |
$2,035.97
|
| Rate for Payer: United Healthcare All Payer |
$1,866.30
|
|
|
DRESSING VERAFLO MED
|
Facility
|
OP
|
$1,737.00
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$521.10 |
| Max. Negotiated Rate |
$1,667.52 |
| Rate for Payer: Aetna Commercial |
$1,337.49
|
| Rate for Payer: Anthem Medicaid |
$597.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,354.86
|
| Rate for Payer: Cash Price |
$868.50
|
| Rate for Payer: Cigna Commercial |
$1,441.71
|
| Rate for Payer: First Health Commercial |
$1,650.15
|
| Rate for Payer: Humana Commercial |
$1,476.45
|
| Rate for Payer: Humana KY Medicaid |
$597.35
|
| Rate for Payer: Kentucky WC Medicaid |
$603.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,424.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,281.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$609.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,528.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,302.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,389.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,511.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,198.53
|
| Rate for Payer: PHCS Commercial |
$1,667.52
|
| Rate for Payer: United Healthcare All Payer |
$1,528.56
|
|
|
DRESSING VERAFLO MED
|
Facility
|
IP
|
$1,737.00
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$521.10 |
| Max. Negotiated Rate |
$1,667.52 |
| Rate for Payer: Aetna Commercial |
$1,337.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,354.86
|
| Rate for Payer: Cash Price |
$868.50
|
| Rate for Payer: Cigna Commercial |
$1,441.71
|
| Rate for Payer: First Health Commercial |
$1,650.15
|
| Rate for Payer: Humana Commercial |
$1,476.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,424.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,281.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,528.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,302.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,389.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,511.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,198.53
|
| Rate for Payer: PHCS Commercial |
$1,667.52
|
| Rate for Payer: United Healthcare All Payer |
$1,528.56
|
|
|
DRESSING VERAFLO SM
|
Facility
|
OP
|
$1,572.40
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$471.72 |
| Max. Negotiated Rate |
$1,509.50 |
| Rate for Payer: Aetna Commercial |
$1,210.75
|
| Rate for Payer: Anthem Medicaid |
$540.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,226.47
|
| Rate for Payer: Cash Price |
$786.20
|
| Rate for Payer: Cigna Commercial |
$1,305.09
|
| Rate for Payer: First Health Commercial |
$1,493.78
|
| Rate for Payer: Humana Commercial |
$1,336.54
|
| Rate for Payer: Humana KY Medicaid |
$540.75
|
| Rate for Payer: Kentucky WC Medicaid |
$546.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,289.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,160.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$471.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$551.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,383.71
|
| Rate for Payer: Ohio Health Group HMO |
$1,179.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,257.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,367.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,084.96
|
| Rate for Payer: PHCS Commercial |
$1,509.50
|
| Rate for Payer: United Healthcare All Payer |
$1,383.71
|
|
|
DRESSING VERAFLO SM
|
Facility
|
IP
|
$1,572.40
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$471.72 |
| Max. Negotiated Rate |
$1,509.50 |
| Rate for Payer: Aetna Commercial |
$1,210.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,226.47
|
| Rate for Payer: Cash Price |
$786.20
|
| Rate for Payer: Cigna Commercial |
$1,305.09
|
| Rate for Payer: First Health Commercial |
$1,493.78
|
| Rate for Payer: Humana Commercial |
$1,336.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,289.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,160.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$471.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,383.71
|
| Rate for Payer: Ohio Health Group HMO |
$1,179.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,257.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,367.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,084.96
|
| Rate for Payer: PHCS Commercial |
$1,509.50
|
| Rate for Payer: United Healthcare All Payer |
$1,383.71
|
|
|
DRESS/OR DETRIME BUR W/O ANES
|
Facility
|
OP
|
$179.00
|
|
| Hospital Charge Code |
45000324
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$53.70 |
| Max. Negotiated Rate |
$171.84 |
| Rate for Payer: Aetna Commercial |
$137.83
|
| Rate for Payer: Anthem Medicaid |
$61.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$139.62
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cigna Commercial |
$148.57
|
| Rate for Payer: First Health Commercial |
$170.05
|
| Rate for Payer: Humana Commercial |
$152.15
|
| Rate for Payer: Humana KY Medicaid |
$61.56
|
| Rate for Payer: Kentucky WC Medicaid |
$62.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$146.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$132.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$62.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$157.52
|
| Rate for Payer: Ohio Health Group HMO |
$134.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$143.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$155.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$123.51
|
| Rate for Payer: PHCS Commercial |
$171.84
|
| Rate for Payer: United Healthcare All Payer |
$157.52
|
|
|
DRESS/OR DETRIME BUR W/O ANES
|
Facility
|
OP
|
$172.00
|
|
| Hospital Charge Code |
76102551
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$51.60 |
| Max. Negotiated Rate |
$165.12 |
| Rate for Payer: Aetna Commercial |
$132.44
|
| Rate for Payer: Anthem Medicaid |
$59.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.16
|
| Rate for Payer: Cash Price |
$86.00
|
| Rate for Payer: Cigna Commercial |
$142.76
|
| Rate for Payer: First Health Commercial |
$163.40
|
| Rate for Payer: Humana Commercial |
$146.20
|
| Rate for Payer: Humana KY Medicaid |
$59.15
|
| Rate for Payer: Kentucky WC Medicaid |
$59.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$141.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$126.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$60.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$151.36
|
| Rate for Payer: Ohio Health Group HMO |
$129.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$137.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$149.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$118.68
|
| Rate for Payer: PHCS Commercial |
$165.12
|
| Rate for Payer: United Healthcare All Payer |
$151.36
|
|
