|
EXC FACE-MM B9+MARG 3.1-4 CM
|
Professional
|
Both
|
$2,750.00
|
|
|
Service Code
|
HCPCS 11444
|
| Hospital Charge Code |
76100067
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$114.72 |
| Max. Negotiated Rate |
$2,750.00 |
| Rate for Payer: Aetna Commercial |
$319.92
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$114.72
|
| Rate for Payer: Anthem Medicaid |
$122.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,750.00
|
| Rate for Payer: Cash Price |
$1,375.00
|
| Rate for Payer: Cash Price |
$1,375.00
|
| Rate for Payer: Cigna Commercial |
$373.26
|
| Rate for Payer: Healthspan PPO |
$307.60
|
| Rate for Payer: Humana Medicaid |
$122.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$279.72
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$124.44
|
| Rate for Payer: Molina Healthcare Passport |
$122.00
|
| Rate for Payer: Multiplan PHCS |
$1,650.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,925.00
|
| Rate for Payer: UHCCP Medicaid |
$120.46
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$123.22
|
|
|
EXC FACE-MM B9+MARG 3.1-4 CM
|
Facility
|
IP
|
$2,050.00
|
|
|
Service Code
|
HCPCS 11444
|
| Hospital Charge Code |
45000034
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
EXC FACE-MM B9+MARG 3.1-4 CM
|
Facility
|
IP
|
$2,750.00
|
|
|
Service Code
|
HCPCS 11444
|
| Hospital Charge Code |
76100067
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$357.50 |
| Max. Negotiated Rate |
$2,640.00 |
| Rate for Payer: Aetna Commercial |
$2,117.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,145.00
|
| Rate for Payer: Cash Price |
$1,375.00
|
| Rate for Payer: Cigna Commercial |
$2,282.50
|
| Rate for Payer: First Health Commercial |
$2,612.50
|
| Rate for Payer: Humana Commercial |
$2,337.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,255.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,029.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$825.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,420.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,062.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$357.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$852.50
|
| Rate for Payer: PHCS Commercial |
$2,640.00
|
| Rate for Payer: United Healthcare All Payer |
$2,420.00
|
|
|
EXC FACE-MM B9+MARG 3.1-4 CM
|
Facility
|
OP
|
$2,750.00
|
|
|
Service Code
|
HCPCS 11444
|
| Hospital Charge Code |
76100067
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$357.50 |
| Max. Negotiated Rate |
$2,640.00 |
| Rate for Payer: Aetna Commercial |
$2,117.50
|
| Rate for Payer: Anthem Medicaid |
$945.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,145.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$1,375.00
|
| Rate for Payer: Cash Price |
$1,375.00
|
| Rate for Payer: Cigna Commercial |
$2,282.50
|
| Rate for Payer: First Health Commercial |
$2,612.50
|
| Rate for Payer: Humana Commercial |
$2,337.50
|
| Rate for Payer: Humana KY Medicaid |
$945.72
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$955.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,255.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,029.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$964.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,420.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,062.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$357.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$852.50
|
| Rate for Payer: PHCS Commercial |
$2,640.00
|
| Rate for Payer: United Healthcare All Payer |
$2,420.00
|
|
|
EXC FACE-MM B9+MARG 3.1-4 CM
|
Facility
|
OP
|
$2,050.00
|
|
|
Service Code
|
HCPCS 11444
|
| Hospital Charge Code |
45000034
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem Medicaid |
$705.00
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Humana KY Medicaid |
$705.00
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$712.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$719.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
EXC FACE-MM B9+MARG 3.1-4 C(P
|
Professional
|
Both
|
$700.00
|
|
|
Service Code
|
HCPCS 11444
|
| Hospital Charge Code |
761P0067
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$114.72 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Commercial |
$319.92
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$114.72
|
| Rate for Payer: Anthem Medicaid |
$122.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$700.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$373.26
|
| Rate for Payer: Healthspan PPO |
$307.60
|
| Rate for Payer: Humana Medicaid |
$122.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$279.72
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$124.44
|
| Rate for Payer: Molina Healthcare Passport |
$122.00
|
| Rate for Payer: Multiplan PHCS |
$420.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$490.00
|
| Rate for Payer: UHCCP Medicaid |
$120.46
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$123.22
|
|
|
EXC FACE-MM B9+MARG 3.1-4 C(T
|
Facility
|
OP
|
$2,050.00
|
|
|
Service Code
|
HCPCS 11444
|
| Hospital Charge Code |
761T0067
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem Medicaid |
$705.00
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Humana KY Medicaid |
$705.00
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$712.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$719.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
EXC FACE-MM B9+MARG 3.1-4 C(T
|
Facility
|
IP
|
$2,050.00
|
|
|
Service Code
|
HCPCS 11444
|
| Hospital Charge Code |
761T0067
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
EXC FACE TUM DEEP < 2 CM
|
Professional
|
Both
|
$6,078.00
|
|
|
Service Code
|
HCPCS 21013
|
| Hospital Charge Code |
76100364
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$205.74 |
| Max. Negotiated Rate |
$6,078.00 |
| Rate for Payer: Aetna Commercial |
$603.32
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$205.74
|
| Rate for Payer: Anthem Medicaid |
$286.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,078.00
|
| Rate for Payer: Cash Price |
$3,039.00
|
| Rate for Payer: Cash Price |
$3,039.00
|
| Rate for Payer: Cigna Commercial |
$846.47
|
| Rate for Payer: Healthspan PPO |
$525.47
|
| Rate for Payer: Humana Medicaid |
$286.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$501.97
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$292.45
|
| Rate for Payer: Molina Healthcare Passport |
$286.72
|
| Rate for Payer: Multiplan PHCS |
$3,646.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,254.60
|
| Rate for Payer: UHCCP Medicaid |
$216.03
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$289.59
|
|
|
EXC FACE TUM DEEP < 2 CM
|
Facility
|
OP
|
$6,078.00
|
|
|
Service Code
|
HCPCS 21013
|
| Hospital Charge Code |
76100364
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$790.14 |
| Max. Negotiated Rate |
$5,834.88 |
| Rate for Payer: Aetna Commercial |
$4,680.06
|
| Rate for Payer: Anthem Medicaid |
$2,090.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,740.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$3,039.00
|
| Rate for Payer: Cash Price |
$3,039.00
|
| Rate for Payer: Cigna Commercial |
$5,044.74
|
| Rate for Payer: First Health Commercial |
$5,774.10
|
| Rate for Payer: Humana Commercial |
$5,166.30
|
| Rate for Payer: Humana KY Medicaid |
$2,090.22
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$2,111.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,983.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,485.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,132.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,348.64
|
| Rate for Payer: Ohio Health Group HMO |
$4,558.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,215.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$790.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,884.18
|
| Rate for Payer: PHCS Commercial |
$5,834.88
|
| Rate for Payer: United Healthcare All Payer |
$5,348.64
|
|
|
EXC FACE TUM DEEP < 2 CM
|
Facility
|
IP
|
$6,078.00
|
|
|
Service Code
|
HCPCS 21013
|
| Hospital Charge Code |
76100364
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$790.14 |
| Max. Negotiated Rate |
$5,834.88 |
| Rate for Payer: Aetna Commercial |
$4,680.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,740.84
|
| Rate for Payer: Cash Price |
$3,039.00
|
| Rate for Payer: Cigna Commercial |
$5,044.74
|
| Rate for Payer: First Health Commercial |
$5,774.10
|
| Rate for Payer: Humana Commercial |
$5,166.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,983.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,485.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,823.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,348.64
|
| Rate for Payer: Ohio Health Group HMO |
$4,558.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,215.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$790.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,884.18
|
| Rate for Payer: PHCS Commercial |
$5,834.88
|
| Rate for Payer: United Healthcare All Payer |
$5,348.64
|
|
|
EXC FACE TUM DEEP 2 CM/>
|
Facility
|
OP
|
$6,382.50
|
|
|
Service Code
|
HCPCS 21014
|
| Hospital Charge Code |
76100365
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$829.72 |
| Max. Negotiated Rate |
$6,127.20 |
| Rate for Payer: Aetna Commercial |
$4,914.52
|
| Rate for Payer: Anthem Medicaid |
$2,194.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,978.35
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,440.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,317.21
|
| Rate for Payer: Cash Price |
$3,191.25
|
| Rate for Payer: Cash Price |
$3,191.25
|
| Rate for Payer: Cigna Commercial |
$5,297.48
|
| Rate for Payer: First Health Commercial |
$6,063.38
|
| Rate for Payer: Humana Commercial |
$5,425.12
|
| Rate for Payer: Humana KY Medicaid |
$2,194.94
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$2,217.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,233.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,710.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,238.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,616.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,786.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,276.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$829.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,978.58
|
| Rate for Payer: PHCS Commercial |
$6,127.20
|
| Rate for Payer: United Healthcare All Payer |
$5,616.60
|
|
|
EXC FACE TUM DEEP 2 CM/>
|
Professional
|
Both
|
$6,382.50
|
|
|
Service Code
|
HCPCS 21014
|
| Hospital Charge Code |
76100365
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$376.05 |
| Max. Negotiated Rate |
$6,382.50 |
| Rate for Payer: Aetna Commercial |
$792.73
|
| Rate for Payer: Anthem Medicaid |
$376.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,382.50
|
| Rate for Payer: Cash Price |
$3,191.25
|
| Rate for Payer: Cash Price |
$3,191.25
|
| Rate for Payer: Cigna Commercial |
$907.38
|
| Rate for Payer: Healthspan PPO |
$565.43
|
| Rate for Payer: Humana Medicaid |
$376.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$665.55
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$383.57
|
| Rate for Payer: Molina Healthcare Passport |
$376.05
|
| Rate for Payer: Multiplan PHCS |
$3,829.50
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,467.75
|
| Rate for Payer: UHCCP Medicaid |
$2,233.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$379.81
|
|
|
EXC FACE TUM DEEP 2 CM/>
|
Facility
|
IP
|
$6,382.50
|
|
|
Service Code
|
HCPCS 21014
|
| Hospital Charge Code |
76100365
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$829.72 |
| Max. Negotiated Rate |
$6,127.20 |
| Rate for Payer: Aetna Commercial |
$4,914.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,978.35
|
| Rate for Payer: Cash Price |
$3,191.25
|
| Rate for Payer: Cigna Commercial |
$5,297.48
|
| Rate for Payer: First Health Commercial |
$6,063.38
|
| Rate for Payer: Humana Commercial |
$5,425.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,233.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,710.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,914.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,616.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,786.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,276.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$829.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,978.58
|
| Rate for Payer: PHCS Commercial |
$6,127.20
|
| Rate for Payer: United Healthcare All Payer |
$5,616.60
|
|
|
EXC FACE TUM DEEP < 2 CM(P
|
Professional
|
Both
|
$1,220.00
|
|
|
Service Code
|
HCPCS 21013
|
| Hospital Charge Code |
761P0364
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$205.74 |
| Max. Negotiated Rate |
$1,220.00 |
| Rate for Payer: Aetna Commercial |
$603.32
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$205.74
|
| Rate for Payer: Anthem Medicaid |
$286.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,220.00
|
| Rate for Payer: Cash Price |
$610.00
|
| Rate for Payer: Cash Price |
$610.00
|
| Rate for Payer: Cigna Commercial |
$846.47
|
| Rate for Payer: Healthspan PPO |
$525.47
|
| Rate for Payer: Humana Medicaid |
$286.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$501.97
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$292.45
|
| Rate for Payer: Molina Healthcare Passport |
$286.72
|
| Rate for Payer: Multiplan PHCS |
$732.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$854.00
|
| Rate for Payer: UHCCP Medicaid |
$216.03
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$289.59
|
|
|
EXC FACE TUM DEEP 2 CM/>(P
|
Professional
|
Both
|
$870.00
|
|
|
Service Code
|
HCPCS 21014
|
| Hospital Charge Code |
761P0365
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$304.50 |
| Max. Negotiated Rate |
$907.38 |
| Rate for Payer: Aetna Commercial |
$792.73
|
| Rate for Payer: Anthem Medicaid |
$376.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$870.00
|
| Rate for Payer: Cash Price |
$435.00
|
| Rate for Payer: Cash Price |
$435.00
|
| Rate for Payer: Cigna Commercial |
$907.38
|
| Rate for Payer: Healthspan PPO |
$565.43
|
| Rate for Payer: Humana Medicaid |
$376.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$665.55
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$383.57
|
| Rate for Payer: Molina Healthcare Passport |
$376.05
|
| Rate for Payer: Multiplan PHCS |
$522.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$609.00
|
| Rate for Payer: UHCCP Medicaid |
$304.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$379.81
|
|
|
EXC FACE TUM DEEP < 2 CM(T
|
Facility
|
OP
|
$4,858.00
|
|
|
Service Code
|
HCPCS 21013
|
| Hospital Charge Code |
761T0364
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$631.54 |
| Max. Negotiated Rate |
$4,663.68 |
| Rate for Payer: Aetna Commercial |
$3,740.66
|
| Rate for Payer: Anthem Medicaid |
$1,670.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,789.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$2,429.00
|
| Rate for Payer: Cash Price |
$2,429.00
|
| Rate for Payer: Cigna Commercial |
$4,032.14
|
| Rate for Payer: First Health Commercial |
$4,615.10
|
| Rate for Payer: Humana Commercial |
$4,129.30
|
| Rate for Payer: Humana KY Medicaid |
$1,670.67
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,687.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,983.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,585.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,704.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,275.04
|
| Rate for Payer: Ohio Health Group HMO |
$3,643.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$971.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$631.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,505.98
|
| Rate for Payer: PHCS Commercial |
$4,663.68
|
| Rate for Payer: United Healthcare All Payer |
$4,275.04
|
|
|
EXC FACE TUM DEEP < 2 CM(T
|
Facility
|
IP
|
$4,858.00
|
|
|
Service Code
|
HCPCS 21013
|
| Hospital Charge Code |
761T0364
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$631.54 |
| Max. Negotiated Rate |
$4,663.68 |
| Rate for Payer: Aetna Commercial |
$3,740.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,789.24
|
| Rate for Payer: Cash Price |
$2,429.00
|
| Rate for Payer: Cigna Commercial |
$4,032.14
|
| Rate for Payer: First Health Commercial |
$4,615.10
|
| Rate for Payer: Humana Commercial |
$4,129.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,983.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,585.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,457.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,275.04
|
| Rate for Payer: Ohio Health Group HMO |
$3,643.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$971.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$631.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,505.98
|
| Rate for Payer: PHCS Commercial |
$4,663.68
|
| Rate for Payer: United Healthcare All Payer |
$4,275.04
|
|
|
EXC FACE TUM DEEP 2 CM/>(T
|
Facility
|
IP
|
$5,512.50
|
|
|
Service Code
|
HCPCS 21014
|
| Hospital Charge Code |
761T0365
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$716.62 |
| Max. Negotiated Rate |
$5,292.00 |
| Rate for Payer: Aetna Commercial |
$4,244.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,299.75
|
| Rate for Payer: Cash Price |
$2,756.25
|
| Rate for Payer: Cigna Commercial |
$4,575.38
|
| Rate for Payer: First Health Commercial |
$5,236.88
|
| Rate for Payer: Humana Commercial |
$4,685.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,520.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,068.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,653.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,851.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,134.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,102.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$716.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,708.88
|
| Rate for Payer: PHCS Commercial |
$5,292.00
|
| Rate for Payer: United Healthcare All Payer |
$4,851.00
|
|
|
EXC FACE TUM DEEP 2 CM/>(T
|
Facility
|
OP
|
$5,512.50
|
|
|
Service Code
|
HCPCS 21014
|
| Hospital Charge Code |
761T0365
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$716.62 |
| Max. Negotiated Rate |
$5,292.00 |
| Rate for Payer: Aetna Commercial |
$4,244.62
|
| Rate for Payer: Anthem Medicaid |
$1,895.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,299.75
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,440.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,317.21
|
| Rate for Payer: Cash Price |
$2,756.25
|
| Rate for Payer: Cash Price |
$2,756.25
|
| Rate for Payer: Cigna Commercial |
$4,575.38
|
| Rate for Payer: First Health Commercial |
$5,236.88
|
| Rate for Payer: Humana Commercial |
$4,685.62
|
| Rate for Payer: Humana KY Medicaid |
$1,895.75
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$1,915.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,520.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,068.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,933.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,851.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,134.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,102.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$716.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,708.88
|
| Rate for Payer: PHCS Commercial |
$5,292.00
|
| Rate for Payer: United Healthcare All Payer |
$4,851.00
|
|
|
EXC FOOT/TOE TUM DEEP <1.5CM
|
Professional
|
Both
|
$483.14
|
|
|
Service Code
|
HCPCS 28045
|
| Hospital Charge Code |
761P2639
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$175.46 |
| Max. Negotiated Rate |
$605.16 |
| Rate for Payer: Aetna Commercial |
$497.90
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$175.46
|
| Rate for Payer: Anthem Medicaid |
$249.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$483.14
|
| Rate for Payer: Cash Price |
$241.57
|
| Rate for Payer: Cash Price |
$241.57
|
| Rate for Payer: Cigna Commercial |
$546.71
|
| Rate for Payer: Healthspan PPO |
$605.16
|
| Rate for Payer: Humana Medicaid |
$249.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$435.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$254.05
|
| Rate for Payer: Molina Healthcare Passport |
$249.07
|
| Rate for Payer: Multiplan PHCS |
$289.88
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$338.20
|
| Rate for Payer: UHCCP Medicaid |
$184.23
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$251.56
|
|
|
EXC FOOT/TOE TUM DEP 1.5CM/>
|
Professional
|
Both
|
$655.00
|
|
|
Service Code
|
HCPCS 28041
|
| Hospital Charge Code |
761P2605
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$229.25 |
| Max. Negotiated Rate |
$785.96 |
| Rate for Payer: Aetna Commercial |
$683.92
|
| Rate for Payer: Anthem Medicaid |
$328.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$655.00
|
| Rate for Payer: Cash Price |
$327.50
|
| Rate for Payer: Cash Price |
$327.50
|
| Rate for Payer: Cigna Commercial |
$785.96
|
| Rate for Payer: Healthspan PPO |
$487.37
|
| Rate for Payer: Humana Medicaid |
$328.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$555.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$334.85
|
| Rate for Payer: Molina Healthcare Passport |
$328.28
|
| Rate for Payer: Multiplan PHCS |
$393.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$458.50
|
| Rate for Payer: UHCCP Medicaid |
$229.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$331.56
|
|
|
EXC FOOT/TOE TUM DEP 1.5CM/>
|
Professional
|
Both
|
$655.00
|
|
|
Service Code
|
HCPCS 28041
|
| Hospital Charge Code |
76102605
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$229.25 |
| Max. Negotiated Rate |
$785.96 |
| Rate for Payer: Aetna Commercial |
$683.92
|
| Rate for Payer: Anthem Medicaid |
$328.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$655.00
|
| Rate for Payer: Cash Price |
$327.50
|
| Rate for Payer: Cash Price |
$327.50
|
| Rate for Payer: Cigna Commercial |
$785.96
|
| Rate for Payer: Healthspan PPO |
$487.37
|
| Rate for Payer: Humana Medicaid |
$328.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$555.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$334.85
|
| Rate for Payer: Molina Healthcare Passport |
$328.28
|
| Rate for Payer: Multiplan PHCS |
$393.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$458.50
|
| Rate for Payer: UHCCP Medicaid |
$229.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$331.56
|
|
|
EXC FOOT/TOE TUM DEP 1.5CM/>
|
Facility
|
OP
|
$655.00
|
|
|
Service Code
|
HCPCS 28041
|
| Hospital Charge Code |
76102605
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$85.15 |
| Max. Negotiated Rate |
$3,440.07 |
| Rate for Payer: Aetna Commercial |
$504.35
|
| Rate for Payer: Anthem Medicaid |
$225.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$510.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,440.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,317.21
|
| Rate for Payer: Cash Price |
$327.50
|
| Rate for Payer: Cash Price |
$327.50
|
| Rate for Payer: Cigna Commercial |
$543.65
|
| Rate for Payer: First Health Commercial |
$622.25
|
| Rate for Payer: Humana Commercial |
$556.75
|
| Rate for Payer: Humana KY Medicaid |
$225.25
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$227.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$537.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$483.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$229.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$576.40
|
| Rate for Payer: Ohio Health Group HMO |
$491.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$131.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$203.05
|
| Rate for Payer: PHCS Commercial |
$628.80
|
| Rate for Payer: United Healthcare All Payer |
$576.40
|
|
|
EXC FOOT/TOE TUM DEP 1.5CM/>
|
Facility
|
IP
|
$655.00
|
|
|
Service Code
|
HCPCS 28041
|
| Hospital Charge Code |
76102605
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$85.15 |
| Max. Negotiated Rate |
$628.80 |
| Rate for Payer: Aetna Commercial |
$504.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$510.90
|
| Rate for Payer: Cash Price |
$327.50
|
| Rate for Payer: Cigna Commercial |
$543.65
|
| Rate for Payer: First Health Commercial |
$622.25
|
| Rate for Payer: Humana Commercial |
$556.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$537.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$483.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$196.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$576.40
|
| Rate for Payer: Ohio Health Group HMO |
$491.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$131.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$203.05
|
| Rate for Payer: PHCS Commercial |
$628.80
|
| Rate for Payer: United Healthcare All Payer |
$576.40
|
|
