|
FRENECTOMY(P
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 41115
|
| Hospital Charge Code |
761P1658
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$101.46 |
| Max. Negotiated Rate |
$278.38 |
| Rate for Payer: Aetna Commercial |
$211.29
|
| Rate for Payer: Ambetter Exchange |
$136.39
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$102.24
|
| Rate for Payer: Anthem Medicaid |
$101.46
|
| Rate for Payer: Buckeye Individual/Medicaid |
$136.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$136.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$163.67
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$209.73
|
| Rate for Payer: Healthspan PPO |
$278.38
|
| Rate for Payer: Humana Medicaid |
$101.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$190.31
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$136.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$136.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.49
|
| Rate for Payer: Molina Healthcare Passport |
$101.46
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$177.31
|
| Rate for Payer: UHCCP Medicaid |
$107.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.47
|
| Rate for Payer: Wellcare Medicare Advantage |
$136.39
|
|
|
FRENECTOMY(T
|
Facility
|
IP
|
$2,670.00
|
|
|
Service Code
|
HCPCS 41115
|
| Hospital Charge Code |
761T1658
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$801.00 |
| Max. Negotiated Rate |
$2,563.20 |
| Rate for Payer: Aetna Commercial |
$2,055.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,082.60
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cigna Commercial |
$2,216.10
|
| Rate for Payer: First Health Commercial |
$2,536.50
|
| Rate for Payer: Humana Commercial |
$2,269.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,189.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,970.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$801.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,349.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,002.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,136.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,322.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,842.30
|
| Rate for Payer: PHCS Commercial |
$2,563.20
|
| Rate for Payer: United Healthcare All Payer |
$2,349.60
|
|
|
FRENECTOMY(T
|
Facility
|
OP
|
$2,670.00
|
|
|
Service Code
|
HCPCS 41115
|
| Hospital Charge Code |
761T1658
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$918.21 |
| Max. Negotiated Rate |
$2,563.20 |
| Rate for Payer: Aetna Commercial |
$2,055.90
|
| Rate for Payer: Anthem Medicaid |
$918.21
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,368.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,082.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,916.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,847.70
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cash Price |
$1,335.00
|
| Rate for Payer: Cigna Commercial |
$2,216.10
|
| Rate for Payer: First Health Commercial |
$2,536.50
|
| Rate for Payer: Humana Commercial |
$2,269.50
|
| Rate for Payer: Humana KY Medicaid |
$918.21
|
| Rate for Payer: Humana Medicare Advantage |
$1,368.67
|
| Rate for Payer: Kentucky WC Medicaid |
$927.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,189.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,970.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,642.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$936.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,349.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,002.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,136.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,322.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,842.30
|
| Rate for Payer: PHCS Commercial |
$2,563.20
|
| Rate for Payer: United Healthcare All Payer |
$2,349.60
|
|
|
FRESH FROZEN PLASMA 24H EA UN
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
HCPCS P9059
|
| Hospital Charge Code |
38000019
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$49.52 |
| Max. Negotiated Rate |
$138.24 |
| Rate for Payer: Aetna Commercial |
$110.88
|
| Rate for Payer: Anthem Medicaid |
$49.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$65.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$91.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$88.68
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$119.52
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: Humana Commercial |
$122.40
|
| Rate for Payer: Humana KY Medicaid |
$49.52
|
| Rate for Payer: Humana Medicare Advantage |
$65.69
|
| Rate for Payer: Kentucky WC Medicaid |
$50.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.72
|
| Rate for Payer: Ohio Health Group HMO |
$108.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$115.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$125.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.36
|
| Rate for Payer: PHCS Commercial |
$138.24
|
| Rate for Payer: United Healthcare All Payer |
$126.72
|
|
|
FRESH FROZEN PLASMA 24H EA UN
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
HCPCS P9059
|
| Hospital Charge Code |
38000019
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$43.20 |
| Max. Negotiated Rate |
$138.24 |
| Rate for Payer: Aetna Commercial |
$110.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.32
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$119.52
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: Humana Commercial |
$122.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.72
|
| Rate for Payer: Ohio Health Group HMO |
$108.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$115.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$125.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.36
|
| Rate for Payer: PHCS Commercial |
$138.24
|
| Rate for Payer: United Healthcare All Payer |
$126.72
|
|
|
FRESH FROZEN PLASMA EA UNIT
|
Facility
|
IP
|
$159.00
|
|
|
Service Code
|
HCPCS P9017
|
| Hospital Charge Code |
38000009
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$47.70 |
| Max. Negotiated Rate |
$152.64 |
| Rate for Payer: Aetna Commercial |
$122.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$124.02
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cigna Commercial |
$131.97
|
| Rate for Payer: First Health Commercial |
$151.05
|
| Rate for Payer: Humana Commercial |
$135.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$130.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$117.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$139.92
|
| Rate for Payer: Ohio Health Group HMO |
$119.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$127.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$138.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$109.71
|
| Rate for Payer: PHCS Commercial |
$152.64
|
| Rate for Payer: United Healthcare All Payer |
$139.92
|
|
|
FRESH FROZEN PLASMA EA UNIT
|
Facility
|
OP
|
$159.00
|
|
|
Service Code
|
HCPCS P9017
|
| Hospital Charge Code |
38000009
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$54.68 |
| Max. Negotiated Rate |
$152.64 |
| Rate for Payer: Aetna Commercial |
$122.43
|
| Rate for Payer: Anthem Medicaid |
$54.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$77.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$124.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$109.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$105.14
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cigna Commercial |
$131.97
|
| Rate for Payer: First Health Commercial |
$151.05
|
| Rate for Payer: Humana Commercial |
$135.15
|
| Rate for Payer: Humana KY Medicaid |
$54.68
|
| Rate for Payer: Humana Medicare Advantage |
$77.88
|
| Rate for Payer: Kentucky WC Medicaid |
$55.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$130.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$117.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$93.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$55.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$139.92
|
| Rate for Payer: Ohio Health Group HMO |
$119.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$127.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$138.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$109.71
|
| Rate for Payer: PHCS Commercial |
$152.64
|
| Rate for Payer: United Healthcare All Payer |
$139.92
|
|
|
FSH FOLLICLE STIM HORMONE
|
Facility
|
IP
|
$176.00
|
|
|
Service Code
|
HCPCS 83001
|
| Hospital Charge Code |
30000353
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$52.80 |
| Max. Negotiated Rate |
$168.96 |
| Rate for Payer: Aetna Commercial |
$135.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.33
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Cigna Commercial |
$146.08
|
| Rate for Payer: First Health Commercial |
$167.20
|
| Rate for Payer: Humana Commercial |
$149.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$144.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$129.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$52.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$154.88
|
| Rate for Payer: Ohio Health Group HMO |
$132.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$140.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$153.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$121.44
|
| Rate for Payer: PHCS Commercial |
$168.96
|
| Rate for Payer: United Healthcare All Payer |
$154.88
|
|
|
FSH FOLLICLE STIM HORMONE
|
Facility
|
OP
|
$176.00
|
|
|
Service Code
|
HCPCS 83001
|
| Hospital Charge Code |
30000353
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.58 |
| Max. Negotiated Rate |
$168.96 |
| Rate for Payer: Aetna Commercial |
$135.52
|
| Rate for Payer: Anthem Medicaid |
$18.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$18.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.33
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$26.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$18.58
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Cigna Commercial |
$146.08
|
| Rate for Payer: First Health Commercial |
$167.20
|
| Rate for Payer: Humana Commercial |
$149.60
|
| Rate for Payer: Humana KY Medicaid |
$18.58
|
| Rate for Payer: Humana Medicare Advantage |
$18.58
|
| Rate for Payer: Kentucky WC Medicaid |
$18.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$144.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$129.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$18.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$154.88
|
| Rate for Payer: Ohio Health Group HMO |
$132.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$140.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$153.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$121.44
|
| Rate for Payer: PHCS Commercial |
$168.96
|
| Rate for Payer: United Healthcare All Payer |
$154.88
|
|
|
FSH FOLLICLE STIM HORMONE
|
Professional
|
Both
|
$176.00
|
|
|
Service Code
|
HCPCS 83001
|
| Hospital Charge Code |
30000353
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.15 |
| Max. Negotiated Rate |
$105.60 |
| Rate for Payer: Aetna Commercial |
$31.84
|
| Rate for Payer: Ambetter Exchange |
$18.58
|
| Rate for Payer: Buckeye Individual/Medicaid |
$18.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$18.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$22.30
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Cash Price |
$88.00
|
| Rate for Payer: Cigna Commercial |
$16.53
|
| Rate for Payer: Healthspan PPO |
$19.48
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$18.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.58
|
| Rate for Payer: Multiplan PHCS |
$105.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$24.15
|
| Rate for Payer: UHCCP Medicaid |
$61.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$11.15
|
| Rate for Payer: Wellcare Medicare Advantage |
$18.58
|
|
|
FSP FIBRIN SPL PROD SEMI Q
|
Facility
|
OP
|
$136.00
|
|
|
Service Code
|
HCPCS 85362
|
| Hospital Charge Code |
30000599
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.89 |
| Max. Negotiated Rate |
$130.56 |
| Rate for Payer: Aetna Commercial |
$104.72
|
| Rate for Payer: Anthem Medicaid |
$6.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$109.21
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$6.89
|
| Rate for Payer: Cash Price |
$68.00
|
| Rate for Payer: Cash Price |
$68.00
|
| Rate for Payer: Cigna Commercial |
$112.88
|
| Rate for Payer: First Health Commercial |
$129.20
|
| Rate for Payer: Humana Commercial |
$115.60
|
| Rate for Payer: Humana KY Medicaid |
$6.89
|
| Rate for Payer: Humana Medicare Advantage |
$6.89
|
| Rate for Payer: Kentucky WC Medicaid |
$6.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$111.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$100.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$119.68
|
| Rate for Payer: Ohio Health Group HMO |
$102.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$118.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$93.84
|
| Rate for Payer: PHCS Commercial |
$130.56
|
| Rate for Payer: United Healthcare All Payer |
$119.68
|
|
|
FSP FIBRIN SPL PROD SEMI Q
|
Facility
|
IP
|
$136.00
|
|
|
Service Code
|
HCPCS 85362
|
| Hospital Charge Code |
30000599
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$40.80 |
| Max. Negotiated Rate |
$130.56 |
| Rate for Payer: Aetna Commercial |
$104.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$109.21
|
| Rate for Payer: Cash Price |
$68.00
|
| Rate for Payer: Cigna Commercial |
$112.88
|
| Rate for Payer: First Health Commercial |
$129.20
|
| Rate for Payer: Humana Commercial |
$115.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$111.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$100.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$119.68
|
| Rate for Payer: Ohio Health Group HMO |
$102.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$118.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$93.84
|
| Rate for Payer: PHCS Commercial |
$130.56
|
| Rate for Payer: United Healthcare All Payer |
$119.68
|
|
|
FULL LEG LASER HAIR REMOVAL
|
Professional
|
Both
|
$650.00
|
|
| Hospital Charge Code |
22200189
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$455.00 |
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Multiplan PHCS |
$390.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$455.00
|
| Rate for Payer: UHCCP Medicaid |
$227.50
|
|
|
Full Leg Lsr Hair Rem-PP#1 50%
|
Professional
|
Both
|
$829.00
|
|
| Hospital Charge Code |
22200353
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$290.15 |
| Max. Negotiated Rate |
$580.30 |
| Rate for Payer: Cash Price |
$414.50
|
| Rate for Payer: Multiplan PHCS |
$497.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$580.30
|
| Rate for Payer: UHCCP Medicaid |
$290.15
|
|
|
Full LegLsr HairRem-PP#2/3 25%
|
Professional
|
Both
|
$414.00
|
|
| Hospital Charge Code |
22200469
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$144.90 |
| Max. Negotiated Rate |
$289.80 |
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Multiplan PHCS |
$248.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$289.80
|
| Rate for Payer: UHCCP Medicaid |
$144.90
|
|
|
FULL MASTOPEXY WITH BIL
|
Professional
|
Both
|
$2,240.00
|
|
| Hospital Charge Code |
22200366
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$784.00 |
| Max. Negotiated Rate |
$1,568.00 |
| Rate for Payer: Cash Price |
$1,120.00
|
| Rate for Payer: Multiplan PHCS |
$1,344.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,568.00
|
| Rate for Payer: UHCCP Medicaid |
$784.00
|
|
|
FULL MASTOPEXY WITH BIL - 80
|
Professional
|
Both
|
$1,120.00
|
|
| Hospital Charge Code |
22200687
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$392.00 |
| Max. Negotiated Rate |
$784.00 |
| Rate for Payer: Cash Price |
$560.00
|
| Rate for Payer: Multiplan PHCS |
$672.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$784.00
|
| Rate for Payer: UHCCP Medicaid |
$392.00
|
|
|
FULL THICKNESS GRAFT
|
Facility
|
IP
|
$5,980.33
|
|
|
Service Code
|
HCPCS 15260
|
| Hospital Charge Code |
76100188
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,794.10 |
| Max. Negotiated Rate |
$5,741.12 |
| Rate for Payer: Aetna Commercial |
$4,604.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,664.66
|
| Rate for Payer: Cash Price |
$2,990.16
|
| Rate for Payer: Cigna Commercial |
$4,963.67
|
| Rate for Payer: First Health Commercial |
$5,681.31
|
| Rate for Payer: Humana Commercial |
$5,083.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,903.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,413.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,794.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,262.69
|
| Rate for Payer: Ohio Health Group HMO |
$4,485.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,784.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,202.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,126.43
|
| Rate for Payer: PHCS Commercial |
$5,741.12
|
| Rate for Payer: United Healthcare All Payer |
$5,262.69
|
|
|
FULL THICKNESS GRAFT
|
Facility
|
OP
|
$5,980.33
|
|
|
Service Code
|
HCPCS 15260
|
| Hospital Charge Code |
76100188
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,690.17 |
| Max. Negotiated Rate |
$5,741.12 |
| Rate for Payer: Aetna Commercial |
$4,604.85
|
| Rate for Payer: Anthem Medicaid |
$2,056.64
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,664.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Cash Price |
$2,990.16
|
| Rate for Payer: Cash Price |
$2,990.16
|
| Rate for Payer: Cigna Commercial |
$4,963.67
|
| Rate for Payer: First Health Commercial |
$5,681.31
|
| Rate for Payer: Humana Commercial |
$5,083.28
|
| Rate for Payer: Humana KY Medicaid |
$2,056.64
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$2,077.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,903.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,413.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,097.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,262.69
|
| Rate for Payer: Ohio Health Group HMO |
$4,485.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,784.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,202.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,126.43
|
| Rate for Payer: PHCS Commercial |
$5,741.12
|
| Rate for Payer: United Healthcare All Payer |
$5,262.69
|
|
|
FULL THICKNESS GRAFT
|
Professional
|
Both
|
$5,980.33
|
|
|
Service Code
|
HCPCS 15260
|
| Hospital Charge Code |
76100188
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$426.52 |
| Max. Negotiated Rate |
$3,588.20 |
| Rate for Payer: Aetna Commercial |
$1,207.11
|
| Rate for Payer: Ambetter Exchange |
$792.74
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$426.52
|
| Rate for Payer: Anthem Medicaid |
$504.67
|
| Rate for Payer: Buckeye Individual/Medicaid |
$792.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$792.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$951.29
|
| Rate for Payer: Cash Price |
$2,990.16
|
| Rate for Payer: Cash Price |
$2,990.16
|
| Rate for Payer: Cigna Commercial |
$1,128.38
|
| Rate for Payer: Healthspan PPO |
$1,097.43
|
| Rate for Payer: Humana Medicaid |
$504.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,080.89
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$792.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$792.74
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$514.76
|
| Rate for Payer: Molina Healthcare Passport |
$504.67
|
| Rate for Payer: Multiplan PHCS |
$3,588.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,030.56
|
| Rate for Payer: UHCCP Medicaid |
$447.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$509.72
|
| Rate for Payer: Wellcare Medicare Advantage |
$792.74
|
|
|
FULL THICKNESS GRAFT - CLOSU(P
|
Professional
|
Both
|
$1,025.00
|
|
|
Service Code
|
HCPCS 15220
|
| Hospital Charge Code |
761P0184
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$308.52 |
| Max. Negotiated Rate |
$882.69 |
| Rate for Payer: Aetna Commercial |
$882.69
|
| Rate for Payer: Ambetter Exchange |
$571.51
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$308.52
|
| Rate for Payer: Anthem Medicaid |
$368.20
|
| Rate for Payer: Buckeye Individual/Medicaid |
$571.51
|
| Rate for Payer: Buckeye Medicare Advantage |
$571.51
|
| Rate for Payer: CareSource Just4Me Medicare |
$685.81
|
| Rate for Payer: Cash Price |
$512.50
|
| Rate for Payer: Cash Price |
$512.50
|
| Rate for Payer: Cigna Commercial |
$838.65
|
| Rate for Payer: Healthspan PPO |
$849.59
|
| Rate for Payer: Humana Medicaid |
$368.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$773.65
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$571.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.51
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$375.56
|
| Rate for Payer: Molina Healthcare Passport |
$368.20
|
| Rate for Payer: Multiplan PHCS |
$615.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$742.96
|
| Rate for Payer: UHCCP Medicaid |
$323.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$371.88
|
| Rate for Payer: Wellcare Medicare Advantage |
$571.51
|
|
|
FULL THICKNESS GRAFT - CLOSUR
|
Professional
|
Both
|
$5,110.65
|
|
|
Service Code
|
HCPCS 15220
|
| Hospital Charge Code |
76100184
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$308.52 |
| Max. Negotiated Rate |
$3,066.39 |
| Rate for Payer: Aetna Commercial |
$882.69
|
| Rate for Payer: Ambetter Exchange |
$571.51
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$308.52
|
| Rate for Payer: Anthem Medicaid |
$368.20
|
| Rate for Payer: Buckeye Individual/Medicaid |
$571.51
|
| Rate for Payer: Buckeye Medicare Advantage |
$571.51
|
| Rate for Payer: CareSource Just4Me Medicare |
$685.81
|
| Rate for Payer: Cash Price |
$2,555.32
|
| Rate for Payer: Cash Price |
$2,555.32
|
| Rate for Payer: Cigna Commercial |
$838.65
|
| Rate for Payer: Healthspan PPO |
$849.59
|
| Rate for Payer: Humana Medicaid |
$368.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$773.65
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$571.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.51
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$375.56
|
| Rate for Payer: Molina Healthcare Passport |
$368.20
|
| Rate for Payer: Multiplan PHCS |
$3,066.39
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$742.96
|
| Rate for Payer: UHCCP Medicaid |
$323.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$371.88
|
| Rate for Payer: Wellcare Medicare Advantage |
$571.51
|
|
|
FULL THICKNESS GRAFT - CLOSUR
|
Facility
|
IP
|
$5,110.65
|
|
|
Service Code
|
HCPCS 15220
|
| Hospital Charge Code |
76100184
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,533.19 |
| Max. Negotiated Rate |
$4,906.22 |
| Rate for Payer: Aetna Commercial |
$3,935.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,986.31
|
| Rate for Payer: Cash Price |
$2,555.32
|
| Rate for Payer: Cigna Commercial |
$4,241.84
|
| Rate for Payer: First Health Commercial |
$4,855.12
|
| Rate for Payer: Humana Commercial |
$4,344.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,190.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,771.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,533.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,497.37
|
| Rate for Payer: Ohio Health Group HMO |
$3,832.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,088.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,446.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,526.35
|
| Rate for Payer: PHCS Commercial |
$4,906.22
|
| Rate for Payer: United Healthcare All Payer |
$4,497.37
|
|
|
FULL THICKNESS GRAFT - CLOSUR
|
Facility
|
OP
|
$5,110.65
|
|
|
Service Code
|
HCPCS 15220
|
| Hospital Charge Code |
76100184
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,690.17 |
| Max. Negotiated Rate |
$4,906.22 |
| Rate for Payer: Aetna Commercial |
$3,935.20
|
| Rate for Payer: Anthem Medicaid |
$1,757.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,986.31
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Cash Price |
$2,555.32
|
| Rate for Payer: Cash Price |
$2,555.32
|
| Rate for Payer: Cigna Commercial |
$4,241.84
|
| Rate for Payer: First Health Commercial |
$4,855.12
|
| Rate for Payer: Humana Commercial |
$4,344.05
|
| Rate for Payer: Humana KY Medicaid |
$1,757.55
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,775.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,190.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,771.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,792.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,497.37
|
| Rate for Payer: Ohio Health Group HMO |
$3,832.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,088.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,446.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,526.35
|
| Rate for Payer: PHCS Commercial |
$4,906.22
|
| Rate for Payer: United Healthcare All Payer |
$4,497.37
|
|
|
FULL THICKNESS GRAFT - CLOSU(T
|
Facility
|
OP
|
$4,085.65
|
|
|
Service Code
|
HCPCS 15220
|
| Hospital Charge Code |
761T0184
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,405.06 |
| Max. Negotiated Rate |
$3,922.22 |
| Rate for Payer: Aetna Commercial |
$3,145.95
|
| Rate for Payer: Anthem Medicaid |
$1,405.06
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,186.81
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Cash Price |
$2,042.83
|
| Rate for Payer: Cash Price |
$2,042.83
|
| Rate for Payer: Cigna Commercial |
$3,391.09
|
| Rate for Payer: First Health Commercial |
$3,881.37
|
| Rate for Payer: Humana Commercial |
$3,472.80
|
| Rate for Payer: Humana KY Medicaid |
$1,405.06
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,419.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,350.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,015.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,433.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,595.37
|
| Rate for Payer: Ohio Health Group HMO |
$3,064.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,268.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,554.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,819.10
|
| Rate for Payer: PHCS Commercial |
$3,922.22
|
| Rate for Payer: United Healthcare All Payer |
$3,595.37
|
|
