|
SKIN BRACHY LESION OR>2CM
|
Facility
|
OP
|
$4,937.00
|
|
|
Service Code
|
HCPCS 77768
|
| Hospital Charge Code |
33300047
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$232.40 |
| Max. Negotiated Rate |
$4,739.52 |
| Rate for Payer: Aetna Commercial |
$3,801.49
|
| Rate for Payer: Anthem Medicaid |
$1,697.83
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$232.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,850.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$325.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$313.74
|
| Rate for Payer: Cash Price |
$2,468.50
|
| Rate for Payer: Cash Price |
$2,468.50
|
| Rate for Payer: Cigna Commercial |
$4,097.71
|
| Rate for Payer: First Health Commercial |
$4,690.15
|
| Rate for Payer: Humana Commercial |
$4,196.45
|
| Rate for Payer: Humana KY Medicaid |
$1,697.83
|
| Rate for Payer: Humana Medicare Advantage |
$232.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,715.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,048.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,643.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$278.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,731.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,344.56
|
| Rate for Payer: Ohio Health Group HMO |
$3,702.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$987.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$641.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,530.47
|
| Rate for Payer: PHCS Commercial |
$4,739.52
|
| Rate for Payer: United Healthcare All Payer |
$4,344.56
|
|
|
SKIN BRACHY LESION OR>2CM
|
Facility
|
OP
|
$4,677.00
|
|
|
Service Code
|
HCPCS 77768
|
| Hospital Charge Code |
33300031
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$232.40 |
| Max. Negotiated Rate |
$4,489.92 |
| Rate for Payer: Aetna Commercial |
$3,601.29
|
| Rate for Payer: Anthem Medicaid |
$1,608.42
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$232.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,648.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$325.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$313.74
|
| Rate for Payer: Cash Price |
$2,338.50
|
| Rate for Payer: Cash Price |
$2,338.50
|
| Rate for Payer: Cigna Commercial |
$3,881.91
|
| Rate for Payer: First Health Commercial |
$4,443.15
|
| Rate for Payer: Humana Commercial |
$3,975.45
|
| Rate for Payer: Humana KY Medicaid |
$1,608.42
|
| Rate for Payer: Humana Medicare Advantage |
$232.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,624.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,835.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,451.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$278.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,640.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,115.76
|
| Rate for Payer: Ohio Health Group HMO |
$3,507.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$935.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$608.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,449.87
|
| Rate for Payer: PHCS Commercial |
$4,489.92
|
| Rate for Payer: United Healthcare All Payer |
$4,115.76
|
|
|
SKIN BRACHY LESION OR>2CM
|
Professional
|
Both
|
$260.00
|
|
|
Service Code
|
HCPCS 77768
|
| Hospital Charge Code |
333P0047
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$91.00 |
| Max. Negotiated Rate |
$552.79 |
| Rate for Payer: Anthem Medicaid |
$261.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$260.00
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Cigna Commercial |
$552.79
|
| Rate for Payer: Humana Medicaid |
$261.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$91.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$267.22
|
| Rate for Payer: Molina Healthcare Passport |
$261.98
|
| Rate for Payer: Multiplan PHCS |
$156.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$182.00
|
| Rate for Payer: UHCCP Medicaid |
$91.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$264.60
|
|
|
SKIN BRACHY LESION OR>2CM
|
Facility
|
IP
|
$4,937.00
|
|
|
Service Code
|
HCPCS 77768
|
| Hospital Charge Code |
33300047
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$641.81 |
| Max. Negotiated Rate |
$4,739.52 |
| Rate for Payer: Aetna Commercial |
$3,801.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,850.86
|
| Rate for Payer: Cash Price |
$2,468.50
|
| Rate for Payer: Cigna Commercial |
$4,097.71
|
| Rate for Payer: First Health Commercial |
$4,690.15
|
| Rate for Payer: Humana Commercial |
$4,196.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,048.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,643.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,481.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,344.56
|
| Rate for Payer: Ohio Health Group HMO |
$3,702.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$987.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$641.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,530.47
|
| Rate for Payer: PHCS Commercial |
$4,739.52
|
| Rate for Payer: United Healthcare All Payer |
$4,344.56
|
|
|
SKIN BRACHY LESION OR>2CM
|
Facility
|
OP
|
$4,677.00
|
|
|
Service Code
|
HCPCS 77768
|
| Hospital Charge Code |
333T0047
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$232.40 |
| Max. Negotiated Rate |
$4,489.92 |
| Rate for Payer: Aetna Commercial |
$3,601.29
|
| Rate for Payer: Anthem Medicaid |
$1,608.42
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$232.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,648.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$325.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$313.74
|
| Rate for Payer: Cash Price |
$2,338.50
|
| Rate for Payer: Cash Price |
$2,338.50
|
| Rate for Payer: Cigna Commercial |
$3,881.91
|
| Rate for Payer: First Health Commercial |
$4,443.15
|
| Rate for Payer: Humana Commercial |
$3,975.45
|
| Rate for Payer: Humana KY Medicaid |
$1,608.42
|
| Rate for Payer: Humana Medicare Advantage |
$232.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,624.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,835.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,451.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$278.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,640.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,115.76
|
| Rate for Payer: Ohio Health Group HMO |
$3,507.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$935.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$608.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,449.87
|
| Rate for Payer: PHCS Commercial |
$4,489.92
|
| Rate for Payer: United Healthcare All Payer |
$4,115.76
|
|
|
SKIN BRACHY LESION OR>2CM
|
Facility
|
IP
|
$4,677.00
|
|
|
Service Code
|
HCPCS 77768
|
| Hospital Charge Code |
333T0047
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$608.01 |
| Max. Negotiated Rate |
$4,489.92 |
| Rate for Payer: Aetna Commercial |
$3,601.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,648.06
|
| Rate for Payer: Cash Price |
$2,338.50
|
| Rate for Payer: Cigna Commercial |
$3,881.91
|
| Rate for Payer: First Health Commercial |
$4,443.15
|
| Rate for Payer: Humana Commercial |
$3,975.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,835.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,451.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,403.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,115.76
|
| Rate for Payer: Ohio Health Group HMO |
$3,507.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$935.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$608.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,449.87
|
| Rate for Payer: PHCS Commercial |
$4,489.92
|
| Rate for Payer: United Healthcare All Payer |
$4,115.76
|
|
|
SKIN BRIGH PROG + TEXT KIT GBL
|
Professional
|
Both
|
$260.00
|
|
| Hospital Charge Code |
22200153
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$91.00 |
| Max. Negotiated Rate |
$260.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$260.00
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Multiplan PHCS |
$156.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$182.00
|
| Rate for Payer: UHCCP Medicaid |
$91.00
|
|
|
SKIN BRIGHTEN PROGRAM KIT GBL
|
Professional
|
Both
|
$180.00
|
|
| Hospital Charge Code |
22200152
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$180.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Multiplan PHCS |
$108.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$126.00
|
| Rate for Payer: UHCCP Medicaid |
$63.00
|
|
|
SKIN DEBRIDEMENT WITH CC
|
Facility
|
IP
|
$19,792.19
|
|
|
Service Code
|
MSDRG 571
|
| Min. Negotiated Rate |
$13,430.42 |
| Max. Negotiated Rate |
$19,792.19 |
| Rate for Payer: Anthem Medicaid |
$13,430.42
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$14,137.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$19,792.19
|
| Rate for Payer: CareSource Just4Me Medicare |
$19,085.33
|
| Rate for Payer: Humana KY Medicaid |
$13,430.42
|
| Rate for Payer: Humana Medicare Advantage |
$14,137.28
|
| Rate for Payer: Kentucky WC Medicaid |
$13,564.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16,964.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,699.02
|
|
|
SKIN DEBRIDEMENT WITH MCC
|
Facility
|
IP
|
$34,184.49
|
|
|
Service Code
|
MSDRG 570
|
| Min. Negotiated Rate |
$23,196.62 |
| Max. Negotiated Rate |
$34,184.49 |
| Rate for Payer: Anthem Medicaid |
$23,196.62
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$24,417.49
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$34,184.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$32,963.61
|
| Rate for Payer: Humana KY Medicaid |
$23,196.62
|
| Rate for Payer: Humana Medicare Advantage |
$24,417.49
|
| Rate for Payer: Kentucky WC Medicaid |
$23,428.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29,300.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$23,660.55
|
|
|
SKIN DEBRIDEMENT WITHOUT CC/MCC
|
Facility
|
IP
|
$13,331.28
|
|
|
Service Code
|
MSDRG 572
|
| Min. Negotiated Rate |
$9,046.22 |
| Max. Negotiated Rate |
$13,331.28 |
| Rate for Payer: Anthem Medicaid |
$9,046.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9,522.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13,331.28
|
| Rate for Payer: CareSource Just4Me Medicare |
$12,855.16
|
| Rate for Payer: Humana KY Medicaid |
$9,046.22
|
| Rate for Payer: Humana Medicare Advantage |
$9,522.34
|
| Rate for Payer: Kentucky WC Medicaid |
$9,136.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,426.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,227.15
|
|
|
SKIN FULL GRAFT ADD-ON
|
Facility
|
OP
|
$3,218.25
|
|
|
Service Code
|
HCPCS 15241
|
| Hospital Charge Code |
76100187
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$418.37 |
| Max. Negotiated Rate |
$3,089.52 |
| Rate for Payer: Aetna Commercial |
$2,478.05
|
| Rate for Payer: Anthem Medicaid |
$1,106.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,510.24
|
| Rate for Payer: Cash Price |
$1,609.12
|
| Rate for Payer: Cigna Commercial |
$2,671.15
|
| Rate for Payer: First Health Commercial |
$3,057.34
|
| Rate for Payer: Humana Commercial |
$2,735.51
|
| Rate for Payer: Humana KY Medicaid |
$1,106.76
|
| Rate for Payer: Kentucky WC Medicaid |
$1,118.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,638.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,375.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$965.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,128.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,832.06
|
| Rate for Payer: Ohio Health Group HMO |
$2,413.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$643.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$418.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$997.66
|
| Rate for Payer: PHCS Commercial |
$3,089.52
|
| Rate for Payer: United Healthcare All Payer |
$2,832.06
|
|
|
SKIN FULL GRAFT ADD-ON
|
Facility
|
OP
|
$3,608.00
|
|
|
Service Code
|
HCPCS 15261
|
| Hospital Charge Code |
76100189
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$469.04 |
| Max. Negotiated Rate |
$3,463.68 |
| Rate for Payer: Aetna Commercial |
$2,778.16
|
| Rate for Payer: Anthem Medicaid |
$1,240.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,814.24
|
| Rate for Payer: Cash Price |
$1,804.00
|
| Rate for Payer: Cigna Commercial |
$2,994.64
|
| Rate for Payer: First Health Commercial |
$3,427.60
|
| Rate for Payer: Humana Commercial |
$3,066.80
|
| Rate for Payer: Humana KY Medicaid |
$1,240.79
|
| Rate for Payer: Kentucky WC Medicaid |
$1,253.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,958.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,662.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,082.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,265.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,175.04
|
| Rate for Payer: Ohio Health Group HMO |
$2,706.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$721.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$469.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,118.48
|
| Rate for Payer: PHCS Commercial |
$3,463.68
|
| Rate for Payer: United Healthcare All Payer |
$3,175.04
|
|
|
SKIN FULL GRAFT ADD-ON
|
Professional
|
Both
|
$3,324.17
|
|
|
Service Code
|
HCPCS 15221
|
| Hospital Charge Code |
76100185
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$49.33 |
| Max. Negotiated Rate |
$3,324.17 |
| Rate for Payer: Aetna Commercial |
$109.53
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$49.33
|
| Rate for Payer: Anthem Medicaid |
$89.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,324.17
|
| Rate for Payer: Cash Price |
$1,662.09
|
| Rate for Payer: Cash Price |
$1,662.09
|
| Rate for Payer: Cigna Commercial |
$102.57
|
| Rate for Payer: Healthspan PPO |
$153.05
|
| Rate for Payer: Humana Medicaid |
$89.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$92.19
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$91.51
|
| Rate for Payer: Molina Healthcare Passport |
$89.72
|
| Rate for Payer: Multiplan PHCS |
$1,994.50
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,326.92
|
| Rate for Payer: UHCCP Medicaid |
$51.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$90.62
|
|
|
SKIN FULL GRAFT ADD-ON
|
Facility
|
IP
|
$3,608.00
|
|
|
Service Code
|
HCPCS 15261
|
| Hospital Charge Code |
76100189
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$469.04 |
| Max. Negotiated Rate |
$3,463.68 |
| Rate for Payer: Aetna Commercial |
$2,778.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,814.24
|
| Rate for Payer: Cash Price |
$1,804.00
|
| Rate for Payer: Cigna Commercial |
$2,994.64
|
| Rate for Payer: First Health Commercial |
$3,427.60
|
| Rate for Payer: Humana Commercial |
$3,066.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,958.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,662.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,082.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,175.04
|
| Rate for Payer: Ohio Health Group HMO |
$2,706.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$721.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$469.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,118.48
|
| Rate for Payer: PHCS Commercial |
$3,463.68
|
| Rate for Payer: United Healthcare All Payer |
$3,175.04
|
|
|
SKIN FULL GRAFT ADD-ON
|
Professional
|
Both
|
$3,218.25
|
|
|
Service Code
|
HCPCS 15241
|
| Hospital Charge Code |
76100187
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$76.80 |
| Max. Negotiated Rate |
$3,218.25 |
| Rate for Payer: Aetna Commercial |
$170.31
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$76.80
|
| Rate for Payer: Anthem Medicaid |
$132.51
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,218.25
|
| Rate for Payer: Cash Price |
$1,609.12
|
| Rate for Payer: Cash Price |
$1,609.12
|
| Rate for Payer: Cigna Commercial |
$160.70
|
| Rate for Payer: Healthspan PPO |
$205.94
|
| Rate for Payer: Humana Medicaid |
$132.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$144.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$135.16
|
| Rate for Payer: Molina Healthcare Passport |
$132.51
|
| Rate for Payer: Multiplan PHCS |
$1,930.95
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,252.78
|
| Rate for Payer: UHCCP Medicaid |
$80.64
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$133.84
|
|
|
SKIN FULL GRAFT ADD-ON
|
Professional
|
Both
|
$3,608.00
|
|
|
Service Code
|
HCPCS 15261
|
| Hospital Charge Code |
76100189
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$107.31 |
| Max. Negotiated Rate |
$3,608.00 |
| Rate for Payer: Aetna Commercial |
$211.13
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$107.31
|
| Rate for Payer: Anthem Medicaid |
$156.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,608.00
|
| Rate for Payer: Cash Price |
$1,804.00
|
| Rate for Payer: Cash Price |
$1,804.00
|
| Rate for Payer: Cigna Commercial |
$204.47
|
| Rate for Payer: Healthspan PPO |
$238.57
|
| Rate for Payer: Humana Medicaid |
$156.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$181.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$159.59
|
| Rate for Payer: Molina Healthcare Passport |
$156.46
|
| Rate for Payer: Multiplan PHCS |
$2,164.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,525.60
|
| Rate for Payer: UHCCP Medicaid |
$112.68
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$158.02
|
|
|
SKIN FULL GRAFT ADD-ON
|
Facility
|
IP
|
$3,218.25
|
|
|
Service Code
|
HCPCS 15241
|
| Hospital Charge Code |
76100187
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$418.37 |
| Max. Negotiated Rate |
$3,089.52 |
| Rate for Payer: Aetna Commercial |
$2,478.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,510.24
|
| Rate for Payer: Cash Price |
$1,609.12
|
| Rate for Payer: Cigna Commercial |
$2,671.15
|
| Rate for Payer: First Health Commercial |
$3,057.34
|
| Rate for Payer: Humana Commercial |
$2,735.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,638.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,375.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$965.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,832.06
|
| Rate for Payer: Ohio Health Group HMO |
$2,413.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$643.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$418.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$997.66
|
| Rate for Payer: PHCS Commercial |
$3,089.52
|
| Rate for Payer: United Healthcare All Payer |
$2,832.06
|
|
|
SKIN FULL GRAFT ADD-ON
|
Facility
|
IP
|
$3,324.17
|
|
|
Service Code
|
HCPCS 15221
|
| Hospital Charge Code |
76100185
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$432.14 |
| Max. Negotiated Rate |
$3,191.20 |
| Rate for Payer: Aetna Commercial |
$2,559.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,592.85
|
| Rate for Payer: Cash Price |
$1,662.09
|
| Rate for Payer: Cigna Commercial |
$2,759.06
|
| Rate for Payer: First Health Commercial |
$3,157.96
|
| Rate for Payer: Humana Commercial |
$2,825.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,725.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,453.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$997.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,925.27
|
| Rate for Payer: Ohio Health Group HMO |
$2,493.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$664.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$432.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,030.49
|
| Rate for Payer: PHCS Commercial |
$3,191.20
|
| Rate for Payer: United Healthcare All Payer |
$2,925.27
|
|
|
SKIN FULL GRAFT ADD-ON
|
Facility
|
OP
|
$3,324.17
|
|
|
Service Code
|
HCPCS 15221
|
| Hospital Charge Code |
76100185
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$432.14 |
| Max. Negotiated Rate |
$3,191.20 |
| Rate for Payer: Aetna Commercial |
$2,559.61
|
| Rate for Payer: Anthem Medicaid |
$1,143.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,592.85
|
| Rate for Payer: Cash Price |
$1,662.09
|
| Rate for Payer: Cigna Commercial |
$2,759.06
|
| Rate for Payer: First Health Commercial |
$3,157.96
|
| Rate for Payer: Humana Commercial |
$2,825.54
|
| Rate for Payer: Humana KY Medicaid |
$1,143.18
|
| Rate for Payer: Kentucky WC Medicaid |
$1,154.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,725.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,453.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$997.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,166.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,925.27
|
| Rate for Payer: Ohio Health Group HMO |
$2,493.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$664.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$432.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,030.49
|
| Rate for Payer: PHCS Commercial |
$3,191.20
|
| Rate for Payer: United Healthcare All Payer |
$2,925.27
|
|
|
SKIN FULL GRAFT ADD-ON(P
|
Professional
|
Both
|
$670.00
|
|
|
Service Code
|
HCPCS 15261
|
| Hospital Charge Code |
761P0189
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$107.31 |
| Max. Negotiated Rate |
$670.00 |
| Rate for Payer: Aetna Commercial |
$211.13
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$107.31
|
| Rate for Payer: Anthem Medicaid |
$156.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$670.00
|
| Rate for Payer: Cash Price |
$335.00
|
| Rate for Payer: Cash Price |
$335.00
|
| Rate for Payer: Cigna Commercial |
$204.47
|
| Rate for Payer: Healthspan PPO |
$238.57
|
| Rate for Payer: Humana Medicaid |
$156.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$181.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$159.59
|
| Rate for Payer: Molina Healthcare Passport |
$156.46
|
| Rate for Payer: Multiplan PHCS |
$402.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$469.00
|
| Rate for Payer: UHCCP Medicaid |
$112.68
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$158.02
|
|
|
SKIN FULL GRAFT ADD-ON(P
|
Professional
|
Both
|
$545.00
|
|
|
Service Code
|
HCPCS 15241
|
| Hospital Charge Code |
761P0187
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$76.80 |
| Max. Negotiated Rate |
$545.00 |
| Rate for Payer: Aetna Commercial |
$170.31
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$76.80
|
| Rate for Payer: Anthem Medicaid |
$132.51
|
| Rate for Payer: Buckeye Medicare Advantage |
$545.00
|
| Rate for Payer: Cash Price |
$272.50
|
| Rate for Payer: Cash Price |
$272.50
|
| Rate for Payer: Cigna Commercial |
$160.70
|
| Rate for Payer: Healthspan PPO |
$205.94
|
| Rate for Payer: Humana Medicaid |
$132.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$144.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$135.16
|
| Rate for Payer: Molina Healthcare Passport |
$132.51
|
| Rate for Payer: Multiplan PHCS |
$327.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$381.50
|
| Rate for Payer: UHCCP Medicaid |
$80.64
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$133.84
|
|
|
SKIN FULL GRAFT ADD-ON(P
|
Professional
|
Both
|
$560.00
|
|
|
Service Code
|
HCPCS 15221
|
| Hospital Charge Code |
761P0185
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$49.33 |
| Max. Negotiated Rate |
$560.00 |
| Rate for Payer: Aetna Commercial |
$109.53
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$49.33
|
| Rate for Payer: Anthem Medicaid |
$89.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$560.00
|
| Rate for Payer: Cash Price |
$280.00
|
| Rate for Payer: Cash Price |
$280.00
|
| Rate for Payer: Cigna Commercial |
$102.57
|
| Rate for Payer: Healthspan PPO |
$153.05
|
| Rate for Payer: Humana Medicaid |
$89.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$92.19
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$91.51
|
| Rate for Payer: Molina Healthcare Passport |
$89.72
|
| Rate for Payer: Multiplan PHCS |
$336.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$392.00
|
| Rate for Payer: UHCCP Medicaid |
$51.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$90.62
|
|
|
SKIN FULL GRAFT ADD-ON(T
|
Facility
|
OP
|
$2,938.00
|
|
|
Service Code
|
HCPCS 15261
|
| Hospital Charge Code |
761T0189
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$381.94 |
| Max. Negotiated Rate |
$2,820.48 |
| Rate for Payer: Aetna Commercial |
$2,262.26
|
| Rate for Payer: Anthem Medicaid |
$1,010.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.64
|
| Rate for Payer: Cash Price |
$1,469.00
|
| Rate for Payer: Cigna Commercial |
$2,438.54
|
| Rate for Payer: First Health Commercial |
$2,791.10
|
| Rate for Payer: Humana Commercial |
$2,497.30
|
| Rate for Payer: Humana KY Medicaid |
$1,010.38
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,409.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,168.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.44
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$587.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$381.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$910.78
|
| Rate for Payer: PHCS Commercial |
$2,820.48
|
| Rate for Payer: United Healthcare All Payer |
$2,585.44
|
|
|
SKIN FULL GRAFT ADD-ON(T
|
Facility
|
OP
|
$2,764.17
|
|
|
Service Code
|
HCPCS 15221
|
| Hospital Charge Code |
761T0185
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$359.34 |
| Max. Negotiated Rate |
$2,653.60 |
| Rate for Payer: Aetna Commercial |
$2,128.41
|
| Rate for Payer: Anthem Medicaid |
$950.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,156.05
|
| Rate for Payer: Cash Price |
$1,382.09
|
| Rate for Payer: Cigna Commercial |
$2,294.26
|
| Rate for Payer: First Health Commercial |
$2,625.96
|
| Rate for Payer: Humana Commercial |
$2,349.54
|
| Rate for Payer: Humana KY Medicaid |
$950.60
|
| Rate for Payer: Kentucky WC Medicaid |
$960.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,266.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,039.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$829.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$969.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,432.47
|
| Rate for Payer: Ohio Health Group HMO |
$2,073.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$552.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$359.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$856.89
|
| Rate for Payer: PHCS Commercial |
$2,653.60
|
| Rate for Payer: United Healthcare All Payer |
$2,432.47
|
|
