|
SKIN FULL GRAFT ADD-ON(T
|
Facility
|
IP
|
$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 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: 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: 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
|
IP
|
$2,673.25
|
|
|
Service Code
|
HCPCS 15241
|
| Hospital Charge Code |
761T0187
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$347.52 |
| Max. Negotiated Rate |
$2,566.32 |
| Rate for Payer: Aetna Commercial |
$2,058.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,085.14
|
| Rate for Payer: Cash Price |
$1,336.62
|
| Rate for Payer: Cigna Commercial |
$2,218.80
|
| Rate for Payer: First Health Commercial |
$2,539.59
|
| Rate for Payer: Humana Commercial |
$2,272.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,192.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,972.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$801.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,352.46
|
| Rate for Payer: Ohio Health Group HMO |
$2,004.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$534.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$347.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$828.71
|
| Rate for Payer: PHCS Commercial |
$2,566.32
|
| Rate for Payer: United Healthcare All Payer |
$2,352.46
|
|
|
SKIN FULL GRAFT ADD-ON(T
|
Facility
|
IP
|
$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 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: 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: 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
|
|
|
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
|
|
|
SKIN FULL GRAFT TRUNK
|
Facility
|
OP
|
$5,303.50
|
|
|
Service Code
|
HCPCS 15200
|
| Hospital Charge Code |
76100183
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$689.46 |
| Max. Negotiated Rate |
$5,091.36 |
| Rate for Payer: Aetna Commercial |
$4,083.70
|
| Rate for Payer: Anthem Medicaid |
$1,823.87
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,136.73
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$2,651.75
|
| Rate for Payer: Cash Price |
$2,651.75
|
| Rate for Payer: Cigna Commercial |
$4,401.90
|
| Rate for Payer: First Health Commercial |
$5,038.32
|
| Rate for Payer: Humana Commercial |
$4,507.98
|
| Rate for Payer: Humana KY Medicaid |
$1,823.87
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,842.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,348.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,913.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,860.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,667.08
|
| Rate for Payer: Ohio Health Group HMO |
$3,977.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,060.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$689.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,644.08
|
| Rate for Payer: PHCS Commercial |
$5,091.36
|
| Rate for Payer: United Healthcare All Payer |
$4,667.08
|
|
|
SKIN FULL GRAFT TRUNK
|
Facility
|
IP
|
$5,303.50
|
|
|
Service Code
|
HCPCS 15200
|
| Hospital Charge Code |
76100183
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$689.46 |
| Max. Negotiated Rate |
$5,091.36 |
| Rate for Payer: Aetna Commercial |
$4,083.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,136.73
|
| Rate for Payer: Cash Price |
$2,651.75
|
| Rate for Payer: Cigna Commercial |
$4,401.90
|
| Rate for Payer: First Health Commercial |
$5,038.32
|
| Rate for Payer: Humana Commercial |
$4,507.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,348.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,913.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,591.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,667.08
|
| Rate for Payer: Ohio Health Group HMO |
$3,977.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,060.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$689.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,644.08
|
| Rate for Payer: PHCS Commercial |
$5,091.36
|
| Rate for Payer: United Healthcare All Payer |
$4,667.08
|
|
|
SKIN FULL GRAFT TRUNK
|
Professional
|
Both
|
$5,303.50
|
|
|
Service Code
|
HCPCS 15200
|
| Hospital Charge Code |
76100183
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$342.26 |
| Max. Negotiated Rate |
$5,303.50 |
| Rate for Payer: Aetna Commercial |
$938.16
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$342.26
|
| Rate for Payer: Anthem Medicaid |
$346.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,303.50
|
| Rate for Payer: Cash Price |
$2,651.75
|
| Rate for Payer: Cash Price |
$2,651.75
|
| Rate for Payer: Cigna Commercial |
$877.19
|
| Rate for Payer: Healthspan PPO |
$896.93
|
| Rate for Payer: Humana Medicaid |
$346.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$832.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$353.37
|
| Rate for Payer: Molina Healthcare Passport |
$346.44
|
| Rate for Payer: Multiplan PHCS |
$3,182.10
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,712.45
|
| Rate for Payer: UHCCP Medicaid |
$359.37
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$349.90
|
|
|
SKIN FULL GRAFT TRUNK ADD-ON
|
Professional
|
Both
|
$2,940.00
|
|
|
Service Code
|
HCPCS 15201
|
| Hospital Charge Code |
76102709
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$53.87 |
| Max. Negotiated Rate |
$2,940.00 |
| Rate for Payer: Aetna Commercial |
$120.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$53.87
|
| Rate for Payer: Anthem Medicaid |
$95.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,940.00
|
| Rate for Payer: Cash Price |
$1,470.00
|
| Rate for Payer: Cash Price |
$1,470.00
|
| Rate for Payer: Cigna Commercial |
$114.65
|
| Rate for Payer: Healthspan PPO |
$165.04
|
| Rate for Payer: Humana Medicaid |
$95.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$102.12
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$97.86
|
| Rate for Payer: Molina Healthcare Passport |
$95.94
|
| Rate for Payer: Multiplan PHCS |
$1,764.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,058.00
|
| Rate for Payer: UHCCP Medicaid |
$56.56
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$96.90
|
|
|
SKIN FULL GRAFT TRUNK ADD-ON
|
Facility
|
IP
|
$2,940.00
|
|
|
Service Code
|
HCPCS 15201
|
| Hospital Charge Code |
76102709
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$382.20 |
| Max. Negotiated Rate |
$2,822.40 |
| Rate for Payer: Aetna Commercial |
$2,263.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,293.20
|
| Rate for Payer: Cash Price |
$1,470.00
|
| Rate for Payer: Cigna Commercial |
$2,440.20
|
| Rate for Payer: First Health Commercial |
$2,793.00
|
| Rate for Payer: Humana Commercial |
$2,499.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,410.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,169.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$882.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,587.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,205.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$588.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$382.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$911.40
|
| Rate for Payer: PHCS Commercial |
$2,822.40
|
| Rate for Payer: United Healthcare All Payer |
$2,587.20
|
|
|
SKIN FULL GRAFT TRUNK ADD-ON
|
Facility
|
OP
|
$2,940.00
|
|
|
Service Code
|
HCPCS 15201
|
| Hospital Charge Code |
76102709
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$382.20 |
| Max. Negotiated Rate |
$2,822.40 |
| Rate for Payer: Aetna Commercial |
$2,263.80
|
| Rate for Payer: Anthem Medicaid |
$1,011.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,293.20
|
| Rate for Payer: Cash Price |
$1,470.00
|
| Rate for Payer: Cigna Commercial |
$2,440.20
|
| Rate for Payer: First Health Commercial |
$2,793.00
|
| Rate for Payer: Humana Commercial |
$2,499.00
|
| Rate for Payer: Humana KY Medicaid |
$1,011.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,021.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,410.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,169.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$882.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,031.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,587.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,205.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$588.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$382.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$911.40
|
| Rate for Payer: PHCS Commercial |
$2,822.40
|
| Rate for Payer: United Healthcare All Payer |
$2,587.20
|
|
|
SKIN FULL GRAFT TRUNK ADD-ON(P
|
Professional
|
Both
|
$345.00
|
|
|
Service Code
|
HCPCS 15201
|
| Hospital Charge Code |
761P2709
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$53.87 |
| Max. Negotiated Rate |
$345.00 |
| Rate for Payer: Aetna Commercial |
$120.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$53.87
|
| Rate for Payer: Anthem Medicaid |
$95.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$345.00
|
| Rate for Payer: Cash Price |
$172.50
|
| Rate for Payer: Cash Price |
$172.50
|
| Rate for Payer: Cigna Commercial |
$114.65
|
| Rate for Payer: Healthspan PPO |
$165.04
|
| Rate for Payer: Humana Medicaid |
$95.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$102.12
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$97.86
|
| Rate for Payer: Molina Healthcare Passport |
$95.94
|
| Rate for Payer: Multiplan PHCS |
$207.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$241.50
|
| Rate for Payer: UHCCP Medicaid |
$56.56
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$96.90
|
|
|
SKIN FULL GRAFT TRUNK ADD-ON(T
|
Facility
|
OP
|
$2,595.00
|
|
|
Service Code
|
HCPCS 15201
|
| Hospital Charge Code |
761T2709
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$337.35 |
| Max. Negotiated Rate |
$2,491.20 |
| Rate for Payer: Aetna Commercial |
$1,998.15
|
| Rate for Payer: Anthem Medicaid |
$892.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,024.10
|
| Rate for Payer: Cash Price |
$1,297.50
|
| Rate for Payer: Cigna Commercial |
$2,153.85
|
| Rate for Payer: First Health Commercial |
$2,465.25
|
| Rate for Payer: Humana Commercial |
$2,205.75
|
| Rate for Payer: Humana KY Medicaid |
$892.42
|
| Rate for Payer: Kentucky WC Medicaid |
$901.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,127.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,915.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$778.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$910.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,283.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,946.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$519.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$337.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$804.45
|
| Rate for Payer: PHCS Commercial |
$2,491.20
|
| Rate for Payer: United Healthcare All Payer |
$2,283.60
|
|
|
SKIN FULL GRAFT TRUNK ADD-ON(T
|
Facility
|
IP
|
$2,595.00
|
|
|
Service Code
|
HCPCS 15201
|
| Hospital Charge Code |
761T2709
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$337.35 |
| Max. Negotiated Rate |
$2,491.20 |
| Rate for Payer: Aetna Commercial |
$1,998.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,024.10
|
| Rate for Payer: Cash Price |
$1,297.50
|
| Rate for Payer: Cigna Commercial |
$2,153.85
|
| Rate for Payer: First Health Commercial |
$2,465.25
|
| Rate for Payer: Humana Commercial |
$2,205.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,127.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,915.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$778.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,283.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,946.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$519.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$337.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$804.45
|
| Rate for Payer: PHCS Commercial |
$2,491.20
|
| Rate for Payer: United Healthcare All Payer |
$2,283.60
|
|
|
SKIN FULL GRAFT TRUNK(P
|
Professional
|
Both
|
$1,145.00
|
|
|
Service Code
|
HCPCS 15200
|
| Hospital Charge Code |
761P0183
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$342.26 |
| Max. Negotiated Rate |
$1,145.00 |
| Rate for Payer: Aetna Commercial |
$938.16
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$342.26
|
| Rate for Payer: Anthem Medicaid |
$346.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,145.00
|
| Rate for Payer: Cash Price |
$572.50
|
| Rate for Payer: Cash Price |
$572.50
|
| Rate for Payer: Cigna Commercial |
$877.19
|
| Rate for Payer: Healthspan PPO |
$896.93
|
| Rate for Payer: Humana Medicaid |
$346.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$832.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$353.37
|
| Rate for Payer: Molina Healthcare Passport |
$346.44
|
| Rate for Payer: Multiplan PHCS |
$687.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$801.50
|
| Rate for Payer: UHCCP Medicaid |
$359.37
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$349.90
|
|
|
SKIN FULL GRAFT TRUNK(T
|
Facility
|
OP
|
$4,158.50
|
|
|
Service Code
|
HCPCS 15200
|
| Hospital Charge Code |
761T0183
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$540.60 |
| Max. Negotiated Rate |
$3,992.16 |
| Rate for Payer: Aetna Commercial |
$3,202.04
|
| Rate for Payer: Anthem Medicaid |
$1,430.11
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,243.63
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$2,079.25
|
| Rate for Payer: Cash Price |
$2,079.25
|
| Rate for Payer: Cigna Commercial |
$3,451.56
|
| Rate for Payer: First Health Commercial |
$3,950.58
|
| Rate for Payer: Humana Commercial |
$3,534.72
|
| Rate for Payer: Humana KY Medicaid |
$1,430.11
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,444.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,409.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,068.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,458.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,659.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,118.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$831.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$540.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,289.14
|
| Rate for Payer: PHCS Commercial |
$3,992.16
|
| Rate for Payer: United Healthcare All Payer |
$3,659.48
|
|
|
SKIN FULL GRAFT TRUNK(T
|
Facility
|
IP
|
$4,158.50
|
|
|
Service Code
|
HCPCS 15200
|
| Hospital Charge Code |
761T0183
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$540.60 |
| Max. Negotiated Rate |
$3,992.16 |
| Rate for Payer: Aetna Commercial |
$3,202.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,243.63
|
| Rate for Payer: Cash Price |
$2,079.25
|
| Rate for Payer: Cigna Commercial |
$3,451.56
|
| Rate for Payer: First Health Commercial |
$3,950.58
|
| Rate for Payer: Humana Commercial |
$3,534.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,409.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,068.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,247.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,659.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,118.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$831.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$540.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,289.14
|
| Rate for Payer: PHCS Commercial |
$3,992.16
|
| Rate for Payer: United Healthcare All Payer |
$3,659.48
|
|
|
SKIN FULL GRFT FACE/GENIT/HF
|
Facility
|
IP
|
$5,607.75
|
|
|
Service Code
|
HCPCS 15240
|
| Hospital Charge Code |
76100186
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$729.01 |
| Max. Negotiated Rate |
$5,383.44 |
| Rate for Payer: Aetna Commercial |
$4,317.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,374.04
|
| Rate for Payer: Cash Price |
$2,803.88
|
| Rate for Payer: Cigna Commercial |
$4,654.43
|
| Rate for Payer: First Health Commercial |
$5,327.36
|
| Rate for Payer: Humana Commercial |
$4,766.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,598.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,138.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,934.82
|
| Rate for Payer: Ohio Health Group HMO |
$4,205.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,121.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$729.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,738.40
|
| Rate for Payer: PHCS Commercial |
$5,383.44
|
| Rate for Payer: United Healthcare All Payer |
$4,934.82
|
|
|
SKIN FULL GRFT FACE/GENIT/HF
|
Professional
|
Both
|
$5,607.75
|
|
|
Service Code
|
HCPCS 15240
|
| Hospital Charge Code |
76100186
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$402.13 |
| Max. Negotiated Rate |
$5,607.75 |
| Rate for Payer: Aetna Commercial |
$1,122.45
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$402.13
|
| Rate for Payer: Anthem Medicaid |
$432.19
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,607.75
|
| Rate for Payer: Cash Price |
$2,803.88
|
| Rate for Payer: Cash Price |
$2,803.88
|
| Rate for Payer: Cigna Commercial |
$1,043.34
|
| Rate for Payer: Healthspan PPO |
$1,019.03
|
| Rate for Payer: Humana Medicaid |
$432.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$999.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$440.83
|
| Rate for Payer: Molina Healthcare Passport |
$432.19
|
| Rate for Payer: Multiplan PHCS |
$3,364.65
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,925.42
|
| Rate for Payer: UHCCP Medicaid |
$422.24
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$436.51
|
|
|
SKIN FULL GRFT FACE/GENIT/HF
|
Facility
|
OP
|
$5,607.75
|
|
|
Service Code
|
HCPCS 15240
|
| Hospital Charge Code |
76100186
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$729.01 |
| Max. Negotiated Rate |
$5,383.44 |
| Rate for Payer: Aetna Commercial |
$4,317.97
|
| Rate for Payer: Anthem Medicaid |
$1,928.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,374.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$2,803.88
|
| Rate for Payer: Cash Price |
$2,803.88
|
| Rate for Payer: Cigna Commercial |
$4,654.43
|
| Rate for Payer: First Health Commercial |
$5,327.36
|
| Rate for Payer: Humana Commercial |
$4,766.59
|
| Rate for Payer: Humana KY Medicaid |
$1,928.51
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,948.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,598.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,138.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,967.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,934.82
|
| Rate for Payer: Ohio Health Group HMO |
$4,205.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,121.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$729.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,738.40
|
| Rate for Payer: PHCS Commercial |
$5,383.44
|
| Rate for Payer: United Healthcare All Payer |
$4,934.82
|
|
|
SKIN FULL GRFT FACE/GENIT/H(P
|
Professional
|
Both
|
$1,340.00
|
|
|
Service Code
|
HCPCS 15240
|
| Hospital Charge Code |
761P0186
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$402.13 |
| Max. Negotiated Rate |
$1,340.00 |
| Rate for Payer: Aetna Commercial |
$1,122.45
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$402.13
|
| Rate for Payer: Anthem Medicaid |
$432.19
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,340.00
|
| Rate for Payer: Cash Price |
$670.00
|
| Rate for Payer: Cash Price |
$670.00
|
| Rate for Payer: Cigna Commercial |
$1,043.34
|
| Rate for Payer: Healthspan PPO |
$1,019.03
|
| Rate for Payer: Humana Medicaid |
$432.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$999.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$440.83
|
| Rate for Payer: Molina Healthcare Passport |
$432.19
|
| Rate for Payer: Multiplan PHCS |
$804.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$938.00
|
| Rate for Payer: UHCCP Medicaid |
$422.24
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$436.51
|
|
|
SKIN FULL GRFT FACE/GENIT/H(T
|
Facility
|
OP
|
$4,267.75
|
|
|
Service Code
|
HCPCS 15240
|
| Hospital Charge Code |
761T0186
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$554.81 |
| Max. Negotiated Rate |
$4,097.04 |
| Rate for Payer: Aetna Commercial |
$3,286.17
|
| Rate for Payer: Anthem Medicaid |
$1,467.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,328.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$2,133.88
|
| Rate for Payer: Cash Price |
$2,133.88
|
| Rate for Payer: Cigna Commercial |
$3,542.23
|
| Rate for Payer: First Health Commercial |
$4,054.36
|
| Rate for Payer: Humana Commercial |
$3,627.59
|
| Rate for Payer: Humana KY Medicaid |
$1,467.68
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,482.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,499.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,149.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,497.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,755.62
|
| Rate for Payer: Ohio Health Group HMO |
$3,200.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$853.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$554.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,323.00
|
| Rate for Payer: PHCS Commercial |
$4,097.04
|
| Rate for Payer: United Healthcare All Payer |
$3,755.62
|
|
|
SKIN FULL GRFT FACE/GENIT/H(T
|
Facility
|
IP
|
$4,267.75
|
|
|
Service Code
|
HCPCS 15240
|
| Hospital Charge Code |
761T0186
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$554.81 |
| Max. Negotiated Rate |
$4,097.04 |
| Rate for Payer: Aetna Commercial |
$3,286.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,328.84
|
| Rate for Payer: Cash Price |
$2,133.88
|
| Rate for Payer: Cigna Commercial |
$3,542.23
|
| Rate for Payer: First Health Commercial |
$4,054.36
|
| Rate for Payer: Humana Commercial |
$3,627.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,499.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,149.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,280.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,755.62
|
| Rate for Payer: Ohio Health Group HMO |
$3,200.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$853.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$554.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,323.00
|
| Rate for Payer: PHCS Commercial |
$4,097.04
|
| Rate for Payer: United Healthcare All Payer |
$3,755.62
|
|
|
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC
|
Facility
|
IP
|
$30,989.69
|
|
|
Service Code
|
MSDRG 577
|
| Min. Negotiated Rate |
$21,028.72 |
| Max. Negotiated Rate |
$30,989.69 |
| Rate for Payer: Anthem Medicaid |
$21,028.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$22,135.49
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$30,989.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$29,882.91
|
| Rate for Payer: Humana KY Medicaid |
$21,028.72
|
| Rate for Payer: Humana Medicare Advantage |
$22,135.49
|
| Rate for Payer: Kentucky WC Medicaid |
$21,239.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26,562.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$21,449.29
|
|
|
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC
|
Facility
|
IP
|
$66,482.07
|
|
|
Service Code
|
MSDRG 576
|
| Min. Negotiated Rate |
$45,112.83 |
| Max. Negotiated Rate |
$66,482.07 |
| Rate for Payer: Anthem Medicaid |
$45,112.83
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$47,487.19
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$66,482.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$64,107.71
|
| Rate for Payer: Humana KY Medicaid |
$45,112.83
|
| Rate for Payer: Humana Medicare Advantage |
$47,487.19
|
| Rate for Payer: Kentucky WC Medicaid |
$45,563.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56,984.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$46,015.09
|
|
|
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$18,839.95
|
|
|
Service Code
|
MSDRG 578
|
| Min. Negotiated Rate |
$12,784.25 |
| Max. Negotiated Rate |
$18,839.95 |
| Rate for Payer: Anthem Medicaid |
$12,784.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$13,457.11
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$18,839.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$18,167.10
|
| Rate for Payer: Humana KY Medicaid |
$12,784.25
|
| Rate for Payer: Humana Medicare Advantage |
$13,457.11
|
| Rate for Payer: Kentucky WC Medicaid |
$12,912.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16,148.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,039.94
|
|
