Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC

Facility

$39,841.73

Service Code	MSDRG 574
Min. Negotiated Rate	$27,035.46
Max. Negotiated Rate	$39,841.73
Rate for Payer: Anthem Medicaid	$27,035.46
Rate for Payer: Anthem Medicare Advantage/PPO	$28,458.38
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$39,841.73
Rate for Payer: CareSource Just4Me Medicare	$38,418.81
Rate for Payer: Humana KY Medicaid	$27,035.46
Rate for Payer: Humana Medicare Advantage	$28,458.38
Rate for Payer: Kentucky WC Medicaid	$27,305.82
Rate for Payer: Molina Healthcare Benefit Exchange	$34,150.06
Rate for Payer: Molina Healthcare Medicaid	$27,576.17

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC

Facility

$72,740.61

Service Code	MSDRG 573
Min. Negotiated Rate	$49,359.70
Max. Negotiated Rate	$72,740.61
Rate for Payer: Anthem Medicaid	$49,359.70
Rate for Payer: Anthem Medicare Advantage/PPO	$51,957.58
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$72,740.61
Rate for Payer: CareSource Just4Me Medicare	$70,142.73
Rate for Payer: Humana KY Medicaid	$49,359.70
Rate for Payer: Humana Medicare Advantage	$51,957.58
Rate for Payer: Kentucky WC Medicaid	$49,853.30
Rate for Payer: Molina Healthcare Benefit Exchange	$62,349.10
Rate for Payer: Molina Healthcare Medicaid	$50,346.90

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC

Facility

$23,934.53

Service Code	MSDRG 575
Min. Negotiated Rate	$16,241.29
Max. Negotiated Rate	$23,934.53
Rate for Payer: Anthem Medicaid	$16,241.29
Rate for Payer: Anthem Medicare Advantage/PPO	$17,096.09
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$23,934.53
Rate for Payer: CareSource Just4Me Medicare	$23,079.72
Rate for Payer: Humana KY Medicaid	$16,241.29
Rate for Payer: Humana Medicare Advantage	$17,096.09
Rate for Payer: Kentucky WC Medicaid	$16,403.70
Rate for Payer: Molina Healthcare Benefit Exchange	$20,515.31
Rate for Payer: Molina Healthcare Medicaid	$16,566.11

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC

Facility

$21,775.03

Service Code	MSDRG 623
Min. Negotiated Rate	$14,775.91
Max. Negotiated Rate	$21,775.03
Rate for Payer: Anthem Medicaid	$14,775.91
Rate for Payer: Anthem Medicare Advantage/PPO	$15,553.59
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$21,775.03
Rate for Payer: CareSource Just4Me Medicare	$20,997.35
Rate for Payer: Humana KY Medicaid	$14,775.91
Rate for Payer: Humana Medicare Advantage	$15,553.59
Rate for Payer: Kentucky WC Medicaid	$14,923.67
Rate for Payer: Molina Healthcare Benefit Exchange	$18,664.31
Rate for Payer: Molina Healthcare Medicaid	$15,071.43

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC

Facility

$44,752.68

Service Code	MSDRG 622
Min. Negotiated Rate	$30,367.89
Max. Negotiated Rate	$44,752.68
Rate for Payer: Anthem Medicaid	$30,367.89
Rate for Payer: Anthem Medicare Advantage/PPO	$31,966.20
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$44,752.68
Rate for Payer: CareSource Just4Me Medicare	$43,154.37
Rate for Payer: Humana KY Medicaid	$30,367.89
Rate for Payer: Humana Medicare Advantage	$31,966.20
Rate for Payer: Kentucky WC Medicaid	$30,671.57
Rate for Payer: Molina Healthcare Benefit Exchange	$38,359.44
Rate for Payer: Molina Healthcare Medicaid	$30,975.25

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC

Facility

$13,037.65

Service Code	MSDRG 624
Min. Negotiated Rate	$8,846.98
Max. Negotiated Rate	$13,037.65
Rate for Payer: Anthem Medicaid	$8,846.98
Rate for Payer: Anthem Medicare Advantage/PPO	$9,312.61
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$13,037.65
Rate for Payer: CareSource Just4Me Medicare	$12,572.02
Rate for Payer: Humana KY Medicaid	$8,846.98
Rate for Payer: Humana Medicare Advantage	$9,312.61
Rate for Payer: Kentucky WC Medicaid	$8,935.45
Rate for Payer: Molina Healthcare Benefit Exchange	$11,175.13
Rate for Payer: Molina Healthcare Medicaid	$9,023.92

SKIN GRAFTS FOR INJURIES WITH CC/MCC

Facility

$38,091.70

Service Code	MSDRG 904
Min. Negotiated Rate	$25,847.94
Max. Negotiated Rate	$38,091.70
Rate for Payer: Anthem Medicaid	$25,847.94
Rate for Payer: Anthem Medicare Advantage/PPO	$27,208.36
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$38,091.70
Rate for Payer: CareSource Just4Me Medicare	$36,731.29
Rate for Payer: Humana KY Medicaid	$25,847.94
Rate for Payer: Humana Medicare Advantage	$27,208.36
Rate for Payer: Kentucky WC Medicaid	$26,106.42
Rate for Payer: Molina Healthcare Benefit Exchange	$32,650.03
Rate for Payer: Molina Healthcare Medicaid	$26,364.90

SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC

Facility

$18,526.44

Service Code	MSDRG 905
Min. Negotiated Rate	$12,571.51
Max. Negotiated Rate	$18,526.44
Rate for Payer: Anthem Medicaid	$12,571.51
Rate for Payer: Anthem Medicare Advantage/PPO	$13,233.17
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$18,526.44
Rate for Payer: CareSource Just4Me Medicare	$17,864.78
Rate for Payer: Humana KY Medicaid	$12,571.51
Rate for Payer: Humana Medicare Advantage	$13,233.17
Rate for Payer: Kentucky WC Medicaid	$12,697.23
Rate for Payer: Molina Healthcare Benefit Exchange	$15,879.80
Rate for Payer: Molina Healthcare Medicaid	$12,822.94

SKIN SUB GRAFT FACE/NK/HF/G

Facility

$3,271.00

Service Code	HCPCS 15275
Hospital Charge Code	76100194
Hospital Revenue Code	761
Min. Negotiated Rate	$425.23
Max. Negotiated Rate	$3,140.16
Rate for Payer: Aetna Commercial	$2,518.67
Rate for Payer: Anthem POS/PPO/Traditional	$2,551.38
Rate for Payer: Cash Price	$1,635.50
Rate for Payer: Cigna Commercial	$2,714.93
Rate for Payer: First Health Commercial	$3,107.45
Rate for Payer: Humana Commercial	$2,780.35
Rate for Payer: Medical Mutual Of Ohio HMO	$2,682.22
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,414.00
Rate for Payer: Molina Healthcare Benefit Exchange	$981.30
Rate for Payer: Ohio Health Choice Commercial	$2,878.48
Rate for Payer: Ohio Health Group HMO	$2,453.25
Rate for Payer: Ohio Health Group PPO Differential	$654.20
Rate for Payer: Ohio Health Group PPO No Differential	$425.23
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,014.01
Rate for Payer: PHCS Commercial	$3,140.16
Rate for Payer: United Healthcare All Payer	$2,878.48

SKIN SUB GRAFT FACE/NK/HF/G

Facility

$3,271.00

Service Code	HCPCS 15275
Hospital Charge Code	76100194
Hospital Revenue Code	761
Min. Negotiated Rate	$425.23
Max. Negotiated Rate	$3,140.16
Rate for Payer: Aetna Commercial	$2,518.67
Rate for Payer: Anthem Medicaid	$1,124.90
Rate for Payer: Anthem Medicare Advantage/PPO	$1,576.98
Rate for Payer: Anthem POS/PPO/Traditional	$2,551.38
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	$1,635.50
Rate for Payer: Cash Price	$1,635.50
Rate for Payer: Cigna Commercial	$2,714.93
Rate for Payer: First Health Commercial	$3,107.45
Rate for Payer: Humana Commercial	$2,780.35
Rate for Payer: Humana KY Medicaid	$1,124.90
Rate for Payer: Humana Medicare Advantage	$1,576.98
Rate for Payer: Kentucky WC Medicaid	$1,136.35
Rate for Payer: Medical Mutual Of Ohio HMO	$2,682.22
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,414.00
Rate for Payer: Molina Healthcare Benefit Exchange	$1,892.38
Rate for Payer: Molina Healthcare Medicaid	$1,147.47
Rate for Payer: Ohio Health Choice Commercial	$2,878.48
Rate for Payer: Ohio Health Group HMO	$2,453.25
Rate for Payer: Ohio Health Group PPO Differential	$654.20
Rate for Payer: Ohio Health Group PPO No Differential	$425.23
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,014.01
Rate for Payer: PHCS Commercial	$3,140.16
Rate for Payer: United Healthcare All Payer	$2,878.48

SKIN SUB GRAFT FACE/NK/HF/G

Professional

Both

$3,271.00

Service Code	HCPCS 15275
Hospital Charge Code	76100194
Hospital Revenue Code	761
Min. Negotiated Rate	$47.41
Max. Negotiated Rate	$3,271.00
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$47.41
Rate for Payer: Anthem Medicaid	$81.60
Rate for Payer: Buckeye Medicare Advantage	$3,271.00
Rate for Payer: Cash Price	$1,635.50
Rate for Payer: Cash Price	$1,635.50
Rate for Payer: Cigna Commercial	$172.63
Rate for Payer: Healthspan PPO	$140.36
Rate for Payer: Humana Medicaid	$81.60
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$127.51
Rate for Payer: Molina Healthcare CHIP/Medicaid	$83.23
Rate for Payer: Molina Healthcare Passport	$81.60
Rate for Payer: Multiplan PHCS	$1,962.60
Rate for Payer: Ohio Health Choice Preferred Health Choice	$2,289.70
Rate for Payer: UHCCP Medicaid	$49.78
Rate for Payer: Wellcare CHIP/Medicaid	$82.42

SKIN SUB GRAFT FACE/NK/HF/G(P

Professional

Both

$100.00

Service Code	HCPCS 15275
Hospital Charge Code	761P0194
Hospital Revenue Code	761
Min. Negotiated Rate	$47.41
Max. Negotiated Rate	$172.63
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$47.41
Rate for Payer: Anthem Medicaid	$81.60
Rate for Payer: Buckeye Medicare Advantage	$100.00
Rate for Payer: Cash Price	$50.00
Rate for Payer: Cash Price	$50.00
Rate for Payer: Cigna Commercial	$172.63
Rate for Payer: Healthspan PPO	$140.36
Rate for Payer: Humana Medicaid	$81.60
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$127.51
Rate for Payer: Molina Healthcare CHIP/Medicaid	$83.23
Rate for Payer: Molina Healthcare Passport	$81.60
Rate for Payer: Multiplan PHCS	$60.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$70.00
Rate for Payer: UHCCP Medicaid	$49.78
Rate for Payer: Wellcare CHIP/Medicaid	$82.42

SKIN SUB GRAFT FACE/NK/HF/G(T

Facility

$3,171.00

Service Code	HCPCS 15275
Hospital Charge Code	761T0194
Hospital Revenue Code	761
Min. Negotiated Rate	$412.23
Max. Negotiated Rate	$3,044.16
Rate for Payer: Aetna Commercial	$2,441.67
Rate for Payer: Anthem Medicaid	$1,090.51
Rate for Payer: Anthem Medicare Advantage/PPO	$1,576.98
Rate for Payer: Anthem POS/PPO/Traditional	$2,473.38
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	$1,585.50
Rate for Payer: Cash Price	$1,585.50
Rate for Payer: Cigna Commercial	$2,631.93
Rate for Payer: First Health Commercial	$3,012.45
Rate for Payer: Humana Commercial	$2,695.35
Rate for Payer: Humana KY Medicaid	$1,090.51
Rate for Payer: Humana Medicare Advantage	$1,576.98
Rate for Payer: Kentucky WC Medicaid	$1,101.61
Rate for Payer: Medical Mutual Of Ohio HMO	$2,600.22
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,340.20
Rate for Payer: Molina Healthcare Benefit Exchange	$1,892.38
Rate for Payer: Molina Healthcare Medicaid	$1,112.39
Rate for Payer: Ohio Health Choice Commercial	$2,790.48
Rate for Payer: Ohio Health Group HMO	$2,378.25
Rate for Payer: Ohio Health Group PPO Differential	$634.20
Rate for Payer: Ohio Health Group PPO No Differential	$412.23
Rate for Payer: Ohio Health Group PPO SOMC Employees	$983.01
Rate for Payer: PHCS Commercial	$3,044.16
Rate for Payer: United Healthcare All Payer	$2,790.48

SKIN SUB GRAFT FACE/NK/HF/G(T

Facility

$3,171.00

Service Code	HCPCS 15275
Hospital Charge Code	761T0194
Hospital Revenue Code	761
Min. Negotiated Rate	$412.23
Max. Negotiated Rate	$3,044.16
Rate for Payer: Aetna Commercial	$2,441.67
Rate for Payer: Anthem POS/PPO/Traditional	$2,473.38
Rate for Payer: Cash Price	$1,585.50
Rate for Payer: Cigna Commercial	$2,631.93
Rate for Payer: First Health Commercial	$3,012.45
Rate for Payer: Humana Commercial	$2,695.35
Rate for Payer: Medical Mutual Of Ohio HMO	$2,600.22
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$2,340.20
Rate for Payer: Molina Healthcare Benefit Exchange	$951.30
Rate for Payer: Ohio Health Choice Commercial	$2,790.48
Rate for Payer: Ohio Health Group HMO	$2,378.25
Rate for Payer: Ohio Health Group PPO Differential	$634.20
Rate for Payer: Ohio Health Group PPO No Differential	$412.23
Rate for Payer: Ohio Health Group PPO SOMC Employees	$983.01
Rate for Payer: PHCS Commercial	$3,044.16
Rate for Payer: United Healthcare All Payer	$2,790.48

SKIN SUB GRAFT F/N/HF/G ADDL

Facility

$447.00

Service Code	HCPCS 15276
Hospital Charge Code	76100195
Hospital Revenue Code	761
Min. Negotiated Rate	$58.11
Max. Negotiated Rate	$429.12
Rate for Payer: Aetna Commercial	$344.19
Rate for Payer: Anthem Medicaid	$153.72
Rate for Payer: Anthem POS/PPO/Traditional	$348.66
Rate for Payer: Cash Price	$223.50
Rate for Payer: Cigna Commercial	$371.01
Rate for Payer: First Health Commercial	$424.65
Rate for Payer: Humana Commercial	$379.95
Rate for Payer: Humana KY Medicaid	$153.72
Rate for Payer: Kentucky WC Medicaid	$155.29
Rate for Payer: Medical Mutual Of Ohio HMO	$366.54
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$329.89
Rate for Payer: Molina Healthcare Benefit Exchange	$134.10
Rate for Payer: Molina Healthcare Medicaid	$156.81
Rate for Payer: Ohio Health Choice Commercial	$393.36
Rate for Payer: Ohio Health Group HMO	$335.25
Rate for Payer: Ohio Health Group PPO Differential	$89.40
Rate for Payer: Ohio Health Group PPO No Differential	$58.11
Rate for Payer: Ohio Health Group PPO SOMC Employees	$138.57
Rate for Payer: PHCS Commercial	$429.12
Rate for Payer: United Healthcare All Payer	$393.36

SKIN SUB GRAFT F/N/HF/G ADDL

Facility

$447.00

Service Code	HCPCS 15276
Hospital Charge Code	76100195
Hospital Revenue Code	761
Min. Negotiated Rate	$58.11
Max. Negotiated Rate	$429.12
Rate for Payer: Aetna Commercial	$344.19
Rate for Payer: Anthem POS/PPO/Traditional	$348.66
Rate for Payer: Cash Price	$223.50
Rate for Payer: Cigna Commercial	$371.01
Rate for Payer: First Health Commercial	$424.65
Rate for Payer: Humana Commercial	$379.95
Rate for Payer: Medical Mutual Of Ohio HMO	$366.54
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$329.89
Rate for Payer: Molina Healthcare Benefit Exchange	$134.10
Rate for Payer: Ohio Health Choice Commercial	$393.36
Rate for Payer: Ohio Health Group HMO	$335.25
Rate for Payer: Ohio Health Group PPO Differential	$89.40
Rate for Payer: Ohio Health Group PPO No Differential	$58.11
Rate for Payer: Ohio Health Group PPO SOMC Employees	$138.57
Rate for Payer: PHCS Commercial	$429.12
Rate for Payer: United Healthcare All Payer	$393.36

SKIN SUB GRAFT F/N/HF/G ADDL

Professional

Both

$447.00

Service Code	HCPCS 15276
Hospital Charge Code	76100195
Hospital Revenue Code	761
Min. Negotiated Rate	$12.98
Max. Negotiated Rate	$447.00
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$12.98
Rate for Payer: Anthem Medicaid	$20.14
Rate for Payer: Buckeye Medicare Advantage	$447.00
Rate for Payer: Cash Price	$223.50
Rate for Payer: Cash Price	$223.50
Rate for Payer: Cigna Commercial	$42.32
Rate for Payer: Healthspan PPO	$30.69
Rate for Payer: Humana Medicaid	$20.14
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$31.08
Rate for Payer: Molina Healthcare CHIP/Medicaid	$20.54
Rate for Payer: Molina Healthcare Passport	$20.14
Rate for Payer: Multiplan PHCS	$268.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$312.90
Rate for Payer: UHCCP Medicaid	$13.63
Rate for Payer: Wellcare CHIP/Medicaid	$20.34

SKIN SUB GRAFT F/N/HF/G ADD(P

Professional

Both

$265.00

Service Code	HCPCS 15276
Hospital Charge Code	761P0195
Hospital Revenue Code	761
Min. Negotiated Rate	$12.98
Max. Negotiated Rate	$265.00
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$12.98
Rate for Payer: Anthem Medicaid	$20.14
Rate for Payer: Buckeye Medicare Advantage	$265.00
Rate for Payer: Cash Price	$132.50
Rate for Payer: Cash Price	$132.50
Rate for Payer: Cigna Commercial	$42.32
Rate for Payer: Healthspan PPO	$30.69
Rate for Payer: Humana Medicaid	$20.14
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$31.08
Rate for Payer: Molina Healthcare CHIP/Medicaid	$20.54
Rate for Payer: Molina Healthcare Passport	$20.14
Rate for Payer: Multiplan PHCS	$159.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$185.50
Rate for Payer: UHCCP Medicaid	$13.63
Rate for Payer: Wellcare CHIP/Medicaid	$20.34

SKIN SUB GRAFT F/N/HF/G ADD(T

Facility

$182.00

Service Code	HCPCS 15276
Hospital Charge Code	761T0195
Hospital Revenue Code	761
Min. Negotiated Rate	$23.66
Max. Negotiated Rate	$174.72
Rate for Payer: Aetna Commercial	$140.14
Rate for Payer: Anthem POS/PPO/Traditional	$141.96
Rate for Payer: Cash Price	$91.00
Rate for Payer: Cigna Commercial	$151.06
Rate for Payer: First Health Commercial	$172.90
Rate for Payer: Humana Commercial	$154.70
Rate for Payer: Medical Mutual Of Ohio HMO	$149.24
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$134.32
Rate for Payer: Molina Healthcare Benefit Exchange	$54.60
Rate for Payer: Ohio Health Choice Commercial	$160.16
Rate for Payer: Ohio Health Group HMO	$136.50
Rate for Payer: Ohio Health Group PPO Differential	$36.40
Rate for Payer: Ohio Health Group PPO No Differential	$23.66
Rate for Payer: Ohio Health Group PPO SOMC Employees	$56.42
Rate for Payer: PHCS Commercial	$174.72
Rate for Payer: United Healthcare All Payer	$160.16

SKIN SUB GRAFT F/N/HF/G ADD(T

Facility

$182.00

Service Code	HCPCS 15276
Hospital Charge Code	761T0195
Hospital Revenue Code	761
Min. Negotiated Rate	$23.66
Max. Negotiated Rate	$174.72
Rate for Payer: Aetna Commercial	$140.14
Rate for Payer: Anthem Medicaid	$62.59
Rate for Payer: Anthem POS/PPO/Traditional	$141.96
Rate for Payer: Cash Price	$91.00
Rate for Payer: Cigna Commercial	$151.06
Rate for Payer: First Health Commercial	$172.90
Rate for Payer: Humana Commercial	$154.70
Rate for Payer: Humana KY Medicaid	$62.59
Rate for Payer: Kentucky WC Medicaid	$63.23
Rate for Payer: Medical Mutual Of Ohio HMO	$149.24
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$134.32
Rate for Payer: Molina Healthcare Benefit Exchange	$54.60
Rate for Payer: Molina Healthcare Medicaid	$63.85
Rate for Payer: Ohio Health Choice Commercial	$160.16
Rate for Payer: Ohio Health Group HMO	$136.50
Rate for Payer: Ohio Health Group PPO Differential	$36.40
Rate for Payer: Ohio Health Group PPO No Differential	$23.66
Rate for Payer: Ohio Health Group PPO SOMC Employees	$56.42
Rate for Payer: PHCS Commercial	$174.72
Rate for Payer: United Healthcare All Payer	$160.16

SKIN TEST CANDIDA

Professional

Both

$26.00

Service Code	HCPCS 86485
Hospital Charge Code	30001575
Hospital Revenue Code	300
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$17.66
Rate for Payer: Anthem Medicaid	$5.68
Rate for Payer: Buckeye Medicare Advantage	$26.00
Rate for Payer: Cash Price	$13.00
Rate for Payer: Cash Price	$13.00
Rate for Payer: Cigna Commercial	$13.80
Rate for Payer: Healthspan PPO	$0.60
Rate for Payer: Humana Medicaid	$5.68
Rate for Payer: Molina Healthcare CHIP/Medicaid	$5.79
Rate for Payer: Molina Healthcare Passport	$5.68
Rate for Payer: Multiplan PHCS	$15.60
Rate for Payer: Ohio Health Choice Preferred Health Choice	$18.20
Rate for Payer: UHCCP Medicaid	$9.10
Rate for Payer: Wellcare CHIP/Medicaid	$5.74

SKIN TEST CANDIDA

Facility

$26.00

Service Code	HCPCS 86485
Hospital Charge Code	30001575
Hospital Revenue Code	300
Min. Negotiated Rate	$3.38
Max. Negotiated Rate	$36.05
Rate for Payer: Aetna Commercial	$20.02
Rate for Payer: Anthem Medicaid	$8.94
Rate for Payer: Anthem Medicare Advantage/PPO	$25.75
Rate for Payer: Anthem POS/PPO/Traditional	$20.88
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$36.05
Rate for Payer: CareSource Just4Me Medicare	$34.76
Rate for Payer: Cash Price	$13.00
Rate for Payer: Cash Price	$13.00
Rate for Payer: Cigna Commercial	$21.58
Rate for Payer: First Health Commercial	$24.70
Rate for Payer: Humana Commercial	$22.10
Rate for Payer: Humana KY Medicaid	$8.94
Rate for Payer: Humana Medicare Advantage	$25.75
Rate for Payer: Kentucky WC Medicaid	$9.03
Rate for Payer: Medical Mutual Of Ohio HMO	$21.32
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$19.19
Rate for Payer: Molina Healthcare Benefit Exchange	$30.90
Rate for Payer: Molina Healthcare Medicaid	$9.12
Rate for Payer: Ohio Health Choice Commercial	$22.88
Rate for Payer: Ohio Health Group HMO	$19.50
Rate for Payer: Ohio Health Group PPO Differential	$5.20
Rate for Payer: Ohio Health Group PPO No Differential	$3.38
Rate for Payer: Ohio Health Group PPO SOMC Employees	$8.06
Rate for Payer: PHCS Commercial	$24.96
Rate for Payer: United Healthcare All Payer	$22.88

SKIN TEST CANDIDA

Facility

$26.00

Service Code	HCPCS 86485
Hospital Charge Code	30001575
Hospital Revenue Code	300
Min. Negotiated Rate	$3.38
Max. Negotiated Rate	$24.96
Rate for Payer: Aetna Commercial	$20.02
Rate for Payer: Anthem POS/PPO/Traditional	$20.88
Rate for Payer: Cash Price	$13.00
Rate for Payer: Cigna Commercial	$21.58
Rate for Payer: First Health Commercial	$24.70
Rate for Payer: Humana Commercial	$22.10
Rate for Payer: Medical Mutual Of Ohio HMO	$21.32
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$19.19
Rate for Payer: Molina Healthcare Benefit Exchange	$7.80
Rate for Payer: Ohio Health Choice Commercial	$22.88
Rate for Payer: Ohio Health Group HMO	$19.50
Rate for Payer: Ohio Health Group PPO Differential	$5.20
Rate for Payer: Ohio Health Group PPO No Differential	$3.38
Rate for Payer: Ohio Health Group PPO SOMC Employees	$8.06
Rate for Payer: PHCS Commercial	$24.96
Rate for Payer: United Healthcare All Payer	$22.88

SKIN TEST- TB -INTRADERMAL

Facility

$24.00

Service Code	HCPCS 86580
Hospital Charge Code	30001103
Hospital Revenue Code	302
Min. Negotiated Rate	$3.12
Max. Negotiated Rate	$23.04
Rate for Payer: Aetna Commercial	$18.48
Rate for Payer: Anthem POS/PPO/Traditional	$19.27
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cigna Commercial	$19.92
Rate for Payer: First Health Commercial	$22.80
Rate for Payer: Humana Commercial	$20.40
Rate for Payer: Medical Mutual Of Ohio HMO	$19.68
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$17.71
Rate for Payer: Molina Healthcare Benefit Exchange	$7.20
Rate for Payer: Ohio Health Choice Commercial	$21.12
Rate for Payer: Ohio Health Group HMO	$18.00
Rate for Payer: Ohio Health Group PPO Differential	$4.80
Rate for Payer: Ohio Health Group PPO No Differential	$3.12
Rate for Payer: Ohio Health Group PPO SOMC Employees	$7.44
Rate for Payer: PHCS Commercial	$23.04
Rate for Payer: United Healthcare All Payer	$21.12

SKIN TEST- TB -INTRADERMAL

Professional

Both

$24.00

Service Code	HCPCS 86580
Hospital Charge Code	30001103
Hospital Revenue Code	302
Min. Negotiated Rate	$6.95
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$11.06
Rate for Payer: Anthem Medicaid	$6.95
Rate for Payer: Buckeye Medicare Advantage	$24.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cigna Commercial	$9.62
Rate for Payer: Healthspan PPO	$7.04
Rate for Payer: Humana Medicaid	$6.95
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$7.54
Rate for Payer: Molina Healthcare CHIP/Medicaid	$7.09
Rate for Payer: Molina Healthcare Passport	$6.95
Rate for Payer: Multiplan PHCS	$14.40
Rate for Payer: Ohio Health Choice Preferred Health Choice	$16.80
Rate for Payer: UHCCP Medicaid	$8.40
Rate for Payer: Wellcare CHIP/Medicaid	$7.02

Know your out-of-pocket cost for care.

All Charges