|
SKIN TEST- TB -INTRADERMAL
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
30001103
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$3.12 |
| Max. Negotiated Rate |
$36.05 |
| Rate for Payer: Aetna Commercial |
$18.48
|
| Rate for Payer: Anthem Medicaid |
$8.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$25.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.27
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$36.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$34.76
|
| Rate for Payer: Cash Price |
$12.00
|
| 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: Humana KY Medicaid |
$8.25
|
| Rate for Payer: Humana Medicare Advantage |
$25.75
|
| Rate for Payer: Kentucky WC Medicaid |
$8.34
|
| 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 |
$30.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.42
|
| 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 TISSUE REARRANGEMENT
|
Facility
|
OP
|
$5,825.33
|
|
|
Service Code
|
HCPCS 14001
|
| Hospital Charge Code |
76100163
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$757.29 |
| Max. Negotiated Rate |
$5,592.32 |
| Rate for Payer: Aetna Commercial |
$4,485.50
|
| Rate for Payer: Anthem Medicaid |
$2,003.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,543.76
|
| 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 |
$2,912.66
|
| Rate for Payer: Cash Price |
$2,912.66
|
| Rate for Payer: Cigna Commercial |
$4,835.02
|
| Rate for Payer: First Health Commercial |
$5,534.06
|
| Rate for Payer: Humana Commercial |
$4,951.53
|
| Rate for Payer: Humana KY Medicaid |
$2,003.33
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,023.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,776.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,299.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,043.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,126.29
|
| Rate for Payer: Ohio Health Group HMO |
$4,369.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,165.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$757.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,805.85
|
| Rate for Payer: PHCS Commercial |
$5,592.32
|
| Rate for Payer: United Healthcare All Payer |
$5,126.29
|
|
|
SKIN TISSUE REARRANGEMENT
|
Facility
|
IP
|
$5,825.33
|
|
|
Service Code
|
HCPCS 14001
|
| Hospital Charge Code |
76100163
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$757.29 |
| Max. Negotiated Rate |
$5,592.32 |
| Rate for Payer: Aetna Commercial |
$4,485.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,543.76
|
| Rate for Payer: Cash Price |
$2,912.66
|
| Rate for Payer: Cigna Commercial |
$4,835.02
|
| Rate for Payer: First Health Commercial |
$5,534.06
|
| Rate for Payer: Humana Commercial |
$4,951.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,776.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,299.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,747.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,126.29
|
| Rate for Payer: Ohio Health Group HMO |
$4,369.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,165.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$757.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,805.85
|
| Rate for Payer: PHCS Commercial |
$5,592.32
|
| Rate for Payer: United Healthcare All Payer |
$5,126.29
|
|
|
SKIN TISSUE REARRANGEMENT
|
Professional
|
Both
|
$5,825.33
|
|
|
Service Code
|
HCPCS 14001
|
| Hospital Charge Code |
76100163
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$331.88 |
| Max. Negotiated Rate |
$5,825.33 |
| Rate for Payer: Aetna Commercial |
$940.13
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$331.88
|
| Rate for Payer: Anthem Medicaid |
$374.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,825.33
|
| Rate for Payer: Cash Price |
$2,912.66
|
| Rate for Payer: Cash Price |
$2,912.66
|
| Rate for Payer: Cigna Commercial |
$954.11
|
| Rate for Payer: Healthspan PPO |
$886.95
|
| Rate for Payer: Humana Medicaid |
$374.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$828.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$381.64
|
| Rate for Payer: Molina Healthcare Passport |
$374.16
|
| Rate for Payer: Multiplan PHCS |
$3,495.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,077.73
|
| Rate for Payer: UHCCP Medicaid |
$348.47
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$377.90
|
|
|
SKIN TISSUE REARRANGEMENT(P
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 14001
|
| Hospital Charge Code |
761P0163
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$331.88 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Aetna Commercial |
$940.13
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$331.88
|
| Rate for Payer: Anthem Medicaid |
$374.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,000.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$954.11
|
| Rate for Payer: Healthspan PPO |
$886.95
|
| Rate for Payer: Humana Medicaid |
$374.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$828.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$381.64
|
| Rate for Payer: Molina Healthcare Passport |
$374.16
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$348.47
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$377.90
|
|
|
SKIN TISSUE REARRANGEMENT(T
|
Facility
|
OP
|
$4,825.33
|
|
|
Service Code
|
HCPCS 14001
|
| Hospital Charge Code |
761T0163
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$627.29 |
| Max. Negotiated Rate |
$4,632.32 |
| Rate for Payer: Aetna Commercial |
$3,715.50
|
| Rate for Payer: Anthem Medicaid |
$1,659.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,763.76
|
| 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 |
$2,412.66
|
| Rate for Payer: Cash Price |
$2,412.66
|
| Rate for Payer: Cigna Commercial |
$4,005.02
|
| Rate for Payer: First Health Commercial |
$4,584.06
|
| Rate for Payer: Humana Commercial |
$4,101.53
|
| Rate for Payer: Humana KY Medicaid |
$1,659.43
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,676.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,956.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,561.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,692.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,246.29
|
| Rate for Payer: Ohio Health Group HMO |
$3,619.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$965.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$627.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,495.85
|
| Rate for Payer: PHCS Commercial |
$4,632.32
|
| Rate for Payer: United Healthcare All Payer |
$4,246.29
|
|
|
SKIN TISSUE REARRANGEMENT(T
|
Facility
|
IP
|
$4,825.33
|
|
|
Service Code
|
HCPCS 14001
|
| Hospital Charge Code |
761T0163
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$627.29 |
| Max. Negotiated Rate |
$4,632.32 |
| Rate for Payer: Aetna Commercial |
$3,715.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,763.76
|
| Rate for Payer: Cash Price |
$2,412.66
|
| Rate for Payer: Cigna Commercial |
$4,005.02
|
| Rate for Payer: First Health Commercial |
$4,584.06
|
| Rate for Payer: Humana Commercial |
$4,101.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,956.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,561.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,447.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,246.29
|
| Rate for Payer: Ohio Health Group HMO |
$3,619.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$965.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$627.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,495.85
|
| Rate for Payer: PHCS Commercial |
$4,632.32
|
| Rate for Payer: United Healthcare All Payer |
$4,246.29
|
|
|
SKIN ULCERS WITH CC
|
Facility
|
IP
|
$14,153.66
|
|
|
Service Code
|
MSDRG 593
|
| Min. Negotiated Rate |
$9,604.27 |
| Max. Negotiated Rate |
$14,153.66 |
| Rate for Payer: Anthem Medicaid |
$9,604.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$10,109.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$14,153.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$13,648.18
|
| Rate for Payer: Humana KY Medicaid |
$9,604.27
|
| Rate for Payer: Humana Medicare Advantage |
$10,109.76
|
| Rate for Payer: Kentucky WC Medicaid |
$9,700.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,131.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,796.36
|
|
|
SKIN ULCERS WITH MCC
|
Facility
|
IP
|
$24,450.41
|
|
|
Service Code
|
MSDRG 592
|
| Min. Negotiated Rate |
$16,591.35 |
| Max. Negotiated Rate |
$24,450.41 |
| Rate for Payer: Anthem Medicaid |
$16,591.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$17,464.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$24,450.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$23,577.18
|
| Rate for Payer: Humana KY Medicaid |
$16,591.35
|
| Rate for Payer: Humana Medicare Advantage |
$17,464.58
|
| Rate for Payer: Kentucky WC Medicaid |
$16,757.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,957.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$16,923.18
|
|
|
SKIN ULCERS WITHOUT CC/MCC
|
Facility
|
IP
|
$9,211.17
|
|
|
Service Code
|
MSDRG 594
|
| Min. Negotiated Rate |
$6,250.44 |
| Max. Negotiated Rate |
$9,211.17 |
| Rate for Payer: Anthem Medicaid |
$6,250.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,579.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9,211.17
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,882.20
|
| Rate for Payer: Humana KY Medicaid |
$6,250.44
|
| Rate for Payer: Humana Medicare Advantage |
$6,579.41
|
| Rate for Payer: Kentucky WC Medicaid |
$6,312.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,895.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,375.45
|
|
|
SKL FIX PHLNGLSHFTFXPRXMIDPXFT
|
Professional
|
Both
|
$907.00
|
|
|
Service Code
|
HCPCS 26727
|
| Hospital Charge Code |
76100738
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$219.32 |
| Max. Negotiated Rate |
$907.00 |
| Rate for Payer: Aetna Commercial |
$660.66
|
| Rate for Payer: Anthem Medicaid |
$219.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$907.00
|
| Rate for Payer: Cash Price |
$453.50
|
| Rate for Payer: Cash Price |
$453.50
|
| Rate for Payer: Cigna Commercial |
$744.94
|
| Rate for Payer: Healthspan PPO |
$598.42
|
| Rate for Payer: Humana Medicaid |
$219.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$570.72
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$223.71
|
| Rate for Payer: Molina Healthcare Passport |
$219.32
|
| Rate for Payer: Multiplan PHCS |
$544.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$634.90
|
| Rate for Payer: UHCCP Medicaid |
$317.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$221.51
|
|
|
SKL FIX PHLNGLSHFTFXPRXMIDPXFT
|
Facility
|
OP
|
$907.00
|
|
|
Service Code
|
HCPCS 26727
|
| Hospital Charge Code |
76100738
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$117.91 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Aetna Commercial |
$698.39
|
| Rate for Payer: Anthem Medicaid |
$311.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$707.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Cash Price |
$453.50
|
| Rate for Payer: Cash Price |
$453.50
|
| Rate for Payer: Cigna Commercial |
$752.81
|
| Rate for Payer: First Health Commercial |
$861.65
|
| Rate for Payer: Humana Commercial |
$770.95
|
| Rate for Payer: Humana KY Medicaid |
$311.92
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Kentucky WC Medicaid |
$315.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$743.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$669.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$318.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$798.16
|
| Rate for Payer: Ohio Health Group HMO |
$680.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$181.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$281.17
|
| Rate for Payer: PHCS Commercial |
$870.72
|
| Rate for Payer: United Healthcare All Payer |
$798.16
|
|
|
SKL FIX PHLNGLSHFTFXPRXMIDPXFT
|
Facility
|
IP
|
$907.00
|
|
|
Service Code
|
HCPCS 26727
|
| Hospital Charge Code |
76100738
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$117.91 |
| Max. Negotiated Rate |
$870.72 |
| Rate for Payer: Aetna Commercial |
$698.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$707.46
|
| Rate for Payer: Cash Price |
$453.50
|
| Rate for Payer: Cigna Commercial |
$752.81
|
| Rate for Payer: First Health Commercial |
$861.65
|
| Rate for Payer: Humana Commercial |
$770.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$743.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$669.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$272.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$798.16
|
| Rate for Payer: Ohio Health Group HMO |
$680.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$181.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$281.17
|
| Rate for Payer: PHCS Commercial |
$870.72
|
| Rate for Payer: United Healthcare All Payer |
$798.16
|
|
|
SKL FIX PHLNGLSHFTFXPRXMIDPXFT
|
Professional
|
Both
|
$907.00
|
|
|
Service Code
|
HCPCS 26727
|
| Hospital Charge Code |
761P0738
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$219.32 |
| Max. Negotiated Rate |
$907.00 |
| Rate for Payer: Aetna Commercial |
$660.66
|
| Rate for Payer: Anthem Medicaid |
$219.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$907.00
|
| Rate for Payer: Cash Price |
$453.50
|
| Rate for Payer: Cash Price |
$453.50
|
| Rate for Payer: Cigna Commercial |
$744.94
|
| Rate for Payer: Healthspan PPO |
$598.42
|
| Rate for Payer: Humana Medicaid |
$219.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$570.72
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$223.71
|
| Rate for Payer: Molina Healthcare Passport |
$219.32
|
| Rate for Payer: Multiplan PHCS |
$544.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$634.90
|
| Rate for Payer: UHCCP Medicaid |
$317.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$221.51
|
|
|
SKN SPLT A-GRFT F/N/HF/G ADD
|
Facility
|
OP
|
$3,505.50
|
|
|
Service Code
|
HCPCS 15121
|
| Hospital Charge Code |
76100182
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$455.72 |
| Max. Negotiated Rate |
$3,365.28 |
| Rate for Payer: Aetna Commercial |
$2,699.24
|
| Rate for Payer: Anthem Medicaid |
$1,205.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,734.29
|
| Rate for Payer: Cash Price |
$1,752.75
|
| Rate for Payer: Cigna Commercial |
$2,909.56
|
| Rate for Payer: First Health Commercial |
$3,330.22
|
| Rate for Payer: Humana Commercial |
$2,979.68
|
| Rate for Payer: Humana KY Medicaid |
$1,205.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1,217.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,874.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,587.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,051.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,229.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,084.84
|
| Rate for Payer: Ohio Health Group HMO |
$2,629.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$701.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$455.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,086.70
|
| Rate for Payer: PHCS Commercial |
$3,365.28
|
| Rate for Payer: United Healthcare All Payer |
$3,084.84
|
|
|
SKN SPLT A-GRFT F/N/HF/G ADD
|
Facility
|
IP
|
$3,505.50
|
|
|
Service Code
|
HCPCS 15121
|
| Hospital Charge Code |
76100182
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$455.72 |
| Max. Negotiated Rate |
$3,365.28 |
| Rate for Payer: Aetna Commercial |
$2,699.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,734.29
|
| Rate for Payer: Cash Price |
$1,752.75
|
| Rate for Payer: Cigna Commercial |
$2,909.56
|
| Rate for Payer: First Health Commercial |
$3,330.22
|
| Rate for Payer: Humana Commercial |
$2,979.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,874.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,587.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,051.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,084.84
|
| Rate for Payer: Ohio Health Group HMO |
$2,629.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$701.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$455.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,086.70
|
| Rate for Payer: PHCS Commercial |
$3,365.28
|
| Rate for Payer: United Healthcare All Payer |
$3,084.84
|
|
|
SKN SPLT A-GRFT F/N/HF/G ADD
|
Professional
|
Both
|
$3,505.50
|
|
|
Service Code
|
HCPCS 15121
|
| Hospital Charge Code |
76100182
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$82.31 |
| Max. Negotiated Rate |
$3,505.50 |
| Rate for Payer: Aetna Commercial |
$255.76
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$82.31
|
| Rate for Payer: Anthem Medicaid |
$169.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,505.50
|
| Rate for Payer: Cash Price |
$1,752.75
|
| Rate for Payer: Cash Price |
$1,752.75
|
| Rate for Payer: Cigna Commercial |
$256.95
|
| Rate for Payer: Healthspan PPO |
$299.94
|
| Rate for Payer: Humana Medicaid |
$169.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$215.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$172.67
|
| Rate for Payer: Molina Healthcare Passport |
$169.28
|
| Rate for Payer: Multiplan PHCS |
$2,103.30
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,453.85
|
| Rate for Payer: UHCCP Medicaid |
$86.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$170.97
|
|
|
SKN SPLT A-GRFT F/N/HF/G AD(P
|
Professional
|
Both
|
$700.00
|
|
|
Service Code
|
HCPCS 15121
|
| Hospital Charge Code |
761P0182
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$82.31 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Commercial |
$255.76
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$82.31
|
| Rate for Payer: Anthem Medicaid |
$169.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$700.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$256.95
|
| Rate for Payer: Healthspan PPO |
$299.94
|
| Rate for Payer: Humana Medicaid |
$169.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$215.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$172.67
|
| Rate for Payer: Molina Healthcare Passport |
$169.28
|
| Rate for Payer: Multiplan PHCS |
$420.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$490.00
|
| Rate for Payer: UHCCP Medicaid |
$86.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$170.97
|
|
|
SKN SPLT A-GRFT F/N/HF/G AD(T
|
Facility
|
OP
|
$2,805.50
|
|
|
Service Code
|
HCPCS 15121
|
| Hospital Charge Code |
761T0182
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$364.72 |
| Max. Negotiated Rate |
$2,693.28 |
| Rate for Payer: Aetna Commercial |
$2,160.24
|
| Rate for Payer: Anthem Medicaid |
$964.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,188.29
|
| Rate for Payer: Cash Price |
$1,402.75
|
| Rate for Payer: Cigna Commercial |
$2,328.56
|
| Rate for Payer: First Health Commercial |
$2,665.22
|
| Rate for Payer: Humana Commercial |
$2,384.68
|
| Rate for Payer: Humana KY Medicaid |
$964.81
|
| Rate for Payer: Kentucky WC Medicaid |
$974.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,300.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,070.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$841.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$984.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,468.84
|
| Rate for Payer: Ohio Health Group HMO |
$2,104.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$561.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$364.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$869.70
|
| Rate for Payer: PHCS Commercial |
$2,693.28
|
| Rate for Payer: United Healthcare All Payer |
$2,468.84
|
|
|
SKN SPLT A-GRFT F/N/HF/G AD(T
|
Facility
|
IP
|
$2,805.50
|
|
|
Service Code
|
HCPCS 15121
|
| Hospital Charge Code |
761T0182
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$364.72 |
| Max. Negotiated Rate |
$2,693.28 |
| Rate for Payer: Aetna Commercial |
$2,160.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,188.29
|
| Rate for Payer: Cash Price |
$1,402.75
|
| Rate for Payer: Cigna Commercial |
$2,328.56
|
| Rate for Payer: First Health Commercial |
$2,665.22
|
| Rate for Payer: Humana Commercial |
$2,384.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,300.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,070.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$841.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,468.84
|
| Rate for Payer: Ohio Health Group HMO |
$2,104.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$561.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$364.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$869.70
|
| Rate for Payer: PHCS Commercial |
$2,693.28
|
| Rate for Payer: United Healthcare All Payer |
$2,468.84
|
|
|
SKN SUB GRFT F/N/HF/G CH ADD
|
Facility
|
IP
|
$221.00
|
|
|
Service Code
|
HCPCS 15278
|
| Hospital Charge Code |
76100198
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$28.73 |
| Max. Negotiated Rate |
$212.16 |
| Rate for Payer: Aetna Commercial |
$170.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$172.38
|
| Rate for Payer: Cash Price |
$110.50
|
| Rate for Payer: Cigna Commercial |
$183.43
|
| Rate for Payer: First Health Commercial |
$209.95
|
| Rate for Payer: Humana Commercial |
$187.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$181.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$163.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$66.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$194.48
|
| Rate for Payer: Ohio Health Group HMO |
$165.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$68.51
|
| Rate for Payer: PHCS Commercial |
$212.16
|
| Rate for Payer: United Healthcare All Payer |
$194.48
|
|
|
SKN SUB GRFT F/N/HF/G CH ADD
|
Facility
|
OP
|
$221.00
|
|
|
Service Code
|
HCPCS 15278
|
| Hospital Charge Code |
76100198
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$28.73 |
| Max. Negotiated Rate |
$212.16 |
| Rate for Payer: Aetna Commercial |
$170.17
|
| Rate for Payer: Anthem Medicaid |
$76.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$172.38
|
| Rate for Payer: Cash Price |
$110.50
|
| Rate for Payer: Cigna Commercial |
$183.43
|
| Rate for Payer: First Health Commercial |
$209.95
|
| Rate for Payer: Humana Commercial |
$187.85
|
| Rate for Payer: Humana KY Medicaid |
$76.00
|
| Rate for Payer: Kentucky WC Medicaid |
$76.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$181.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$163.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$66.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$77.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$194.48
|
| Rate for Payer: Ohio Health Group HMO |
$165.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$68.51
|
| Rate for Payer: PHCS Commercial |
$212.16
|
| Rate for Payer: United Healthcare All Payer |
$194.48
|
|
|
SKN SUB GRFT F/N/HF/G CH ADD
|
Professional
|
Both
|
$221.00
|
|
|
Service Code
|
HCPCS 15278
|
| Hospital Charge Code |
76100198
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$28.90 |
| Max. Negotiated Rate |
$221.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$28.90
|
| Rate for Payer: Anthem Medicaid |
$44.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$221.00
|
| Rate for Payer: Cash Price |
$110.50
|
| Rate for Payer: Cash Price |
$110.50
|
| Rate for Payer: Cigna Commercial |
$92.93
|
| Rate for Payer: Healthspan PPO |
$74.37
|
| Rate for Payer: Humana Medicaid |
$44.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$68.21
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$44.99
|
| Rate for Payer: Molina Healthcare Passport |
$44.11
|
| Rate for Payer: Multiplan PHCS |
$132.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$154.70
|
| Rate for Payer: UHCCP Medicaid |
$30.34
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$44.55
|
|
|
SKN SUB GRFT F/N/HF/G CH AD(P
|
Professional
|
Both
|
$130.00
|
|
|
Service Code
|
HCPCS 15278
|
| Hospital Charge Code |
761P0198
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$28.90 |
| Max. Negotiated Rate |
$130.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$28.90
|
| Rate for Payer: Anthem Medicaid |
$44.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$130.00
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cigna Commercial |
$92.93
|
| Rate for Payer: Healthspan PPO |
$74.37
|
| Rate for Payer: Humana Medicaid |
$44.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$68.21
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$44.99
|
| Rate for Payer: Molina Healthcare Passport |
$44.11
|
| Rate for Payer: Multiplan PHCS |
$78.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$91.00
|
| Rate for Payer: UHCCP Medicaid |
$30.34
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$44.55
|
|
|
SKN SUB GRFT F/N/HF/G CH AD(T
|
Facility
|
IP
|
$91.00
|
|
|
Service Code
|
HCPCS 15278
|
| Hospital Charge Code |
761T0198
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$11.83 |
| Max. Negotiated Rate |
$87.36 |
| Rate for Payer: Aetna Commercial |
$70.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$70.98
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cigna Commercial |
$75.53
|
| Rate for Payer: First Health Commercial |
$86.45
|
| Rate for Payer: Humana Commercial |
$77.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.08
|
| Rate for Payer: Ohio Health Group HMO |
$68.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.21
|
| Rate for Payer: PHCS Commercial |
$87.36
|
| Rate for Payer: United Healthcare All Payer |
$80.08
|
|
