|
SKIN BRIGH PROG + TEXT KIT GBL
|
Facility
|
OP
|
$260.00
|
|
| Hospital Charge Code |
22200153
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$78.00 |
| Max. Negotiated Rate |
$249.60 |
| Rate for Payer: Aetna Commercial |
$200.20
|
| Rate for Payer: Anthem Medicaid |
$89.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$202.80
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Cigna Commercial |
$215.80
|
| Rate for Payer: First Health Commercial |
$247.00
|
| Rate for Payer: Humana Commercial |
$221.00
|
| Rate for Payer: Humana KY Medicaid |
$89.41
|
| Rate for Payer: Kentucky WC Medicaid |
$90.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$213.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$191.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$91.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$228.80
|
| Rate for Payer: Ohio Health Group HMO |
$195.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$208.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$226.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$179.40
|
| Rate for Payer: PHCS Commercial |
$249.60
|
| Rate for Payer: United Healthcare All Payer |
$228.80
|
|
|
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 |
$182.00 |
| 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 |
$126.00 |
| 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 BRIGHTEN PROGRAM KIT GBL
|
Facility
|
IP
|
$180.00
|
|
| Hospital Charge Code |
22200152
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$54.00 |
| Max. Negotiated Rate |
$172.80 |
| Rate for Payer: Aetna Commercial |
$138.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$140.40
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$149.40
|
| Rate for Payer: First Health Commercial |
$171.00
|
| Rate for Payer: Humana Commercial |
$153.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$147.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$132.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$158.40
|
| Rate for Payer: Ohio Health Group HMO |
$135.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$144.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$156.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.20
|
| Rate for Payer: PHCS Commercial |
$172.80
|
| Rate for Payer: United Healthcare All Payer |
$158.40
|
|
|
SKIN BRIGHTEN PROGRAM KIT GBL
|
Facility
|
OP
|
$180.00
|
|
| Hospital Charge Code |
22200152
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$54.00 |
| Max. Negotiated Rate |
$172.80 |
| Rate for Payer: Aetna Commercial |
$138.60
|
| Rate for Payer: Anthem Medicaid |
$61.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$140.40
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna Commercial |
$149.40
|
| Rate for Payer: First Health Commercial |
$171.00
|
| Rate for Payer: Humana Commercial |
$153.00
|
| Rate for Payer: Humana KY Medicaid |
$61.90
|
| Rate for Payer: Kentucky WC Medicaid |
$62.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$147.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$132.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$63.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$158.40
|
| Rate for Payer: Ohio Health Group HMO |
$135.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$144.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$156.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.20
|
| Rate for Payer: PHCS Commercial |
$172.80
|
| Rate for Payer: United Healthcare All Payer |
$158.40
|
|
|
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 |
$965.48 |
| 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 |
$2,638.97
|
| 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 |
$2,574.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,799.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,220.59
|
| 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 |
$997.25 |
| 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 |
$2,659.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,892.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,293.68
|
| Rate for Payer: PHCS Commercial |
$3,191.20
|
| Rate for Payer: United Healthcare All Payer |
$2,925.27
|
|
|
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 |
$1,994.50 |
| Rate for Payer: Aetna Commercial |
$109.53
|
| Rate for Payer: Ambetter Exchange |
$64.96
|
| 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 Individual/Medicaid |
$64.96
|
| Rate for Payer: Buckeye Medicare Advantage |
$64.96
|
| Rate for Payer: CareSource Just4Me Medicare |
$77.95
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$64.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$64.96
|
| 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 |
$84.45
|
| Rate for Payer: UHCCP Medicaid |
$51.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$90.62
|
| Rate for Payer: Wellcare Medicare Advantage |
$64.96
|
|
|
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 |
$965.48 |
| 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 |
$2,638.97
|
| 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 |
$2,574.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,799.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,220.59
|
| 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 |
$1,082.40 |
| 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 |
$2,886.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,138.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,489.52
|
| 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 |
$1,930.95 |
| Rate for Payer: Aetna Commercial |
$170.31
|
| Rate for Payer: Ambetter Exchange |
$100.50
|
| 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 Individual/Medicaid |
$100.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$100.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$120.60
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$100.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$100.50
|
| 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 |
$130.65
|
| Rate for Payer: UHCCP Medicaid |
$80.64
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$133.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$100.50
|
|
|
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 |
$1,082.40 |
| 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 |
$2,886.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,138.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,489.52
|
| 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
|
$3,608.00
|
|
|
Service Code
|
HCPCS 15261
|
| Hospital Charge Code |
76100189
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$107.31 |
| Max. Negotiated Rate |
$2,164.80 |
| Rate for Payer: Aetna Commercial |
$211.13
|
| Rate for Payer: Ambetter Exchange |
$126.48
|
| 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 Individual/Medicaid |
$126.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$126.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$151.78
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$126.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$126.48
|
| 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 |
$164.42
|
| Rate for Payer: UHCCP Medicaid |
$112.68
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$158.02
|
| Rate for Payer: Wellcare Medicare Advantage |
$126.48
|
|
|
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 |
$997.25 |
| 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 |
$2,659.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,892.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,293.68
|
| 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
|
$545.00
|
|
|
Service Code
|
HCPCS 15241
|
| Hospital Charge Code |
761P0187
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$76.80 |
| Max. Negotiated Rate |
$327.00 |
| Rate for Payer: Aetna Commercial |
$170.31
|
| Rate for Payer: Ambetter Exchange |
$100.50
|
| 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 Individual/Medicaid |
$100.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$100.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$120.60
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$100.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$100.50
|
| 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 |
$130.65
|
| Rate for Payer: UHCCP Medicaid |
$80.64
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$133.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$100.50
|
|
|
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 |
$336.00 |
| Rate for Payer: Aetna Commercial |
$109.53
|
| Rate for Payer: Ambetter Exchange |
$64.96
|
| 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 Individual/Medicaid |
$64.96
|
| Rate for Payer: Buckeye Medicare Advantage |
$64.96
|
| Rate for Payer: CareSource Just4Me Medicare |
$77.95
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$64.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$64.96
|
| 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 |
$84.45
|
| Rate for Payer: UHCCP Medicaid |
$51.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$90.62
|
| Rate for Payer: Wellcare Medicare Advantage |
$64.96
|
|
|
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 |
$402.00 |
| Rate for Payer: Aetna Commercial |
$211.13
|
| Rate for Payer: Ambetter Exchange |
$126.48
|
| 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 Individual/Medicaid |
$126.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$126.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$151.78
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$126.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$126.48
|
| 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 |
$164.42
|
| Rate for Payer: UHCCP Medicaid |
$112.68
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$158.02
|
| Rate for Payer: Wellcare Medicare Advantage |
$126.48
|
|
|
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 |
$801.98 |
| 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 |
$2,192.07
|
| 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 |
$2,138.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,325.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,844.54
|
| 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
|
OP
|
$2,673.25
|
|
|
Service Code
|
HCPCS 15241
|
| Hospital Charge Code |
761T0187
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$801.98 |
| Max. Negotiated Rate |
$2,566.32 |
| Rate for Payer: Aetna Commercial |
$2,058.40
|
| Rate for Payer: Anthem Medicaid |
$919.33
|
| 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: Humana KY Medicaid |
$919.33
|
| Rate for Payer: Kentucky WC Medicaid |
$928.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,192.07
|
| 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: Molina Healthcare Medicaid |
$937.78
|
| 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 |
$2,138.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,325.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,844.54
|
| 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
|
OP
|
$2,764.17
|
|
|
Service Code
|
HCPCS 15221
|
| Hospital Charge Code |
761T0185
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$829.25 |
| 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 |
$2,211.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,404.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,907.28
|
| 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
|
IP
|
$2,764.17
|
|
|
Service Code
|
HCPCS 15221
|
| Hospital Charge Code |
761T0185
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$829.25 |
| 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 |
$2,211.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,404.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,907.28
|
| 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
|
$2,938.00
|
|
|
Service Code
|
HCPCS 15261
|
| Hospital Charge Code |
761T0189
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$881.40 |
| 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 |
$2,350.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,556.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,027.22
|
| 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
|
$2,938.00
|
|
|
Service Code
|
HCPCS 15261
|
| Hospital Charge Code |
761T0189
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$881.40 |
| 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 |
$2,350.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,556.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,027.22
|
| Rate for Payer: PHCS Commercial |
$2,820.48
|
| Rate for Payer: United Healthcare All Payer |
$2,585.44
|
|
|
SKIN FULL GRAFT TRUNK
|
Facility
|
OP
|
$5,303.50
|
|
|
Service Code
|
HCPCS 15200
|
| Hospital Charge Code |
76100183
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,690.17 |
| 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 |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,136.73
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Cash Price |
$2,651.75
|
| 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 |
$1,690.17
|
| 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 |
$2,028.20
|
| 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 |
$4,242.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,614.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,659.41
|
| 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 |
$1,591.05 |
| 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 |
$4,242.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,614.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,659.41
|
| Rate for Payer: PHCS Commercial |
$5,091.36
|
| Rate for Payer: United Healthcare All Payer |
$4,667.08
|
|
