|
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 |
$3,182.10 |
| Rate for Payer: Aetna Commercial |
$938.16
|
| Rate for Payer: Ambetter Exchange |
$633.13
|
| 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 Individual/Medicaid |
$633.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$633.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$759.76
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$633.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$633.13
|
| 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 |
$823.07
|
| Rate for Payer: UHCCP Medicaid |
$359.37
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$349.90
|
| Rate for Payer: Wellcare Medicare Advantage |
$633.13
|
|
|
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 |
$882.00 |
| 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 |
$2,352.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,557.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,028.60
|
| Rate for Payer: PHCS Commercial |
$2,822.40
|
| Rate for Payer: United Healthcare All Payer |
$2,587.20
|
|
|
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 |
$1,764.00 |
| Rate for Payer: Aetna Commercial |
$120.24
|
| Rate for Payer: Ambetter Exchange |
$71.97
|
| 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 Individual/Medicaid |
$71.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$71.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$86.36
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$71.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$71.97
|
| 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 |
$93.56
|
| Rate for Payer: UHCCP Medicaid |
$56.56
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$96.90
|
| Rate for Payer: Wellcare Medicare Advantage |
$71.97
|
|
|
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 |
$882.00 |
| 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 |
$2,352.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,557.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,028.60
|
| 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 |
$207.00 |
| Rate for Payer: Aetna Commercial |
$120.24
|
| Rate for Payer: Ambetter Exchange |
$71.97
|
| 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 Individual/Medicaid |
$71.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$71.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$86.36
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$71.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$71.97
|
| 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 |
$93.56
|
| Rate for Payer: UHCCP Medicaid |
$56.56
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$96.90
|
| Rate for Payer: Wellcare Medicare Advantage |
$71.97
|
|
|
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 |
$778.50 |
| 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 |
$2,076.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,257.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,790.55
|
| 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 |
$778.50 |
| 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 |
$2,076.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,257.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,790.55
|
| 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 |
$938.16 |
| Rate for Payer: Aetna Commercial |
$938.16
|
| Rate for Payer: Ambetter Exchange |
$633.13
|
| 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 Individual/Medicaid |
$633.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$633.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$759.76
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$633.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$633.13
|
| 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 |
$823.07
|
| Rate for Payer: UHCCP Medicaid |
$359.37
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$349.90
|
| Rate for Payer: Wellcare Medicare Advantage |
$633.13
|
|
|
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 |
$1,247.55 |
| Max. Negotiated Rate |
$3,992.16 |
| Rate for Payer: Aetna Commercial |
$3,202.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,243.63
|
| Rate for Payer: Cash Price |
$2,079.25
|
| Rate for Payer: Cigna Commercial |
$3,451.55
|
| Rate for Payer: First Health Commercial |
$3,950.57
|
| 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 |
$3,326.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,617.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,869.36
|
| Rate for Payer: PHCS Commercial |
$3,992.16
|
| Rate for Payer: United Healthcare All Payer |
$3,659.48
|
|
|
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 |
$1,430.11 |
| Max. Negotiated Rate |
$3,992.16 |
| Rate for Payer: Aetna Commercial |
$3,202.05
|
| Rate for Payer: Anthem Medicaid |
$1,430.11
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,243.63
|
| 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 |
$2,079.25
|
| Rate for Payer: Cash Price |
$2,079.25
|
| Rate for Payer: Cigna Commercial |
$3,451.55
|
| Rate for Payer: First Health Commercial |
$3,950.57
|
| Rate for Payer: Humana Commercial |
$3,534.72
|
| Rate for Payer: Humana KY Medicaid |
$1,430.11
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| 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 |
$2,028.20
|
| 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 |
$3,326.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,617.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,869.36
|
| 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
|
OP
|
$5,885.00
|
|
|
Service Code
|
HCPCS 15240
|
| Hospital Charge Code |
76100186
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,690.17 |
| Max. Negotiated Rate |
$5,649.60 |
| Rate for Payer: Aetna Commercial |
$4,531.45
|
| Rate for Payer: Anthem Medicaid |
$2,023.85
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,590.30
|
| 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 |
$2,942.50
|
| Rate for Payer: Cash Price |
$2,942.50
|
| Rate for Payer: Cigna Commercial |
$4,884.55
|
| Rate for Payer: First Health Commercial |
$5,590.75
|
| Rate for Payer: Humana Commercial |
$5,002.25
|
| Rate for Payer: Humana KY Medicaid |
$2,023.85
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$2,044.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,825.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,343.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,064.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,178.80
|
| Rate for Payer: Ohio Health Group HMO |
$4,413.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,708.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,119.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,060.65
|
| Rate for Payer: PHCS Commercial |
$5,649.60
|
| Rate for Payer: United Healthcare All Payer |
$5,178.80
|
|
|
SKIN FULL GRFT FACE/GENIT/HF
|
Professional
|
Both
|
$5,885.00
|
|
|
Service Code
|
HCPCS 15240
|
| Hospital Charge Code |
76100186
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$402.13 |
| Max. Negotiated Rate |
$3,531.00 |
| Rate for Payer: Aetna Commercial |
$1,122.45
|
| Rate for Payer: Ambetter Exchange |
$745.41
|
| 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 Individual/Medicaid |
$745.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$745.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$894.49
|
| Rate for Payer: Cash Price |
$2,942.50
|
| Rate for Payer: Cash Price |
$2,942.50
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$745.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$745.41
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$440.83
|
| Rate for Payer: Molina Healthcare Passport |
$432.19
|
| Rate for Payer: Multiplan PHCS |
$3,531.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$969.03
|
| Rate for Payer: UHCCP Medicaid |
$422.24
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$436.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$745.41
|
|
|
SKIN FULL GRFT FACE/GENIT/HF
|
Facility
|
IP
|
$5,885.00
|
|
|
Service Code
|
HCPCS 15240
|
| Hospital Charge Code |
76100186
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,765.50 |
| Max. Negotiated Rate |
$5,649.60 |
| Rate for Payer: Aetna Commercial |
$4,531.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,590.30
|
| Rate for Payer: Cash Price |
$2,942.50
|
| Rate for Payer: Cigna Commercial |
$4,884.55
|
| Rate for Payer: First Health Commercial |
$5,590.75
|
| Rate for Payer: Humana Commercial |
$5,002.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,825.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,343.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,765.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,178.80
|
| Rate for Payer: Ohio Health Group HMO |
$4,413.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,708.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,119.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,060.65
|
| Rate for Payer: PHCS Commercial |
$5,649.60
|
| Rate for Payer: United Healthcare All Payer |
$5,178.80
|
|
|
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 |
$1,122.45 |
| Rate for Payer: Aetna Commercial |
$1,122.45
|
| Rate for Payer: Ambetter Exchange |
$745.41
|
| 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 Individual/Medicaid |
$745.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$745.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$894.49
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$745.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$745.41
|
| 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 |
$969.03
|
| Rate for Payer: UHCCP Medicaid |
$422.24
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$436.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$745.41
|
|
|
SKIN FULL GRFT FACE/GENIT/H(T
|
Facility
|
OP
|
$4,545.00
|
|
|
Service Code
|
HCPCS 15240
|
| Hospital Charge Code |
761T0186
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,563.03 |
| Max. Negotiated Rate |
$4,363.20 |
| Rate for Payer: Aetna Commercial |
$3,499.65
|
| Rate for Payer: Anthem Medicaid |
$1,563.03
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,545.10
|
| 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 |
$2,272.50
|
| Rate for Payer: Cash Price |
$2,272.50
|
| Rate for Payer: Cigna Commercial |
$3,772.35
|
| Rate for Payer: First Health Commercial |
$4,317.75
|
| Rate for Payer: Humana Commercial |
$3,863.25
|
| Rate for Payer: Humana KY Medicaid |
$1,563.03
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,578.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,726.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,354.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,594.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,999.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,408.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,954.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,136.05
|
| Rate for Payer: PHCS Commercial |
$4,363.20
|
| Rate for Payer: United Healthcare All Payer |
$3,999.60
|
|
|
SKIN FULL GRFT FACE/GENIT/H(T
|
Facility
|
IP
|
$4,545.00
|
|
|
Service Code
|
HCPCS 15240
|
| Hospital Charge Code |
761T0186
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,363.50 |
| Max. Negotiated Rate |
$4,363.20 |
| Rate for Payer: Aetna Commercial |
$3,499.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,545.10
|
| Rate for Payer: Cash Price |
$2,272.50
|
| Rate for Payer: Cigna Commercial |
$3,772.35
|
| Rate for Payer: First Health Commercial |
$4,317.75
|
| Rate for Payer: Humana Commercial |
$3,863.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,726.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,354.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,363.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,999.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,408.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,954.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,136.05
|
| Rate for Payer: PHCS Commercial |
$4,363.20
|
| Rate for Payer: United Healthcare All Payer |
$3,999.60
|
|
|
SKINPEN-BODY LG AREA
|
Professional
|
Both
|
$1,000.00
|
|
| Hospital Charge Code |
22200777
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$350.00 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$350.00
|
|
|
SKINPEN-BODY LG AREA PP#1 50%
|
Professional
|
Both
|
$1,275.00
|
|
| Hospital Charge Code |
22200778
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$446.25 |
| Max. Negotiated Rate |
$892.50 |
| Rate for Payer: Cash Price |
$637.50
|
| Rate for Payer: Multiplan PHCS |
$765.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$892.50
|
| Rate for Payer: UHCCP Medicaid |
$446.25
|
|
|
SKINPEN-BODY LG AREAPP#2/3 25%
|
Professional
|
Both
|
$638.00
|
|
| Hospital Charge Code |
22200779
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$223.30 |
| Max. Negotiated Rate |
$446.60 |
| Rate for Payer: Cash Price |
$319.00
|
| Rate for Payer: Multiplan PHCS |
$382.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$446.60
|
| Rate for Payer: UHCCP Medicaid |
$223.30
|
|
|
SKINPEN-BODY SM AREA
|
Professional
|
Both
|
$800.00
|
|
| Hospital Charge Code |
22200774
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$280.00 |
| Max. Negotiated Rate |
$560.00 |
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$560.00
|
| Rate for Payer: UHCCP Medicaid |
$280.00
|
|
|
SKINPEN-BODY SM AREA PP#1 50%
|
Professional
|
Both
|
$1,020.00
|
|
| Hospital Charge Code |
22200775
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$357.00 |
| Max. Negotiated Rate |
$714.00 |
| Rate for Payer: Cash Price |
$510.00
|
| Rate for Payer: Multiplan PHCS |
$612.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$714.00
|
| Rate for Payer: UHCCP Medicaid |
$357.00
|
|
|
SKINPEN-BODY SM AREAPP#2/3 25%
|
Professional
|
Both
|
$510.00
|
|
| Hospital Charge Code |
22200776
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$178.50 |
| Max. Negotiated Rate |
$357.00 |
| Rate for Payer: Cash Price |
$255.00
|
| Rate for Payer: Multiplan PHCS |
$306.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$357.00
|
| Rate for Payer: UHCCP Medicaid |
$178.50
|
|
|
SKINPEN-CHEST
|
Professional
|
Both
|
$400.00
|
|
| Hospital Charge Code |
22200771
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$140.00 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$140.00
|
|
|
SKINPEN-CHEST PP#1 50%
|
Professional
|
Both
|
$510.00
|
|
| Hospital Charge Code |
22200772
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$178.50 |
| Max. Negotiated Rate |
$357.00 |
| Rate for Payer: Cash Price |
$255.00
|
| Rate for Payer: Multiplan PHCS |
$306.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$357.00
|
| Rate for Payer: UHCCP Medicaid |
$178.50
|
|
|
SKINPEN-CHEST PP#2/3 25%
|
Professional
|
Both
|
$255.00
|
|
| Hospital Charge Code |
22200773
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$89.25 |
| Max. Negotiated Rate |
$178.50 |
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Multiplan PHCS |
$153.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$178.50
|
| Rate for Payer: UHCCP Medicaid |
$89.25
|
|
