|
SKIN TEST- TB -INTRADERMAL
|
Professional
|
Both
|
$25.00
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
30001103
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$4.45 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: Aetna Commercial |
$11.06
|
| Rate for Payer: Ambetter Exchange |
$8.88
|
| Rate for Payer: Anthem Medicaid |
$6.95
|
| Rate for Payer: Buckeye Individual/Medicaid |
$8.88
|
| Rate for Payer: Buckeye Medicare Advantage |
$8.88
|
| Rate for Payer: CareSource Just4Me Medicare |
$10.66
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cash Price |
$12.50
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$8.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.88
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$7.09
|
| Rate for Payer: Molina Healthcare Passport |
$6.95
|
| Rate for Payer: Multiplan PHCS |
$15.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$11.54
|
| Rate for Payer: UHCCP Medicaid |
$8.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$4.45
|
| Rate for Payer: Wellcare Medicare Advantage |
$8.88
|
|
|
SKIN TEST- TB -INTRADERMAL
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
30001103
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$17.25 |
| Max. Negotiated Rate |
$31.68 |
| Rate for Payer: Aetna Commercial |
$19.25
|
| Rate for Payer: Anthem Medicaid |
$22.63
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$22.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.07
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$31.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$22.63
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cigna Commercial |
$20.75
|
| Rate for Payer: First Health Commercial |
$23.75
|
| Rate for Payer: Humana Commercial |
$21.25
|
| Rate for Payer: Humana KY Medicaid |
$22.63
|
| Rate for Payer: Humana Medicare Advantage |
$22.63
|
| Rate for Payer: Kentucky WC Medicaid |
$22.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.00
|
| Rate for Payer: Ohio Health Group HMO |
$18.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.25
|
| Rate for Payer: PHCS Commercial |
$24.00
|
| Rate for Payer: United Healthcare All Payer |
$22.00
|
|
|
SKIN TISSUE REARRANGEMENT
|
Facility
|
OP
|
$5,825.33
|
|
|
Service Code
|
HCPCS 14001
|
| Hospital Charge Code |
76100163
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,690.17 |
| 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 |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,543.76
|
| 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 |
$2,912.66
|
| 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 |
$1,690.17
|
| 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 |
$2,028.20
|
| 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 |
$4,660.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,068.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,019.48
|
| 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 |
$3,495.20 |
| Rate for Payer: Aetna Commercial |
$940.13
|
| Rate for Payer: Ambetter Exchange |
$615.84
|
| 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 Individual/Medicaid |
$615.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$615.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$739.01
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$615.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.84
|
| 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 |
$800.59
|
| Rate for Payer: UHCCP Medicaid |
$348.47
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$377.90
|
| Rate for Payer: Wellcare Medicare Advantage |
$615.84
|
|
|
SKIN TISSUE REARRANGEMENT
|
Facility
|
IP
|
$5,825.33
|
|
|
Service Code
|
HCPCS 14001
|
| Hospital Charge Code |
76100163
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,747.60 |
| 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 |
$4,660.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,068.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,019.48
|
| Rate for Payer: PHCS Commercial |
$5,592.32
|
| Rate for Payer: United Healthcare All Payer |
$5,126.29
|
|
|
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 |
$954.11 |
| Rate for Payer: Aetna Commercial |
$940.13
|
| Rate for Payer: Ambetter Exchange |
$615.84
|
| 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 Individual/Medicaid |
$615.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$615.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$739.01
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$615.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.84
|
| 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 |
$800.59
|
| Rate for Payer: UHCCP Medicaid |
$348.47
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$377.90
|
| Rate for Payer: Wellcare Medicare Advantage |
$615.84
|
|
|
SKIN TISSUE REARRANGEMENT(T
|
Facility
|
OP
|
$4,825.33
|
|
|
Service Code
|
HCPCS 14001
|
| Hospital Charge Code |
761T0163
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,659.43 |
| 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 |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,763.76
|
| 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 |
$2,412.66
|
| 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 |
$1,690.17
|
| 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 |
$2,028.20
|
| 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 |
$3,860.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,198.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,329.48
|
| 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 |
$1,447.60 |
| 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 |
$3,860.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,198.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,329.48
|
| Rate for Payer: PHCS Commercial |
$4,632.32
|
| Rate for Payer: United Healthcare All Payer |
$4,246.29
|
|
|
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 |
$744.94 |
| Rate for Payer: Aetna Commercial |
$660.66
|
| Rate for Payer: Ambetter Exchange |
$454.32
|
| Rate for Payer: Anthem Medicaid |
$219.32
|
| Rate for Payer: Buckeye Individual/Medicaid |
$454.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$454.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$545.18
|
| 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 |
$598.41
|
| Rate for Payer: Humana Medicaid |
$219.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$570.72
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$454.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$454.32
|
| 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 |
$590.62
|
| Rate for Payer: UHCCP Medicaid |
$317.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$221.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$454.32
|
|
|
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 |
$744.94 |
| Rate for Payer: Aetna Commercial |
$660.66
|
| Rate for Payer: Ambetter Exchange |
$454.32
|
| Rate for Payer: Anthem Medicaid |
$219.32
|
| Rate for Payer: Buckeye Individual/Medicaid |
$454.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$454.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$545.18
|
| 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 |
$598.41
|
| Rate for Payer: Humana Medicaid |
$219.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$570.72
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$454.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$454.32
|
| 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 |
$590.62
|
| Rate for Payer: UHCCP Medicaid |
$317.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$221.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$454.32
|
|
|
SKL FIX PHLNGLSHFTFXPRXMIDPXFT
|
Facility
|
IP
|
$907.00
|
|
|
Service Code
|
HCPCS 26727
|
| Hospital Charge Code |
76100738
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$272.10 |
| 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 |
$725.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$789.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$625.83
|
| Rate for Payer: PHCS Commercial |
$870.72
|
| Rate for Payer: United Healthcare All Payer |
$798.16
|
|
|
SKL FIX PHLNGLSHFTFXPRXMIDPXFT
|
Facility
|
OP
|
$907.00
|
|
|
Service Code
|
HCPCS 26727
|
| Hospital Charge Code |
76100738
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$311.92 |
| Max. Negotiated Rate |
$4,197.13 |
| Rate for Payer: Aetna Commercial |
$698.39
|
| Rate for Payer: Anthem Medicaid |
$311.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,997.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$707.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| 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 |
$2,997.95
|
| 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 |
$3,597.54
|
| 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 |
$725.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$789.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$625.83
|
| Rate for Payer: PHCS Commercial |
$870.72
|
| Rate for Payer: United Healthcare All Payer |
$798.16
|
|
|
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 |
$1,051.65 |
| 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 |
$2,909.57
|
| 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 |
$2,804.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,049.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,418.80
|
| 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 |
$2,103.30 |
| Rate for Payer: Aetna Commercial |
$255.76
|
| Rate for Payer: Ambetter Exchange |
$123.22
|
| 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 Individual/Medicaid |
$123.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$123.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$147.86
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$123.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$123.22
|
| 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 |
$160.19
|
| Rate for Payer: UHCCP Medicaid |
$86.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$170.97
|
| Rate for Payer: Wellcare Medicare Advantage |
$123.22
|
|
|
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 |
$1,051.65 |
| 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 |
$2,909.57
|
| 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 |
$2,804.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,049.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,418.80
|
| 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 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 |
$420.00 |
| Rate for Payer: Aetna Commercial |
$255.76
|
| Rate for Payer: Ambetter Exchange |
$123.22
|
| 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 Individual/Medicaid |
$123.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$123.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$147.86
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$123.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$123.22
|
| 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 |
$160.19
|
| Rate for Payer: UHCCP Medicaid |
$86.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$170.97
|
| Rate for Payer: Wellcare Medicare Advantage |
$123.22
|
|
|
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 |
$841.65 |
| 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 |
$2,328.57
|
| 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 |
$2,244.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,440.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,935.80
|
| 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
|
OP
|
$2,805.50
|
|
|
Service Code
|
HCPCS 15121
|
| Hospital Charge Code |
761T0182
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$841.65 |
| 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 |
$2,328.57
|
| 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 |
$2,244.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,440.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,935.80
|
| 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 |
$66.30 |
| 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 |
$176.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$192.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$152.49
|
| 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 |
$66.30 |
| 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 |
$176.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$192.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$152.49
|
| 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 |
$132.60 |
| Rate for Payer: Ambetter Exchange |
$52.92
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$28.90
|
| Rate for Payer: Anthem Medicaid |
$65.05
|
| Rate for Payer: Buckeye Individual/Medicaid |
$52.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$52.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$63.50
|
| 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 |
$65.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$68.21
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$52.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$52.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$66.35
|
| Rate for Payer: Molina Healthcare Passport |
$65.05
|
| Rate for Payer: Multiplan PHCS |
$132.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$68.80
|
| Rate for Payer: UHCCP Medicaid |
$30.34
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$65.70
|
| Rate for Payer: Wellcare Medicare Advantage |
$52.92
|
|
|
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 |
$92.93 |
| Rate for Payer: Ambetter Exchange |
$52.92
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$28.90
|
| Rate for Payer: Anthem Medicaid |
$65.05
|
| Rate for Payer: Buckeye Individual/Medicaid |
$52.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$52.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$63.50
|
| 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 |
$65.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$68.21
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$52.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$52.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$66.35
|
| Rate for Payer: Molina Healthcare Passport |
$65.05
|
| Rate for Payer: Multiplan PHCS |
$78.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$68.80
|
| Rate for Payer: UHCCP Medicaid |
$30.34
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$65.70
|
| Rate for Payer: Wellcare Medicare Advantage |
$52.92
|
|
|
SKN SUB GRFT F/N/HF/G CH AD(T
|
Facility
|
OP
|
$91.00
|
|
|
Service Code
|
HCPCS 15278
|
| Hospital Charge Code |
761T0198
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$27.30 |
| Max. Negotiated Rate |
$87.36 |
| Rate for Payer: Aetna Commercial |
$70.07
|
| Rate for Payer: Anthem Medicaid |
$31.29
|
| 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: Humana KY Medicaid |
$31.29
|
| Rate for Payer: Kentucky WC Medicaid |
$31.61
|
| 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: Molina Healthcare Medicaid |
$31.92
|
| 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 |
$72.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.79
|
| Rate for Payer: PHCS Commercial |
$87.36
|
| Rate for Payer: United Healthcare All Payer |
$80.08
|
|
|
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 |
$27.30 |
| 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 |
$72.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.79
|
| Rate for Payer: PHCS Commercial |
$87.36
|
| Rate for Payer: United Healthcare All Payer |
$80.08
|
|
|
SKN SUB GRFT T/A/L CHILD ADD
|
Professional
|
Both
|
$575.00
|
|
|
Service Code
|
HCPCS 15274
|
| Hospital Charge Code |
76100193
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$23.19 |
| Max. Negotiated Rate |
$345.00 |
| Rate for Payer: Ambetter Exchange |
$41.54
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$23.19
|
| Rate for Payer: Anthem Medicaid |
$55.00
|
| Rate for Payer: Buckeye Individual/Medicaid |
$41.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$41.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$49.85
|
| Rate for Payer: Cash Price |
$287.50
|
| Rate for Payer: Cash Price |
$287.50
|
| Rate for Payer: Cigna Commercial |
$75.03
|
| Rate for Payer: Healthspan PPO |
$62.80
|
| Rate for Payer: Humana Medicaid |
$55.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$54.99
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$41.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$56.10
|
| Rate for Payer: Molina Healthcare Passport |
$55.00
|
| Rate for Payer: Multiplan PHCS |
$345.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$54.00
|
| Rate for Payer: UHCCP Medicaid |
$24.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$55.55
|
| Rate for Payer: Wellcare Medicare Advantage |
$41.54
|
|
