|
SPLENIC ARTERIOGRAM
|
Facility
|
IP
|
$7,900.00
|
|
|
Service Code
|
HCPCS 75726
|
| Hospital Charge Code |
32000384
|
|
Hospital Revenue Code
|
321
|
| Min. Negotiated Rate |
$2,370.00 |
| Max. Negotiated Rate |
$7,584.00 |
| Rate for Payer: Aetna Commercial |
$6,083.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,162.00
|
| Rate for Payer: Cash Price |
$3,950.00
|
| Rate for Payer: Cigna Commercial |
$6,557.00
|
| Rate for Payer: First Health Commercial |
$7,505.00
|
| Rate for Payer: Humana Commercial |
$6,715.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,478.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,830.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,370.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,952.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,925.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,873.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,451.00
|
| Rate for Payer: PHCS Commercial |
$7,584.00
|
| Rate for Payer: United Healthcare All Payer |
$6,952.00
|
|
|
SPLENIC ARTERIOGRAM
|
Facility
|
OP
|
$7,900.00
|
|
|
Service Code
|
HCPCS 75726
|
| Hospital Charge Code |
32000384
|
|
Hospital Revenue Code
|
321
|
| Min. Negotiated Rate |
$2,716.81 |
| Max. Negotiated Rate |
$7,584.00 |
| Rate for Payer: Aetna Commercial |
$6,083.00
|
| Rate for Payer: Anthem Medicaid |
$2,716.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,994.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,162.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,992.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,742.93
|
| Rate for Payer: Cash Price |
$3,950.00
|
| Rate for Payer: Cash Price |
$3,950.00
|
| Rate for Payer: Cigna Commercial |
$6,557.00
|
| Rate for Payer: First Health Commercial |
$7,505.00
|
| Rate for Payer: Humana Commercial |
$6,715.00
|
| Rate for Payer: Humana KY Medicaid |
$2,716.81
|
| Rate for Payer: Humana Medicare Advantage |
$4,994.76
|
| Rate for Payer: Kentucky WC Medicaid |
$2,744.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,478.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,830.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,993.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,771.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,952.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,925.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,873.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,451.00
|
| Rate for Payer: PHCS Commercial |
$7,584.00
|
| Rate for Payer: United Healthcare All Payer |
$6,952.00
|
|
|
SPLINT FABRICATION
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
HCPCS 97139
|
| Hospital Charge Code |
42000022
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$38.40 |
| Rate for Payer: Aetna Commercial |
$30.80
|
| Rate for Payer: Anthem Medicaid |
$13.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31.20
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$33.20
|
| Rate for Payer: First Health Commercial |
$38.00
|
| Rate for Payer: Humana Commercial |
$34.00
|
| Rate for Payer: Humana KY Medicaid |
$13.76
|
| Rate for Payer: Kentucky WC Medicaid |
$13.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$14.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$35.20
|
| Rate for Payer: Ohio Health Group HMO |
$30.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$34.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.60
|
| Rate for Payer: PHCS Commercial |
$38.40
|
| Rate for Payer: United Healthcare All Payer |
$35.20
|
|
|
SPLINT FABRICATION
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
HCPCS 97139
|
| Hospital Charge Code |
42000022
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$38.40 |
| Rate for Payer: Aetna Commercial |
$30.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31.20
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$33.20
|
| Rate for Payer: First Health Commercial |
$38.00
|
| Rate for Payer: Humana Commercial |
$34.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$35.20
|
| Rate for Payer: Ohio Health Group HMO |
$30.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$34.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.60
|
| Rate for Payer: PHCS Commercial |
$38.40
|
| Rate for Payer: United Healthcare All Payer |
$35.20
|
|
|
Splint supplies misc
|
Professional
|
Both
|
$25.00
|
|
|
Service Code
|
HCPCS Q4051
|
| Hospital Charge Code |
27000249
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5.84 |
| Max. Negotiated Rate |
$17.50 |
| Rate for Payer: Aetna Commercial |
$16.01
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$5.84
|
| Rate for Payer: Multiplan PHCS |
$15.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$17.50
|
| Rate for Payer: UHCCP Medicaid |
$8.75
|
|
|
SPLIT GRAF EA ADTL 100 CM
|
Facility
|
IP
|
$2,996.12
|
|
|
Service Code
|
HCPCS 15101
|
| Hospital Charge Code |
76100176
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$898.84 |
| Max. Negotiated Rate |
$2,876.28 |
| Rate for Payer: Aetna Commercial |
$2,307.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,336.97
|
| Rate for Payer: Cash Price |
$1,498.06
|
| Rate for Payer: Cigna Commercial |
$2,486.78
|
| Rate for Payer: First Health Commercial |
$2,846.31
|
| Rate for Payer: Humana Commercial |
$2,546.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,456.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,211.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$898.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,636.59
|
| Rate for Payer: Ohio Health Group HMO |
$2,247.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,396.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,606.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,067.32
|
| Rate for Payer: PHCS Commercial |
$2,876.28
|
| Rate for Payer: United Healthcare All Payer |
$2,636.59
|
|
|
SPLIT GRAF EA ADTL 100 CM
|
Professional
|
Both
|
$2,996.12
|
|
|
Service Code
|
HCPCS 15101
|
| Hospital Charge Code |
76100176
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$57.28 |
| Max. Negotiated Rate |
$1,797.67 |
| Rate for Payer: Aetna Commercial |
$167.22
|
| Rate for Payer: Ambetter Exchange |
$104.03
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$57.28
|
| Rate for Payer: Anthem Medicaid |
$101.14
|
| Rate for Payer: Buckeye Individual/Medicaid |
$104.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$104.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$124.84
|
| Rate for Payer: Cash Price |
$1,498.06
|
| Rate for Payer: Cash Price |
$1,498.06
|
| Rate for Payer: Cigna Commercial |
$165.77
|
| Rate for Payer: Healthspan PPO |
$211.60
|
| Rate for Payer: Humana Medicaid |
$101.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$140.36
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$104.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$104.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.16
|
| Rate for Payer: Molina Healthcare Passport |
$101.14
|
| Rate for Payer: Multiplan PHCS |
$1,797.67
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$135.24
|
| Rate for Payer: UHCCP Medicaid |
$60.14
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.15
|
| Rate for Payer: Wellcare Medicare Advantage |
$104.03
|
|
|
SPLIT GRAF EA ADTL 100 CM
|
Facility
|
OP
|
$2,996.12
|
|
|
Service Code
|
HCPCS 15101
|
| Hospital Charge Code |
76100176
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$898.84 |
| Max. Negotiated Rate |
$2,876.28 |
| Rate for Payer: Aetna Commercial |
$2,307.01
|
| Rate for Payer: Anthem Medicaid |
$1,030.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,336.97
|
| Rate for Payer: Cash Price |
$1,498.06
|
| Rate for Payer: Cigna Commercial |
$2,486.78
|
| Rate for Payer: First Health Commercial |
$2,846.31
|
| Rate for Payer: Humana Commercial |
$2,546.70
|
| Rate for Payer: Humana KY Medicaid |
$1,030.37
|
| Rate for Payer: Kentucky WC Medicaid |
$1,040.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,456.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,211.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$898.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,051.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,636.59
|
| Rate for Payer: Ohio Health Group HMO |
$2,247.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,396.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,606.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,067.32
|
| Rate for Payer: PHCS Commercial |
$2,876.28
|
| Rate for Payer: United Healthcare All Payer |
$2,636.59
|
|
|
SPLIT GRAF EA ADTL 100 CM(P
|
Professional
|
Both
|
$295.00
|
|
|
Service Code
|
HCPCS 15101
|
| Hospital Charge Code |
761P0176
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$57.28 |
| Max. Negotiated Rate |
$211.60 |
| Rate for Payer: Aetna Commercial |
$167.22
|
| Rate for Payer: Ambetter Exchange |
$104.03
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$57.28
|
| Rate for Payer: Anthem Medicaid |
$101.14
|
| Rate for Payer: Buckeye Individual/Medicaid |
$104.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$104.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$124.84
|
| Rate for Payer: Cash Price |
$147.50
|
| Rate for Payer: Cash Price |
$147.50
|
| Rate for Payer: Cigna Commercial |
$165.77
|
| Rate for Payer: Healthspan PPO |
$211.60
|
| Rate for Payer: Humana Medicaid |
$101.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$140.36
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$104.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$104.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.16
|
| Rate for Payer: Molina Healthcare Passport |
$101.14
|
| Rate for Payer: Multiplan PHCS |
$177.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$135.24
|
| Rate for Payer: UHCCP Medicaid |
$60.14
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.15
|
| Rate for Payer: Wellcare Medicare Advantage |
$104.03
|
|
|
SPLIT GRAF EA ADTL 100 CM(T
|
Facility
|
OP
|
$2,701.12
|
|
|
Service Code
|
HCPCS 15101
|
| Hospital Charge Code |
761T0176
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$810.34 |
| Max. Negotiated Rate |
$2,593.08 |
| Rate for Payer: Aetna Commercial |
$2,079.86
|
| Rate for Payer: Anthem Medicaid |
$928.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,106.87
|
| Rate for Payer: Cash Price |
$1,350.56
|
| Rate for Payer: Cigna Commercial |
$2,241.93
|
| Rate for Payer: First Health Commercial |
$2,566.06
|
| Rate for Payer: Humana Commercial |
$2,295.95
|
| Rate for Payer: Humana KY Medicaid |
$928.92
|
| Rate for Payer: Kentucky WC Medicaid |
$938.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,214.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,993.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$810.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$947.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,376.99
|
| Rate for Payer: Ohio Health Group HMO |
$2,025.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,160.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,349.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,863.77
|
| Rate for Payer: PHCS Commercial |
$2,593.08
|
| Rate for Payer: United Healthcare All Payer |
$2,376.99
|
|
|
SPLIT GRAF EA ADTL 100 CM(T
|
Facility
|
IP
|
$2,701.12
|
|
|
Service Code
|
HCPCS 15101
|
| Hospital Charge Code |
761T0176
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$810.34 |
| Max. Negotiated Rate |
$2,593.08 |
| Rate for Payer: Aetna Commercial |
$2,079.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,106.87
|
| Rate for Payer: Cash Price |
$1,350.56
|
| Rate for Payer: Cigna Commercial |
$2,241.93
|
| Rate for Payer: First Health Commercial |
$2,566.06
|
| Rate for Payer: Humana Commercial |
$2,295.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,214.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,993.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$810.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,376.99
|
| Rate for Payer: Ohio Health Group HMO |
$2,025.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,160.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,349.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,863.77
|
| Rate for Payer: PHCS Commercial |
$2,593.08
|
| Rate for Payer: United Healthcare All Payer |
$2,376.99
|
|
|
SPLIT OF BLOOD OR PROD EA UN
|
Facility
|
IP
|
$222.00
|
|
|
Service Code
|
HCPCS 86985
|
| Hospital Charge Code |
30001245
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$66.60 |
| Max. Negotiated Rate |
$213.12 |
| Rate for Payer: Aetna Commercial |
$170.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$178.27
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$184.26
|
| Rate for Payer: First Health Commercial |
$210.90
|
| Rate for Payer: Humana Commercial |
$188.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$182.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$163.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$66.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$195.36
|
| Rate for Payer: Ohio Health Group HMO |
$166.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$177.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$193.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$153.18
|
| Rate for Payer: PHCS Commercial |
$213.12
|
| Rate for Payer: United Healthcare All Payer |
$195.36
|
|
|
SPLIT OF BLOOD OR PROD EA UN
|
Facility
|
OP
|
$222.00
|
|
|
Service Code
|
HCPCS 86985
|
| Hospital Charge Code |
30001245
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$153.18 |
| Max. Negotiated Rate |
$221.66 |
| Rate for Payer: Aetna Commercial |
$170.94
|
| Rate for Payer: Anthem Medicaid |
$158.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$158.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$178.27
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$221.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$158.33
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$184.26
|
| Rate for Payer: First Health Commercial |
$210.90
|
| Rate for Payer: Humana Commercial |
$188.70
|
| Rate for Payer: Humana KY Medicaid |
$158.33
|
| Rate for Payer: Humana Medicare Advantage |
$158.33
|
| Rate for Payer: Kentucky WC Medicaid |
$159.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$182.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$163.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$161.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$195.36
|
| Rate for Payer: Ohio Health Group HMO |
$166.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$177.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$193.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$153.18
|
| Rate for Payer: PHCS Commercial |
$213.12
|
| Rate for Payer: United Healthcare All Payer |
$195.36
|
|
|
SPLIT-THICKNESS AUTOGRAFT 100
|
Facility
|
OP
|
$6,706.01
|
|
|
Service Code
|
HCPCS 15120
|
| Hospital Charge Code |
76100181
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,306.20 |
| Max. Negotiated Rate |
$6,437.77 |
| Rate for Payer: Aetna Commercial |
$5,163.63
|
| Rate for Payer: Anthem Medicaid |
$2,306.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,382.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,230.69
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,735.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,566.59
|
| Rate for Payer: Cash Price |
$3,353.00
|
| Rate for Payer: Cash Price |
$3,353.00
|
| Rate for Payer: Cigna Commercial |
$5,565.99
|
| Rate for Payer: First Health Commercial |
$6,370.71
|
| Rate for Payer: Humana Commercial |
$5,700.11
|
| Rate for Payer: Humana KY Medicaid |
$2,306.20
|
| Rate for Payer: Humana Medicare Advantage |
$3,382.66
|
| Rate for Payer: Kentucky WC Medicaid |
$2,329.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,498.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,949.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,059.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,352.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,901.29
|
| Rate for Payer: Ohio Health Group HMO |
$5,029.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,364.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,834.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,627.15
|
| Rate for Payer: PHCS Commercial |
$6,437.77
|
| Rate for Payer: United Healthcare All Payer |
$5,901.29
|
|
|
SPLIT-THICKNESS AUTOGRAFT 100
|
Professional
|
Both
|
$6,706.01
|
|
|
Service Code
|
HCPCS 15120
|
| Hospital Charge Code |
76100181
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$351.26 |
| Max. Negotiated Rate |
$4,023.61 |
| Rate for Payer: Aetna Commercial |
$1,123.66
|
| Rate for Payer: Ambetter Exchange |
$650.98
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$351.26
|
| Rate for Payer: Anthem Medicaid |
$453.31
|
| Rate for Payer: Buckeye Individual/Medicaid |
$650.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$650.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$781.18
|
| Rate for Payer: Cash Price |
$3,353.00
|
| Rate for Payer: Cash Price |
$3,353.00
|
| Rate for Payer: Cigna Commercial |
$1,073.04
|
| Rate for Payer: Healthspan PPO |
$1,050.83
|
| Rate for Payer: Humana Medicaid |
$453.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$986.17
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$650.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$650.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$462.38
|
| Rate for Payer: Molina Healthcare Passport |
$453.31
|
| Rate for Payer: Multiplan PHCS |
$4,023.61
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$846.27
|
| Rate for Payer: UHCCP Medicaid |
$368.82
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$457.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$650.98
|
|
|
SPLIT-THICKNESS AUTOGRAFT 100
|
Facility
|
IP
|
$6,706.01
|
|
|
Service Code
|
HCPCS 15120
|
| Hospital Charge Code |
76100181
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,011.80 |
| Max. Negotiated Rate |
$6,437.77 |
| Rate for Payer: Aetna Commercial |
$5,163.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,230.69
|
| Rate for Payer: Cash Price |
$3,353.00
|
| Rate for Payer: Cigna Commercial |
$5,565.99
|
| Rate for Payer: First Health Commercial |
$6,370.71
|
| Rate for Payer: Humana Commercial |
$5,700.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,498.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,949.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,011.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,901.29
|
| Rate for Payer: Ohio Health Group HMO |
$5,029.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,364.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,834.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,627.15
|
| Rate for Payer: PHCS Commercial |
$6,437.77
|
| Rate for Payer: United Healthcare All Payer |
$5,901.29
|
|
|
SPLIT-THICKNESS AUTOGRAFT 10(P
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 15120
|
| Hospital Charge Code |
761P0181
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$351.26 |
| Max. Negotiated Rate |
$1,123.66 |
| Rate for Payer: Aetna Commercial |
$1,123.66
|
| Rate for Payer: Ambetter Exchange |
$650.98
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$351.26
|
| Rate for Payer: Anthem Medicaid |
$453.31
|
| Rate for Payer: Buckeye Individual/Medicaid |
$650.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$650.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$781.18
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,073.04
|
| Rate for Payer: Healthspan PPO |
$1,050.83
|
| Rate for Payer: Humana Medicaid |
$453.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$986.17
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$650.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$650.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$462.38
|
| Rate for Payer: Molina Healthcare Passport |
$453.31
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$846.27
|
| Rate for Payer: UHCCP Medicaid |
$368.82
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$457.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$650.98
|
|
|
SPLIT-THICKNESS AUTOGRAFT 10(T
|
Facility
|
IP
|
$5,206.01
|
|
|
Service Code
|
HCPCS 15120
|
| Hospital Charge Code |
761T0181
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,561.80 |
| Max. Negotiated Rate |
$4,997.77 |
| Rate for Payer: Aetna Commercial |
$4,008.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,060.69
|
| Rate for Payer: Cash Price |
$2,603.00
|
| Rate for Payer: Cigna Commercial |
$4,320.99
|
| Rate for Payer: First Health Commercial |
$4,945.71
|
| Rate for Payer: Humana Commercial |
$4,425.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,268.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,842.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,561.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,581.29
|
| Rate for Payer: Ohio Health Group HMO |
$3,904.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,164.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,529.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,592.15
|
| Rate for Payer: PHCS Commercial |
$4,997.77
|
| Rate for Payer: United Healthcare All Payer |
$4,581.29
|
|
|
SPLIT-THICKNESS AUTOGRAFT 10(T
|
Facility
|
OP
|
$5,206.01
|
|
|
Service Code
|
HCPCS 15120
|
| Hospital Charge Code |
761T0181
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,790.35 |
| Max. Negotiated Rate |
$4,997.77 |
| Rate for Payer: Aetna Commercial |
$4,008.63
|
| Rate for Payer: Anthem Medicaid |
$1,790.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,382.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,060.69
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,735.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,566.59
|
| Rate for Payer: Cash Price |
$2,603.00
|
| Rate for Payer: Cash Price |
$2,603.00
|
| Rate for Payer: Cigna Commercial |
$4,320.99
|
| Rate for Payer: First Health Commercial |
$4,945.71
|
| Rate for Payer: Humana Commercial |
$4,425.11
|
| Rate for Payer: Humana KY Medicaid |
$1,790.35
|
| Rate for Payer: Humana Medicare Advantage |
$3,382.66
|
| Rate for Payer: Kentucky WC Medicaid |
$1,808.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,268.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,842.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,059.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,826.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,581.29
|
| Rate for Payer: Ohio Health Group HMO |
$3,904.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,164.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,529.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,592.15
|
| Rate for Payer: PHCS Commercial |
$4,997.77
|
| Rate for Payer: United Healthcare All Payer |
$4,581.29
|
|
|
SPLIT-THICKNESS AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)
|
Facility
|
OP
|
$4,735.72
|
|
|
Service Code
|
CPT 15120
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,382.66 |
| Max. Negotiated Rate |
$4,735.72 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,382.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,735.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,566.59
|
| Rate for Payer: Humana Medicare Advantage |
$3,382.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,059.19
|
|
|
SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)
|
Facility
|
OP
|
$2,366.24
|
|
|
Service Code
|
CPT 15100
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,690.17 |
| Max. Negotiated Rate |
$2,366.24 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
|
|
SPLT THCKN SKN GRFT <100 SQ CM
|
Professional
|
Both
|
$1,139.00
|
|
|
Service Code
|
HCPCS 15100
|
| Hospital Charge Code |
761P0175
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$365.96 |
| Max. Negotiated Rate |
$1,031.79 |
| Rate for Payer: Aetna Commercial |
$1,031.79
|
| Rate for Payer: Ambetter Exchange |
$674.94
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$365.96
|
| Rate for Payer: Anthem Medicaid |
$379.61
|
| Rate for Payer: Buckeye Individual/Medicaid |
$674.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$674.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$809.93
|
| Rate for Payer: Cash Price |
$569.50
|
| Rate for Payer: Cash Price |
$569.50
|
| Rate for Payer: Cigna Commercial |
$1,007.18
|
| Rate for Payer: Healthspan PPO |
$972.22
|
| Rate for Payer: Humana Medicaid |
$379.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$897.12
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$674.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$674.94
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$387.20
|
| Rate for Payer: Molina Healthcare Passport |
$379.61
|
| Rate for Payer: Multiplan PHCS |
$683.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$877.42
|
| Rate for Payer: UHCCP Medicaid |
$384.26
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$383.41
|
| Rate for Payer: Wellcare Medicare Advantage |
$674.94
|
|
|
SPLT THCKN SKN GRFT <100 SQ CM
|
Facility
|
IP
|
$5,141.96
|
|
|
Service Code
|
HCPCS 15100
|
| Hospital Charge Code |
761T0175
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,542.59 |
| Max. Negotiated Rate |
$4,936.28 |
| Rate for Payer: Aetna Commercial |
$3,959.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,010.73
|
| Rate for Payer: Cash Price |
$2,570.98
|
| Rate for Payer: Cigna Commercial |
$4,267.83
|
| Rate for Payer: First Health Commercial |
$4,884.86
|
| Rate for Payer: Humana Commercial |
$4,370.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,216.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,794.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,542.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,524.92
|
| Rate for Payer: Ohio Health Group HMO |
$3,856.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,113.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,473.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,547.95
|
| Rate for Payer: PHCS Commercial |
$4,936.28
|
| Rate for Payer: United Healthcare All Payer |
$4,524.92
|
|
|
SPLT THCKN SKN GRFT <100 SQ CM
|
Professional
|
Both
|
$6,280.96
|
|
|
Service Code
|
HCPCS 15100
|
| Hospital Charge Code |
76100175
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$365.96 |
| Max. Negotiated Rate |
$3,768.58 |
| Rate for Payer: Aetna Commercial |
$1,031.79
|
| Rate for Payer: Ambetter Exchange |
$674.94
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$365.96
|
| Rate for Payer: Anthem Medicaid |
$379.61
|
| Rate for Payer: Buckeye Individual/Medicaid |
$674.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$674.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$809.93
|
| Rate for Payer: Cash Price |
$3,140.48
|
| Rate for Payer: Cash Price |
$3,140.48
|
| Rate for Payer: Cigna Commercial |
$1,007.18
|
| Rate for Payer: Healthspan PPO |
$972.22
|
| Rate for Payer: Humana Medicaid |
$379.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$897.12
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$674.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$674.94
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$387.20
|
| Rate for Payer: Molina Healthcare Passport |
$379.61
|
| Rate for Payer: Multiplan PHCS |
$3,768.58
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$877.42
|
| Rate for Payer: UHCCP Medicaid |
$384.26
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$383.41
|
| Rate for Payer: Wellcare Medicare Advantage |
$674.94
|
|
|
SPLT THCKN SKN GRFT <100 SQ CM
|
Facility
|
OP
|
$5,141.96
|
|
|
Service Code
|
HCPCS 15100
|
| Hospital Charge Code |
761T0175
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,690.17 |
| Max. Negotiated Rate |
$4,936.28 |
| Rate for Payer: Aetna Commercial |
$3,959.31
|
| Rate for Payer: Anthem Medicaid |
$1,768.32
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,010.73
|
| 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 |
$2,570.98
|
| Rate for Payer: Cash Price |
$2,570.98
|
| Rate for Payer: Cigna Commercial |
$4,267.83
|
| Rate for Payer: First Health Commercial |
$4,884.86
|
| Rate for Payer: Humana Commercial |
$4,370.67
|
| Rate for Payer: Humana KY Medicaid |
$1,768.32
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,786.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,216.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,794.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,803.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,524.92
|
| Rate for Payer: Ohio Health Group HMO |
$3,856.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,113.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,473.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,547.95
|
| Rate for Payer: PHCS Commercial |
$4,936.28
|
| Rate for Payer: United Healthcare All Payer |
$4,524.92
|
|
