|
ADENOSINE FLOWWIRE 1MG(60MGKIT
|
Facility
|
OP
|
$204.73
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
25001830
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.61 |
| Max. Negotiated Rate |
$196.54 |
| Rate for Payer: Aetna Commercial |
$157.64
|
| Rate for Payer: Anthem Medicaid |
$70.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$159.69
|
| Rate for Payer: Cash Price |
$102.36
|
| Rate for Payer: Cigna Commercial |
$169.93
|
| Rate for Payer: First Health Commercial |
$194.49
|
| Rate for Payer: Humana Commercial |
$174.02
|
| Rate for Payer: Humana KY Medicaid |
$70.41
|
| Rate for Payer: Kentucky WC Medicaid |
$71.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$167.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$151.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$71.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$180.16
|
| Rate for Payer: Ohio Health Group HMO |
$153.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.47
|
| Rate for Payer: PHCS Commercial |
$196.54
|
| Rate for Payer: United Healthcare All Payer |
$180.16
|
|
|
ADENOSINE FLOWWIRE 1MG(60MGKIT
|
Facility
|
IP
|
$204.73
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
25001830
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.61 |
| Max. Negotiated Rate |
$196.54 |
| Rate for Payer: Aetna Commercial |
$157.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$159.69
|
| Rate for Payer: Cash Price |
$102.36
|
| Rate for Payer: Cigna Commercial |
$169.93
|
| Rate for Payer: First Health Commercial |
$194.49
|
| Rate for Payer: Humana Commercial |
$174.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$167.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$151.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$180.16
|
| Rate for Payer: Ohio Health Group HMO |
$153.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.47
|
| Rate for Payer: PHCS Commercial |
$196.54
|
| Rate for Payer: United Healthcare All Payer |
$180.16
|
|
|
ADENOSINE INTRACORNAKIT 6MGCCL
|
Facility
|
IP
|
$114.42
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
25001831
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.87 |
| Max. Negotiated Rate |
$109.84 |
| Rate for Payer: Aetna Commercial |
$88.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.25
|
| Rate for Payer: Cash Price |
$57.21
|
| Rate for Payer: Cigna Commercial |
$94.97
|
| Rate for Payer: First Health Commercial |
$108.70
|
| Rate for Payer: Humana Commercial |
$97.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.69
|
| Rate for Payer: Ohio Health Group HMO |
$85.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.47
|
| Rate for Payer: PHCS Commercial |
$109.84
|
| Rate for Payer: United Healthcare All Payer |
$100.69
|
|
|
ADENOSINE INTRACORNAKIT 6MGCCL
|
Facility
|
OP
|
$114.42
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
25001831
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.87 |
| Max. Negotiated Rate |
$109.84 |
| Rate for Payer: Aetna Commercial |
$88.10
|
| Rate for Payer: Anthem Medicaid |
$39.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.25
|
| Rate for Payer: Cash Price |
$57.21
|
| Rate for Payer: Cigna Commercial |
$94.97
|
| Rate for Payer: First Health Commercial |
$108.70
|
| Rate for Payer: Humana Commercial |
$97.26
|
| Rate for Payer: Humana KY Medicaid |
$39.35
|
| Rate for Payer: Kentucky WC Medicaid |
$39.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.69
|
| Rate for Payer: Ohio Health Group HMO |
$85.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.47
|
| Rate for Payer: PHCS Commercial |
$109.84
|
| Rate for Payer: United Healthcare All Payer |
$100.69
|
|
|
ADJACENT TISSUE 10SQ CM OR LES
|
Professional
|
Both
|
$900.00
|
|
|
Service Code
|
HCPCS 14020
|
| Hospital Charge Code |
761P0164
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$286.02 |
| Max. Negotiated Rate |
$938.23 |
| Rate for Payer: Aetna Commercial |
$807.28
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$286.02
|
| Rate for Payer: Anthem Medicaid |
$321.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$900.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$938.23
|
| Rate for Payer: Healthspan PPO |
$765.32
|
| Rate for Payer: Humana Medicaid |
$321.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$715.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$328.17
|
| Rate for Payer: Molina Healthcare Passport |
$321.74
|
| Rate for Payer: Multiplan PHCS |
$540.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$630.00
|
| Rate for Payer: UHCCP Medicaid |
$300.32
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$324.96
|
|
|
ADJACENT TISSUE 10SQ CM OR LES
|
Facility
|
OP
|
$6,209.00
|
|
|
Service Code
|
HCPCS 14020
|
| Hospital Charge Code |
76100164
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$807.17 |
| Max. Negotiated Rate |
$5,960.64 |
| Rate for Payer: Aetna Commercial |
$4,780.93
|
| Rate for Payer: Anthem Medicaid |
$2,135.28
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,843.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$3,104.50
|
| Rate for Payer: Cash Price |
$3,104.50
|
| Rate for Payer: Cigna Commercial |
$5,153.47
|
| Rate for Payer: First Health Commercial |
$5,898.55
|
| Rate for Payer: Humana Commercial |
$5,277.65
|
| Rate for Payer: Humana KY Medicaid |
$2,135.28
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,157.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,091.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,582.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,178.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,463.92
|
| Rate for Payer: Ohio Health Group HMO |
$4,656.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,241.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$807.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,924.79
|
| Rate for Payer: PHCS Commercial |
$5,960.64
|
| Rate for Payer: United Healthcare All Payer |
$5,463.92
|
|
|
ADJACENT TISSUE 10SQ CM OR LES
|
Facility
|
IP
|
$6,209.00
|
|
|
Service Code
|
HCPCS 14020
|
| Hospital Charge Code |
76100164
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$807.17 |
| Max. Negotiated Rate |
$5,960.64 |
| Rate for Payer: Aetna Commercial |
$4,780.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,843.02
|
| Rate for Payer: Cash Price |
$3,104.50
|
| Rate for Payer: Cigna Commercial |
$5,153.47
|
| Rate for Payer: First Health Commercial |
$5,898.55
|
| Rate for Payer: Humana Commercial |
$5,277.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,091.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,582.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,862.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,463.92
|
| Rate for Payer: Ohio Health Group HMO |
$4,656.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,241.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$807.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,924.79
|
| Rate for Payer: PHCS Commercial |
$5,960.64
|
| Rate for Payer: United Healthcare All Payer |
$5,463.92
|
|
|
ADJACENT TISSUE 10SQ CM OR LES
|
Professional
|
Both
|
$6,209.00
|
|
|
Service Code
|
HCPCS 14020
|
| Hospital Charge Code |
76100164
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$286.02 |
| Max. Negotiated Rate |
$6,209.00 |
| Rate for Payer: Aetna Commercial |
$807.28
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$286.02
|
| Rate for Payer: Anthem Medicaid |
$321.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,209.00
|
| Rate for Payer: Cash Price |
$3,104.50
|
| Rate for Payer: Cash Price |
$3,104.50
|
| Rate for Payer: Cigna Commercial |
$938.23
|
| Rate for Payer: Healthspan PPO |
$765.32
|
| Rate for Payer: Humana Medicaid |
$321.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$715.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$328.17
|
| Rate for Payer: Molina Healthcare Passport |
$321.74
|
| Rate for Payer: Multiplan PHCS |
$3,725.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,346.30
|
| Rate for Payer: UHCCP Medicaid |
$300.32
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$324.96
|
|
|
ADJACENT TISSUE 10SQ CM OR LES
|
Facility
|
IP
|
$5,309.00
|
|
|
Service Code
|
HCPCS 14020
|
| Hospital Charge Code |
761T0164
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$690.17 |
| Max. Negotiated Rate |
$5,096.64 |
| Rate for Payer: Aetna Commercial |
$4,087.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,141.02
|
| Rate for Payer: Cash Price |
$2,654.50
|
| Rate for Payer: Cigna Commercial |
$4,406.47
|
| Rate for Payer: First Health Commercial |
$5,043.55
|
| Rate for Payer: Humana Commercial |
$4,512.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,353.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,918.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,592.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,671.92
|
| Rate for Payer: Ohio Health Group HMO |
$3,981.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,061.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$690.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,645.79
|
| Rate for Payer: PHCS Commercial |
$5,096.64
|
| Rate for Payer: United Healthcare All Payer |
$4,671.92
|
|
|
ADJACENT TISSUE 10SQ CM OR LES
|
Facility
|
OP
|
$5,309.00
|
|
|
Service Code
|
HCPCS 14020
|
| Hospital Charge Code |
761T0164
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$690.17 |
| Max. Negotiated Rate |
$5,096.64 |
| Rate for Payer: Aetna Commercial |
$4,087.93
|
| Rate for Payer: Anthem Medicaid |
$1,825.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,141.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$2,654.50
|
| Rate for Payer: Cash Price |
$2,654.50
|
| Rate for Payer: Cigna Commercial |
$4,406.47
|
| Rate for Payer: First Health Commercial |
$5,043.55
|
| Rate for Payer: Humana Commercial |
$4,512.65
|
| Rate for Payer: Humana KY Medicaid |
$1,825.77
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,844.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,353.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,918.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,862.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,671.92
|
| Rate for Payer: Ohio Health Group HMO |
$3,981.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,061.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$690.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,645.79
|
| Rate for Payer: PHCS Commercial |
$5,096.64
|
| Rate for Payer: United Healthcare All Payer |
$4,671.92
|
|
|
ADJACENT TISSUE TNSFER 10SQ CM
|
Professional
|
Both
|
$1,200.00
|
|
|
Service Code
|
HCPCS 14040
|
| Hospital Charge Code |
761P0166
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$314.75 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$915.68
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$314.75
|
| Rate for Payer: Anthem Medicaid |
$317.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,200.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$988.90
|
| Rate for Payer: Healthspan PPO |
$849.42
|
| Rate for Payer: Humana Medicaid |
$317.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$805.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$323.62
|
| Rate for Payer: Molina Healthcare Passport |
$317.27
|
| Rate for Payer: Multiplan PHCS |
$720.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$840.00
|
| Rate for Payer: UHCCP Medicaid |
$330.49
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$320.44
|
|
|
ADJACENT TISSUE TNSFER 10SQ CM
|
Professional
|
Both
|
$6,210.00
|
|
|
Service Code
|
HCPCS 14040
|
| Hospital Charge Code |
76100166
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$314.75 |
| Max. Negotiated Rate |
$6,210.00 |
| Rate for Payer: Aetna Commercial |
$915.68
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$314.75
|
| Rate for Payer: Anthem Medicaid |
$317.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,210.00
|
| Rate for Payer: Cash Price |
$3,105.00
|
| Rate for Payer: Cash Price |
$3,105.00
|
| Rate for Payer: Cigna Commercial |
$988.90
|
| Rate for Payer: Healthspan PPO |
$849.42
|
| Rate for Payer: Humana Medicaid |
$317.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$805.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$323.62
|
| Rate for Payer: Molina Healthcare Passport |
$317.27
|
| Rate for Payer: Multiplan PHCS |
$3,726.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,347.00
|
| Rate for Payer: UHCCP Medicaid |
$330.49
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$320.44
|
|
|
ADJACENT TISSUE TNSFER 10SQ CM
|
Facility
|
IP
|
$6,210.00
|
|
|
Service Code
|
HCPCS 14040
|
| Hospital Charge Code |
76100166
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$807.30 |
| Max. Negotiated Rate |
$5,961.60 |
| Rate for Payer: Aetna Commercial |
$4,781.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,843.80
|
| Rate for Payer: Cash Price |
$3,105.00
|
| Rate for Payer: Cigna Commercial |
$5,154.30
|
| Rate for Payer: First Health Commercial |
$5,899.50
|
| Rate for Payer: Humana Commercial |
$5,278.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,092.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,582.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,863.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,464.80
|
| Rate for Payer: Ohio Health Group HMO |
$4,657.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,242.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$807.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,925.10
|
| Rate for Payer: PHCS Commercial |
$5,961.60
|
| Rate for Payer: United Healthcare All Payer |
$5,464.80
|
|
|
ADJACENT TISSUE TNSFER 10SQ CM
|
Facility
|
IP
|
$5,010.00
|
|
|
Service Code
|
HCPCS 14040
|
| Hospital Charge Code |
761T0166
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$651.30 |
| Max. Negotiated Rate |
$4,809.60 |
| Rate for Payer: Aetna Commercial |
$3,857.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,907.80
|
| Rate for Payer: Cash Price |
$2,505.00
|
| Rate for Payer: Cigna Commercial |
$4,158.30
|
| Rate for Payer: First Health Commercial |
$4,759.50
|
| Rate for Payer: Humana Commercial |
$4,258.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,108.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,697.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,503.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,408.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,757.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,002.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$651.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,553.10
|
| Rate for Payer: PHCS Commercial |
$4,809.60
|
| Rate for Payer: United Healthcare All Payer |
$4,408.80
|
|
|
ADJACENT TISSUE TNSFER 10SQ CM
|
Facility
|
OP
|
$6,210.00
|
|
|
Service Code
|
HCPCS 14040
|
| Hospital Charge Code |
76100166
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$807.30 |
| Max. Negotiated Rate |
$5,961.60 |
| Rate for Payer: Aetna Commercial |
$4,781.70
|
| Rate for Payer: Anthem Medicaid |
$2,135.62
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,843.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$3,105.00
|
| Rate for Payer: Cash Price |
$3,105.00
|
| Rate for Payer: Cigna Commercial |
$5,154.30
|
| Rate for Payer: First Health Commercial |
$5,899.50
|
| Rate for Payer: Humana Commercial |
$5,278.50
|
| Rate for Payer: Humana KY Medicaid |
$2,135.62
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,157.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,092.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,582.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,178.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,464.80
|
| Rate for Payer: Ohio Health Group HMO |
$4,657.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,242.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$807.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,925.10
|
| Rate for Payer: PHCS Commercial |
$5,961.60
|
| Rate for Payer: United Healthcare All Payer |
$5,464.80
|
|
|
ADJACENT TISSUE TNSFER 10SQ CM
|
Facility
|
OP
|
$5,010.00
|
|
|
Service Code
|
HCPCS 14040
|
| Hospital Charge Code |
761T0166
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$651.30 |
| Max. Negotiated Rate |
$4,809.60 |
| Rate for Payer: Aetna Commercial |
$3,857.70
|
| Rate for Payer: Anthem Medicaid |
$1,722.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,907.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$2,505.00
|
| Rate for Payer: Cash Price |
$2,505.00
|
| Rate for Payer: Cigna Commercial |
$4,158.30
|
| Rate for Payer: First Health Commercial |
$4,759.50
|
| Rate for Payer: Humana Commercial |
$4,258.50
|
| Rate for Payer: Humana KY Medicaid |
$1,722.94
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,740.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,108.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,697.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,757.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,408.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,757.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,002.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$651.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,553.10
|
| Rate for Payer: PHCS Commercial |
$4,809.60
|
| Rate for Payer: United Healthcare All Payer |
$4,408.80
|
|
|
ADJACENT TISSUE TRANS 10.1-30
|
Facility
|
IP
|
$6,672.10
|
|
|
Service Code
|
HCPCS 14021
|
| Hospital Charge Code |
76100165
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$867.37 |
| Max. Negotiated Rate |
$6,405.22 |
| Rate for Payer: Aetna Commercial |
$5,137.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,204.24
|
| Rate for Payer: Cash Price |
$3,336.05
|
| Rate for Payer: Cigna Commercial |
$5,537.84
|
| Rate for Payer: First Health Commercial |
$6,338.50
|
| Rate for Payer: Humana Commercial |
$5,671.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,471.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,924.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,001.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,871.45
|
| Rate for Payer: Ohio Health Group HMO |
$5,004.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,334.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$867.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,068.35
|
| Rate for Payer: PHCS Commercial |
$6,405.22
|
| Rate for Payer: United Healthcare All Payer |
$5,871.45
|
|
|
ADJACENT TISSUE TRANS 10.1-30
|
Facility
|
OP
|
$6,672.10
|
|
|
Service Code
|
HCPCS 14021
|
| Hospital Charge Code |
76100165
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$867.37 |
| Max. Negotiated Rate |
$6,405.22 |
| Rate for Payer: Aetna Commercial |
$5,137.52
|
| Rate for Payer: Anthem Medicaid |
$2,294.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,204.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$3,336.05
|
| Rate for Payer: Cash Price |
$3,336.05
|
| Rate for Payer: Cigna Commercial |
$5,537.84
|
| Rate for Payer: First Health Commercial |
$6,338.50
|
| Rate for Payer: Humana Commercial |
$5,671.28
|
| Rate for Payer: Humana KY Medicaid |
$2,294.54
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,317.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,471.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,924.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,340.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,871.45
|
| Rate for Payer: Ohio Health Group HMO |
$5,004.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,334.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$867.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,068.35
|
| Rate for Payer: PHCS Commercial |
$6,405.22
|
| Rate for Payer: United Healthcare All Payer |
$5,871.45
|
|
|
ADJACENT TISSUE TRANS 10.1-30
|
Professional
|
Both
|
$6,672.10
|
|
|
Service Code
|
HCPCS 14021
|
| Hospital Charge Code |
76100165
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$358.35 |
| Max. Negotiated Rate |
$6,672.10 |
| Rate for Payer: Aetna Commercial |
$1,043.99
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$358.35
|
| Rate for Payer: Anthem Medicaid |
$464.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,672.10
|
| Rate for Payer: Cash Price |
$3,336.05
|
| Rate for Payer: Cash Price |
$3,336.05
|
| Rate for Payer: Cigna Commercial |
$1,103.60
|
| Rate for Payer: Healthspan PPO |
$971.29
|
| Rate for Payer: Humana Medicaid |
$464.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$914.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$473.64
|
| Rate for Payer: Molina Healthcare Passport |
$464.35
|
| Rate for Payer: Multiplan PHCS |
$4,003.26
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,670.47
|
| Rate for Payer: UHCCP Medicaid |
$376.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$468.99
|
|
|
ADJACENT TISSUE TRANS 10.1-3(P
|
Professional
|
Both
|
$1,173.00
|
|
|
Service Code
|
HCPCS 14021
|
| Hospital Charge Code |
761P0165
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$358.35 |
| Max. Negotiated Rate |
$1,173.00 |
| Rate for Payer: Aetna Commercial |
$1,043.99
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$358.35
|
| Rate for Payer: Anthem Medicaid |
$464.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,173.00
|
| Rate for Payer: Cash Price |
$586.50
|
| Rate for Payer: Cash Price |
$586.50
|
| Rate for Payer: Cigna Commercial |
$1,103.60
|
| Rate for Payer: Healthspan PPO |
$971.29
|
| Rate for Payer: Humana Medicaid |
$464.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$914.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$473.64
|
| Rate for Payer: Molina Healthcare Passport |
$464.35
|
| Rate for Payer: Multiplan PHCS |
$703.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$821.10
|
| Rate for Payer: UHCCP Medicaid |
$376.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$468.99
|
|
|
ADJACENT TISSUE TRANS 10.1-3(T
|
Facility
|
OP
|
$5,499.10
|
|
|
Service Code
|
HCPCS 14021
|
| Hospital Charge Code |
761T0165
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$714.88 |
| Max. Negotiated Rate |
$5,279.14 |
| Rate for Payer: Aetna Commercial |
$4,234.31
|
| Rate for Payer: Anthem Medicaid |
$1,891.14
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,289.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$2,749.55
|
| Rate for Payer: Cash Price |
$2,749.55
|
| Rate for Payer: Cigna Commercial |
$4,564.25
|
| Rate for Payer: First Health Commercial |
$5,224.14
|
| Rate for Payer: Humana Commercial |
$4,674.24
|
| Rate for Payer: Humana KY Medicaid |
$1,891.14
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,910.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,509.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,058.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,929.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,839.21
|
| Rate for Payer: Ohio Health Group HMO |
$4,124.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,099.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$714.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,704.72
|
| Rate for Payer: PHCS Commercial |
$5,279.14
|
| Rate for Payer: United Healthcare All Payer |
$4,839.21
|
|
|
ADJACENT TISSUE TRANS 10.1-3(T
|
Facility
|
IP
|
$5,499.10
|
|
|
Service Code
|
HCPCS 14021
|
| Hospital Charge Code |
761T0165
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$714.88 |
| Max. Negotiated Rate |
$5,279.14 |
| Rate for Payer: Aetna Commercial |
$4,234.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,289.30
|
| Rate for Payer: Cash Price |
$2,749.55
|
| Rate for Payer: Cigna Commercial |
$4,564.25
|
| Rate for Payer: First Health Commercial |
$5,224.14
|
| Rate for Payer: Humana Commercial |
$4,674.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,509.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,058.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,649.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,839.21
|
| Rate for Payer: Ohio Health Group HMO |
$4,124.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,099.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$714.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,704.72
|
| Rate for Payer: PHCS Commercial |
$5,279.14
|
| Rate for Payer: United Healthcare All Payer |
$4,839.21
|
|
|
ADJACENT TISSUE TRANSFER
|
Facility
|
OP
|
$7,648.25
|
|
|
Service Code
|
HCPCS 14060
|
| Hospital Charge Code |
76100168
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$994.27 |
| Max. Negotiated Rate |
$7,342.32 |
| Rate for Payer: Aetna Commercial |
$5,889.15
|
| Rate for Payer: Anthem Medicaid |
$2,630.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,965.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$3,824.12
|
| Rate for Payer: Cash Price |
$3,824.12
|
| Rate for Payer: Cigna Commercial |
$6,348.05
|
| Rate for Payer: First Health Commercial |
$7,265.84
|
| Rate for Payer: Humana Commercial |
$6,501.01
|
| Rate for Payer: Humana KY Medicaid |
$2,630.23
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,657.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,271.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,644.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,683.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,730.46
|
| Rate for Payer: Ohio Health Group HMO |
$5,736.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,529.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$994.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,370.96
|
| Rate for Payer: PHCS Commercial |
$7,342.32
|
| Rate for Payer: United Healthcare All Payer |
$6,730.46
|
|
|
ADJACENT TISSUE TRANSFER
|
Professional
|
Both
|
$7,648.25
|
|
|
Service Code
|
HCPCS 14060
|
| Hospital Charge Code |
76100168
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$340.75 |
| Max. Negotiated Rate |
$7,648.25 |
| Rate for Payer: Aetna Commercial |
$968.10
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$340.75
|
| Rate for Payer: Anthem Medicaid |
$469.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$7,648.25
|
| Rate for Payer: Cash Price |
$3,824.12
|
| Rate for Payer: Cash Price |
$3,824.12
|
| Rate for Payer: Cigna Commercial |
$1,017.71
|
| Rate for Payer: Healthspan PPO |
$866.52
|
| Rate for Payer: Humana Medicaid |
$469.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$852.48
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$478.75
|
| Rate for Payer: Molina Healthcare Passport |
$469.36
|
| Rate for Payer: Multiplan PHCS |
$4,588.95
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5,353.78
|
| Rate for Payer: UHCCP Medicaid |
$357.79
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$474.05
|
|
|
ADJACENT TISSUE TRANSFER
|
Professional
|
Both
|
$5,819.08
|
|
|
Service Code
|
HCPCS 14000
|
| Hospital Charge Code |
76100162
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$214.30 |
| Max. Negotiated Rate |
$5,819.08 |
| Rate for Payer: Aetna Commercial |
$706.57
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$255.40
|
| Rate for Payer: Anthem Medicaid |
$214.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,819.08
|
| Rate for Payer: Cash Price |
$2,909.54
|
| Rate for Payer: Cash Price |
$2,909.54
|
| Rate for Payer: Cigna Commercial |
$844.80
|
| Rate for Payer: Healthspan PPO |
$680.08
|
| Rate for Payer: Humana Medicaid |
$214.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$629.72
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$218.59
|
| Rate for Payer: Molina Healthcare Passport |
$214.30
|
| Rate for Payer: Multiplan PHCS |
$3,491.45
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,073.36
|
| Rate for Payer: UHCCP Medicaid |
$268.17
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$216.44
|
|
