|
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 |
$1,862.70 |
| 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 |
$4,967.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,401.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,284.21
|
| 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
|
OP
|
$5,309.00
|
|
|
Service Code
|
HCPCS 14020
|
| Hospital Charge Code |
761T0164
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,690.17 |
| 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 |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,141.02
|
| 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 |
$2,654.50
|
| 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 |
$1,690.17
|
| 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 |
$2,028.20
|
| 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 |
$4,247.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,618.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,663.21
|
| Rate for Payer: PHCS Commercial |
$5,096.64
|
| Rate for Payer: United Healthcare All Payer |
$4,671.92
|
|
|
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 |
$3,725.40 |
| Rate for Payer: Aetna Commercial |
$807.28
|
| Rate for Payer: Ambetter Exchange |
$531.99
|
| 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 Individual/Medicaid |
$531.99
|
| Rate for Payer: Buckeye Medicare Advantage |
$531.99
|
| Rate for Payer: CareSource Just4Me Medicare |
$638.39
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$531.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.99
|
| 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 |
$691.59
|
| Rate for Payer: UHCCP Medicaid |
$300.32
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$324.96
|
| Rate for Payer: Wellcare Medicare Advantage |
$531.99
|
|
|
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 |
$1,592.70 |
| 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 |
$4,247.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,618.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,663.21
|
| 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 |
$988.90 |
| Rate for Payer: Aetna Commercial |
$915.68
|
| Rate for Payer: Ambetter Exchange |
$586.08
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$314.75
|
| Rate for Payer: Anthem Medicaid |
$408.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$586.08
|
| Rate for Payer: Buckeye Medicare Advantage |
$586.08
|
| Rate for Payer: CareSource Just4Me Medicare |
$703.30
|
| 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 |
$408.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$805.08
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$586.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$586.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$416.22
|
| Rate for Payer: Molina Healthcare Passport |
$408.06
|
| Rate for Payer: Multiplan PHCS |
$720.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$761.90
|
| Rate for Payer: UHCCP Medicaid |
$330.49
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$412.14
|
| Rate for Payer: Wellcare Medicare Advantage |
$586.08
|
|
|
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 |
$1,863.00 |
| 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 |
$4,968.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,402.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,284.90
|
| Rate for Payer: PHCS Commercial |
$5,961.60
|
| Rate for Payer: United Healthcare All Payer |
$5,464.80
|
|
|
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 |
$3,726.00 |
| Rate for Payer: Aetna Commercial |
$915.68
|
| Rate for Payer: Ambetter Exchange |
$586.08
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$314.75
|
| Rate for Payer: Anthem Medicaid |
$408.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$586.08
|
| Rate for Payer: Buckeye Medicare Advantage |
$586.08
|
| Rate for Payer: CareSource Just4Me Medicare |
$703.30
|
| 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 |
$408.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$805.08
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$586.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$586.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$416.22
|
| Rate for Payer: Molina Healthcare Passport |
$408.06
|
| Rate for Payer: Multiplan PHCS |
$3,726.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$761.90
|
| Rate for Payer: UHCCP Medicaid |
$330.49
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$412.14
|
| Rate for Payer: Wellcare Medicare Advantage |
$586.08
|
|
|
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 |
$1,690.17 |
| 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 |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,843.80
|
| 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 |
$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 |
$1,690.17
|
| 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 |
$2,028.20
|
| 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 |
$4,968.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,402.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,284.90
|
| 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 |
$1,503.00 |
| 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 |
$4,008.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,358.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,456.90
|
| 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
|
$5,010.00
|
|
|
Service Code
|
HCPCS 14040
|
| Hospital Charge Code |
761T0166
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,690.17 |
| 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 |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,907.80
|
| 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 |
$2,505.00
|
| 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 |
$1,690.17
|
| 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 |
$2,028.20
|
| 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 |
$4,008.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,358.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,456.90
|
| 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
|
OP
|
$6,672.10
|
|
|
Service Code
|
HCPCS 14021
|
| Hospital Charge Code |
76100165
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,690.17 |
| 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 |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,204.24
|
| 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 |
$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 |
$6,338.49
|
| Rate for Payer: Humana Commercial |
$5,671.28
|
| Rate for Payer: Humana KY Medicaid |
$2,294.54
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| 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 |
$2,028.20
|
| 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 |
$5,004.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,337.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,804.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,603.75
|
| 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
|
IP
|
$6,672.10
|
|
|
Service Code
|
HCPCS 14021
|
| Hospital Charge Code |
76100165
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,001.63 |
| 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 |
$6,338.49
|
| 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 |
$5,004.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,337.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,804.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,603.75
|
| 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 |
$4,003.26 |
| Rate for Payer: Aetna Commercial |
$1,043.99
|
| Rate for Payer: Ambetter Exchange |
$666.35
|
| 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 Individual/Medicaid |
$666.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$666.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$799.62
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$666.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$666.35
|
| 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 |
$866.25
|
| Rate for Payer: UHCCP Medicaid |
$376.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$468.99
|
| Rate for Payer: Wellcare Medicare Advantage |
$666.35
|
|
|
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 |
$1,103.60 |
| Rate for Payer: Aetna Commercial |
$1,043.99
|
| Rate for Payer: Ambetter Exchange |
$666.35
|
| 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 Individual/Medicaid |
$666.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$666.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$799.62
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$666.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$666.35
|
| 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 |
$866.25
|
| Rate for Payer: UHCCP Medicaid |
$376.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$468.99
|
| Rate for Payer: Wellcare Medicare Advantage |
$666.35
|
|
|
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 |
$1,690.17 |
| 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 |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,289.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Cash Price |
$2,749.55
|
| Rate for Payer: Cash Price |
$2,749.55
|
| Rate for Payer: Cigna Commercial |
$4,564.25
|
| Rate for Payer: First Health Commercial |
$5,224.15
|
| Rate for Payer: Humana Commercial |
$4,674.23
|
| Rate for Payer: Humana KY Medicaid |
$1,891.14
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| 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 |
$2,028.20
|
| 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 |
$4,399.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,784.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,794.38
|
| 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 |
$1,649.73 |
| 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 |
$5,224.15
|
| Rate for Payer: Humana Commercial |
$4,674.23
|
| 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 |
$4,399.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,784.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,794.38
|
| Rate for Payer: PHCS Commercial |
$5,279.14
|
| Rate for Payer: United Healthcare All Payer |
$4,839.21
|
|
|
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 |
$4,588.95 |
| Rate for Payer: Aetna Commercial |
$968.10
|
| Rate for Payer: Ambetter Exchange |
$623.88
|
| 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 Individual/Medicaid |
$623.88
|
| Rate for Payer: Buckeye Medicare Advantage |
$623.88
|
| Rate for Payer: CareSource Just4Me Medicare |
$748.66
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$623.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$623.88
|
| 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 |
$811.04
|
| Rate for Payer: UHCCP Medicaid |
$357.79
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$474.05
|
| Rate for Payer: Wellcare Medicare Advantage |
$623.88
|
|
|
ADJACENT TISSUE TRANSFER
|
Professional
|
Both
|
$5,819.08
|
|
|
Service Code
|
HCPCS 14000
|
| Hospital Charge Code |
76100162
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$255.40 |
| Max. Negotiated Rate |
$3,491.45 |
| Rate for Payer: Aetna Commercial |
$706.57
|
| Rate for Payer: Ambetter Exchange |
$475.50
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$255.40
|
| Rate for Payer: Anthem Medicaid |
$260.03
|
| Rate for Payer: Buckeye Individual/Medicaid |
$475.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$475.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$570.60
|
| 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 |
$260.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$629.72
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$475.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$475.50
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$265.23
|
| Rate for Payer: Molina Healthcare Passport |
$260.03
|
| Rate for Payer: Multiplan PHCS |
$3,491.45
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$618.15
|
| Rate for Payer: UHCCP Medicaid |
$268.17
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$262.63
|
| Rate for Payer: Wellcare Medicare Advantage |
$475.50
|
|
|
ADJACENT TISSUE TRANSFER
|
Facility
|
IP
|
$7,648.25
|
|
|
Service Code
|
HCPCS 14060
|
| Hospital Charge Code |
76100168
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,294.47 |
| Max. Negotiated Rate |
$7,342.32 |
| Rate for Payer: Aetna Commercial |
$5,889.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,965.64
|
| 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: 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 |
$2,294.47
|
| 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 |
$6,118.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,653.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,277.29
|
| Rate for Payer: PHCS Commercial |
$7,342.32
|
| Rate for Payer: United Healthcare All Payer |
$6,730.46
|
|
|
ADJACENT TISSUE TRANSFER
|
Facility
|
IP
|
$5,819.08
|
|
|
Service Code
|
HCPCS 14000
|
| Hospital Charge Code |
76100162
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,745.72 |
| Max. Negotiated Rate |
$5,586.32 |
| Rate for Payer: Aetna Commercial |
$4,480.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,538.88
|
| Rate for Payer: Cash Price |
$2,909.54
|
| Rate for Payer: Cigna Commercial |
$4,829.84
|
| Rate for Payer: First Health Commercial |
$5,528.13
|
| Rate for Payer: Humana Commercial |
$4,946.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,771.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,294.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,745.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,120.79
|
| Rate for Payer: Ohio Health Group HMO |
$4,364.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,655.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,062.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,015.17
|
| Rate for Payer: PHCS Commercial |
$5,586.32
|
| Rate for Payer: United Healthcare All Payer |
$5,120.79
|
|
|
ADJACENT TISSUE TRANSFER
|
Facility
|
OP
|
$7,648.25
|
|
|
Service Code
|
HCPCS 14060
|
| Hospital Charge Code |
76100168
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,690.17 |
| 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 |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,965.64
|
| 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 |
$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 |
$1,690.17
|
| 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 |
$2,028.20
|
| 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 |
$6,118.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,653.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,277.29
|
| Rate for Payer: PHCS Commercial |
$7,342.32
|
| Rate for Payer: United Healthcare All Payer |
$6,730.46
|
|
|
ADJACENT TISSUE TRANSFER
|
Facility
|
OP
|
$5,819.08
|
|
|
Service Code
|
HCPCS 14000
|
| Hospital Charge Code |
76100162
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,690.17 |
| Max. Negotiated Rate |
$5,586.32 |
| Rate for Payer: Aetna Commercial |
$4,480.69
|
| Rate for Payer: Anthem Medicaid |
$2,001.18
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,538.88
|
| 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 |
$2,909.54
|
| Rate for Payer: Cash Price |
$2,909.54
|
| Rate for Payer: Cigna Commercial |
$4,829.84
|
| Rate for Payer: First Health Commercial |
$5,528.13
|
| Rate for Payer: Humana Commercial |
$4,946.22
|
| Rate for Payer: Humana KY Medicaid |
$2,001.18
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$2,021.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,771.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,294.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,041.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,120.79
|
| Rate for Payer: Ohio Health Group HMO |
$4,364.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,655.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,062.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,015.17
|
| Rate for Payer: PHCS Commercial |
$5,586.32
|
| Rate for Payer: United Healthcare All Payer |
$5,120.79
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM
|
Facility
|
OP
|
$4,735.72
|
|
|
Service Code
|
CPT 14301
|
|
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
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS
|
Facility
|
OP
|
$2,366.24
|
|
|
Service Code
|
CPT 14040
|
|
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
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 SQ CM OR LESS
|
Facility
|
OP
|
$2,366.24
|
|
|
Service Code
|
CPT 14000
|
|
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
|
|
