|
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
|
|
|
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
|
Facility
|
IP
|
$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 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 |
$2,294.48
|
| 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 OR REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM
|
Facility
|
OP
|
$4,343.37
|
|
|
Service Code
|
CPT 14301
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,102.41 |
| Max. Negotiated Rate |
$4,343.37 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,102.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,343.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,188.25
|
| Rate for Payer: Humana Medicare Advantage |
$3,102.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.89
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS
|
Facility
|
OP
|
$2,207.77
|
|
|
Service Code
|
CPT 14040
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,576.98 |
| Max. Negotiated Rate |
$2,207.77 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 SQ CM OR LESS
|
Facility
|
OP
|
$2,207.77
|
|
|
Service Code
|
CPT 14000
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,576.98 |
| Max. Negotiated Rate |
$2,207.77 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
|
|
ADJACENT TISSUE TRANSFER(P
|
Professional
|
Both
|
$2,000.00
|
|
|
Service Code
|
HCPCS 14060
|
| Hospital Charge Code |
761P0168
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$340.75 |
| Max. Negotiated Rate |
$2,000.00 |
| 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 |
$2,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| 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 |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,400.00
|
| Rate for Payer: UHCCP Medicaid |
$357.79
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$474.05
|
|
|
ADJACENT TISSUE TRANSFER(P
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 14000
|
| Hospital Charge Code |
761P0162
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$214.30 |
| Max. Negotiated Rate |
$844.80 |
| 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 |
$800.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| 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 |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$560.00
|
| Rate for Payer: UHCCP Medicaid |
$268.17
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$216.44
|
|
|
ADJACENT TISSUE TRANSFER(T
|
Facility
|
OP
|
$5,648.25
|
|
|
Service Code
|
HCPCS 14060
|
| Hospital Charge Code |
761T0168
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$734.27 |
| Max. Negotiated Rate |
$5,422.32 |
| Rate for Payer: Aetna Commercial |
$4,349.15
|
| Rate for Payer: Anthem Medicaid |
$1,942.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,405.64
|
| 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 |
$2,824.12
|
| Rate for Payer: Cash Price |
$2,824.12
|
| Rate for Payer: Cigna Commercial |
$4,688.05
|
| Rate for Payer: First Health Commercial |
$5,365.84
|
| Rate for Payer: Humana Commercial |
$4,801.01
|
| Rate for Payer: Humana KY Medicaid |
$1,942.43
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,962.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,631.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,168.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,981.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,970.46
|
| Rate for Payer: Ohio Health Group HMO |
$4,236.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,129.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$734.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,750.96
|
| Rate for Payer: PHCS Commercial |
$5,422.32
|
| Rate for Payer: United Healthcare All Payer |
$4,970.46
|
|
|
ADJACENT TISSUE TRANSFER(T
|
Facility
|
IP
|
$5,019.08
|
|
|
Service Code
|
HCPCS 14000
|
| Hospital Charge Code |
761T0162
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$652.48 |
| Max. Negotiated Rate |
$4,818.32 |
| Rate for Payer: Aetna Commercial |
$3,864.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,914.88
|
| Rate for Payer: Cash Price |
$2,509.54
|
| Rate for Payer: Cigna Commercial |
$4,165.84
|
| Rate for Payer: First Health Commercial |
$4,768.13
|
| Rate for Payer: Humana Commercial |
$4,266.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,115.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,704.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,505.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,416.79
|
| Rate for Payer: Ohio Health Group HMO |
$3,764.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,003.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$652.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,555.91
|
| Rate for Payer: PHCS Commercial |
$4,818.32
|
| Rate for Payer: United Healthcare All Payer |
$4,416.79
|
|
|
ADJACENT TISSUE TRANSFER(T
|
Facility
|
OP
|
$5,019.08
|
|
|
Service Code
|
HCPCS 14000
|
| Hospital Charge Code |
761T0162
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$652.48 |
| Max. Negotiated Rate |
$4,818.32 |
| Rate for Payer: Aetna Commercial |
$3,864.69
|
| Rate for Payer: Anthem Medicaid |
$1,726.06
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,914.88
|
| 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 |
$2,509.54
|
| Rate for Payer: Cash Price |
$2,509.54
|
| Rate for Payer: Cigna Commercial |
$4,165.84
|
| Rate for Payer: First Health Commercial |
$4,768.13
|
| Rate for Payer: Humana Commercial |
$4,266.22
|
| Rate for Payer: Humana KY Medicaid |
$1,726.06
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,743.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,115.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,704.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,760.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,416.79
|
| Rate for Payer: Ohio Health Group HMO |
$3,764.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,003.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$652.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,555.91
|
| Rate for Payer: PHCS Commercial |
$4,818.32
|
| Rate for Payer: United Healthcare All Payer |
$4,416.79
|
|
|
ADJACENT TISSUE TRANSFER(T
|
Facility
|
IP
|
$5,648.25
|
|
|
Service Code
|
HCPCS 14060
|
| Hospital Charge Code |
761T0168
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$734.27 |
| Max. Negotiated Rate |
$5,422.32 |
| Rate for Payer: Aetna Commercial |
$4,349.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,405.64
|
| Rate for Payer: Cash Price |
$2,824.12
|
| Rate for Payer: Cigna Commercial |
$4,688.05
|
| Rate for Payer: First Health Commercial |
$5,365.84
|
| Rate for Payer: Humana Commercial |
$4,801.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,631.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,168.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,694.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,970.46
|
| Rate for Payer: Ohio Health Group HMO |
$4,236.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,129.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$734.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,750.96
|
| Rate for Payer: PHCS Commercial |
$5,422.32
|
| Rate for Payer: United Healthcare All Payer |
$4,970.46
|
|
|
ADJ/REV EXT FIXATION SYS WANES
|
Facility
|
IP
|
$8,568.00
|
|
|
Service Code
|
HCPCS 20693
|
| Hospital Charge Code |
761T0353
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,113.84 |
| Max. Negotiated Rate |
$8,225.28 |
| Rate for Payer: Aetna Commercial |
$6,597.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,683.04
|
| Rate for Payer: Cash Price |
$4,284.00
|
| Rate for Payer: Cigna Commercial |
$7,111.44
|
| Rate for Payer: First Health Commercial |
$8,139.60
|
| Rate for Payer: Humana Commercial |
$7,282.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,025.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,323.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,570.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,539.84
|
| Rate for Payer: Ohio Health Group HMO |
$6,426.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,713.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,113.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,656.08
|
| Rate for Payer: PHCS Commercial |
$8,225.28
|
| Rate for Payer: United Healthcare All Payer |
$7,539.84
|
|
|
ADJ/REV EXT FIXATION SYS WANES
|
Facility
|
OP
|
$9,568.00
|
|
|
Service Code
|
HCPCS 20693
|
| Hospital Charge Code |
76100353
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,243.84 |
| Max. Negotiated Rate |
$9,185.28 |
| Rate for Payer: Aetna Commercial |
$7,367.36
|
| Rate for Payer: Anthem Medicaid |
$3,290.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,186.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,463.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,661.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,351.78
|
| Rate for Payer: Cash Price |
$4,784.00
|
| Rate for Payer: Cash Price |
$4,784.00
|
| Rate for Payer: Cigna Commercial |
$7,941.44
|
| Rate for Payer: First Health Commercial |
$9,089.60
|
| Rate for Payer: Humana Commercial |
$8,132.80
|
| Rate for Payer: Humana KY Medicaid |
$3,290.44
|
| Rate for Payer: Humana Medicare Advantage |
$6,186.50
|
| Rate for Payer: Kentucky WC Medicaid |
$3,323.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,845.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,061.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,423.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,356.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,419.84
|
| Rate for Payer: Ohio Health Group HMO |
$7,176.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,913.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,243.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,966.08
|
| Rate for Payer: PHCS Commercial |
$9,185.28
|
| Rate for Payer: United Healthcare All Payer |
$8,419.84
|
|
|
ADJ/REV EXT FIXATION SYS WANES
|
Professional
|
Both
|
$9,568.00
|
|
|
Service Code
|
HCPCS 20693
|
| Hospital Charge Code |
76100353
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$236.03 |
| Max. Negotiated Rate |
$9,568.00 |
| Rate for Payer: Aetna Commercial |
$672.90
|
| Rate for Payer: Anthem Medicaid |
$236.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$9,568.00
|
| Rate for Payer: Cash Price |
$4,784.00
|
| Rate for Payer: Cash Price |
$4,784.00
|
| Rate for Payer: Cigna Commercial |
$746.59
|
| Rate for Payer: Healthspan PPO |
$609.51
|
| Rate for Payer: Humana Medicaid |
$236.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$563.43
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$240.75
|
| Rate for Payer: Molina Healthcare Passport |
$236.03
|
| Rate for Payer: Multiplan PHCS |
$5,740.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$6,697.60
|
| Rate for Payer: UHCCP Medicaid |
$3,348.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$238.39
|
|
|
ADJ/REV EXT FIXATION SYS WANES
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 20693
|
| Hospital Charge Code |
761P0353
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$236.03 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Aetna Commercial |
$672.90
|
| Rate for Payer: Anthem Medicaid |
$236.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,000.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$746.59
|
| Rate for Payer: Healthspan PPO |
$609.51
|
| Rate for Payer: Humana Medicaid |
$236.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$563.43
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$240.75
|
| Rate for Payer: Molina Healthcare Passport |
$236.03
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$350.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$238.39
|
|
|
ADJ/REV EXT FIXATION SYS WANES
|
Facility
|
IP
|
$9,568.00
|
|
|
Service Code
|
HCPCS 20693
|
| Hospital Charge Code |
76100353
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,243.84 |
| Max. Negotiated Rate |
$9,185.28 |
| Rate for Payer: Aetna Commercial |
$7,367.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,463.04
|
| Rate for Payer: Cash Price |
$4,784.00
|
| Rate for Payer: Cigna Commercial |
$7,941.44
|
| Rate for Payer: First Health Commercial |
$9,089.60
|
| Rate for Payer: Humana Commercial |
$8,132.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,845.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,061.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,870.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,419.84
|
| Rate for Payer: Ohio Health Group HMO |
$7,176.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,913.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,243.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,966.08
|
| Rate for Payer: PHCS Commercial |
$9,185.28
|
| Rate for Payer: United Healthcare All Payer |
$8,419.84
|
|
|
ADJ/REV EXT FIXATION SYS WANES
|
Facility
|
OP
|
$8,568.00
|
|
|
Service Code
|
HCPCS 20693
|
| Hospital Charge Code |
761T0353
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,113.84 |
| Max. Negotiated Rate |
$8,661.10 |
| Rate for Payer: Aetna Commercial |
$6,597.36
|
| Rate for Payer: Anthem Medicaid |
$2,946.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,186.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,683.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,661.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,351.78
|
| Rate for Payer: Cash Price |
$4,284.00
|
| Rate for Payer: Cash Price |
$4,284.00
|
| Rate for Payer: Cigna Commercial |
$7,111.44
|
| Rate for Payer: First Health Commercial |
$8,139.60
|
| Rate for Payer: Humana Commercial |
$7,282.80
|
| Rate for Payer: Humana KY Medicaid |
$2,946.54
|
| Rate for Payer: Humana Medicare Advantage |
$6,186.50
|
| Rate for Payer: Kentucky WC Medicaid |
$2,976.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,025.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,323.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,423.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,005.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,539.84
|
| Rate for Payer: Ohio Health Group HMO |
$6,426.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,713.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,113.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,656.08
|
| Rate for Payer: PHCS Commercial |
$8,225.28
|
| Rate for Payer: United Healthcare All Payer |
$7,539.84
|
|
|
ADJ. TISSUE TRANSFER 10.1-30.0
|
Facility
|
OP
|
$7,214.82
|
|
|
Service Code
|
HCPCS 14041
|
| Hospital Charge Code |
76100167
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$937.93 |
| Max. Negotiated Rate |
$6,926.23 |
| Rate for Payer: Aetna Commercial |
$5,555.41
|
| Rate for Payer: Anthem Medicaid |
$2,481.18
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,627.56
|
| 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 |
$3,607.41
|
| Rate for Payer: Cash Price |
$3,607.41
|
| Rate for Payer: Cigna Commercial |
$5,988.30
|
| Rate for Payer: First Health Commercial |
$6,854.08
|
| Rate for Payer: Humana Commercial |
$6,132.60
|
| Rate for Payer: Humana KY Medicaid |
$2,481.18
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,506.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,916.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,324.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,530.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,349.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,411.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,442.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$937.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,236.59
|
| Rate for Payer: PHCS Commercial |
$6,926.23
|
| Rate for Payer: United Healthcare All Payer |
$6,349.04
|
|
|
ADJ. TISSUE TRANSFER 10.1-30.0
|
Facility
|
IP
|
$7,214.82
|
|
|
Service Code
|
HCPCS 14041
|
| Hospital Charge Code |
76100167
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$937.93 |
| Max. Negotiated Rate |
$6,926.23 |
| Rate for Payer: Aetna Commercial |
$5,555.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,627.56
|
| Rate for Payer: Cash Price |
$3,607.41
|
| Rate for Payer: Cigna Commercial |
$5,988.30
|
| Rate for Payer: First Health Commercial |
$6,854.08
|
| Rate for Payer: Humana Commercial |
$6,132.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,916.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,324.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,164.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,349.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,411.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,442.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$937.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,236.59
|
| Rate for Payer: PHCS Commercial |
$6,926.23
|
| Rate for Payer: United Healthcare All Payer |
$6,349.04
|
|
|
ADJ. TISSUE TRANSFER 10.1-30.0
|
Professional
|
Both
|
$7,214.82
|
|
|
Service Code
|
HCPCS 14041
|
| Hospital Charge Code |
76100167
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$384.45 |
| Max. Negotiated Rate |
$7,214.82 |
| Rate for Payer: Aetna Commercial |
$1,130.23
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$384.45
|
| Rate for Payer: Anthem Medicaid |
$445.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$7,214.82
|
| Rate for Payer: Cash Price |
$3,607.41
|
| Rate for Payer: Cash Price |
$3,607.41
|
| Rate for Payer: Cigna Commercial |
$1,204.11
|
| Rate for Payer: Healthspan PPO |
$1,056.06
|
| Rate for Payer: Humana Medicaid |
$445.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$992.69
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$454.52
|
| Rate for Payer: Molina Healthcare Passport |
$445.61
|
| Rate for Payer: Multiplan PHCS |
$4,328.89
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5,050.37
|
| Rate for Payer: UHCCP Medicaid |
$403.67
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$450.07
|
|
|
ADJ. TISSUE TRANSFER 10.1-30.0
|
Facility
|
IP
|
$5,714.82
|
|
|
Service Code
|
HCPCS 14041
|
| Hospital Charge Code |
761T0167
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$742.93 |
| Max. Negotiated Rate |
$5,486.23 |
| Rate for Payer: Aetna Commercial |
$4,400.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,457.56
|
| Rate for Payer: Cash Price |
$2,857.41
|
| Rate for Payer: Cigna Commercial |
$4,743.30
|
| Rate for Payer: First Health Commercial |
$5,429.08
|
| Rate for Payer: Humana Commercial |
$4,857.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,686.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,217.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,714.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,029.04
|
| Rate for Payer: Ohio Health Group HMO |
$4,286.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,142.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$742.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,771.59
|
| Rate for Payer: PHCS Commercial |
$5,486.23
|
| Rate for Payer: United Healthcare All Payer |
$5,029.04
|
|
|
ADJ. TISSUE TRANSFER 10.1-30.0
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 14041
|
| Hospital Charge Code |
761P0167
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$384.45 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Aetna Commercial |
$1,130.23
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$384.45
|
| Rate for Payer: Anthem Medicaid |
$445.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,500.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,204.11
|
| Rate for Payer: Healthspan PPO |
$1,056.06
|
| Rate for Payer: Humana Medicaid |
$445.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$992.69
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$454.52
|
| Rate for Payer: Molina Healthcare Passport |
$445.61
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,050.00
|
| Rate for Payer: UHCCP Medicaid |
$403.67
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$450.07
|
|
|
ADJ. TISSUE TRANSFER 10.1-30.0
|
Facility
|
OP
|
$5,714.82
|
|
|
Service Code
|
HCPCS 14041
|
| Hospital Charge Code |
761T0167
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$742.93 |
| Max. Negotiated Rate |
$5,486.23 |
| Rate for Payer: Aetna Commercial |
$4,400.41
|
| Rate for Payer: Anthem Medicaid |
$1,965.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,457.56
|
| 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 |
$2,857.41
|
| Rate for Payer: Cash Price |
$2,857.41
|
| Rate for Payer: Cigna Commercial |
$4,743.30
|
| Rate for Payer: First Health Commercial |
$5,429.08
|
| Rate for Payer: Humana Commercial |
$4,857.60
|
| Rate for Payer: Humana KY Medicaid |
$1,965.33
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,985.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,686.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,217.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,004.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,029.04
|
| Rate for Payer: Ohio Health Group HMO |
$4,286.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,142.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$742.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,771.59
|
| Rate for Payer: PHCS Commercial |
$5,486.23
|
| Rate for Payer: United Healthcare All Payer |
$5,029.04
|
|
|
ADM FEE VAC 1ST SHOT
|
Professional
|
Both
|
$76.00
|
|
|
Service Code
|
HCPCS 90471
|
| Hospital Charge Code |
77000001
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$23.94 |
| Max. Negotiated Rate |
$76.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$76.00
|
| Rate for Payer: Cash Price |
$38.00
|
| Rate for Payer: Cash Price |
$38.00
|
| Rate for Payer: Cigna Commercial |
$28.79
|
| Rate for Payer: Healthspan PPO |
$23.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$24.58
|
| Rate for Payer: Multiplan PHCS |
$45.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$53.20
|
| Rate for Payer: UHCCP Medicaid |
$26.60
|
|
