|
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 |
$1,200.00 |
| 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 |
$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: 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 |
$1,200.00
|
| 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(P
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 14000
|
| Hospital Charge Code |
761P0162
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$255.40 |
| Max. Negotiated Rate |
$844.80 |
| 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 |
$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 |
$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 |
$480.00
|
| 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(T
|
Facility
|
IP
|
$5,019.08
|
|
|
Service Code
|
HCPCS 14000
|
| Hospital Charge Code |
761T0162
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,505.72 |
| 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 |
$4,015.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,366.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,463.17
|
| 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 |
$1,690.17 |
| 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 |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,914.88
|
| 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 |
$2,509.54
|
| 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 |
$1,690.17
|
| 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 |
$2,028.20
|
| 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 |
$4,015.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,366.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,463.17
|
| 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 |
$1,694.47 |
| 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 |
$1,694.47
|
| 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 |
$4,518.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,913.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,897.29
|
| Rate for Payer: PHCS Commercial |
$5,422.32
|
| Rate for Payer: United Healthcare All Payer |
$4,970.46
|
|
|
ADJACENT TISSUE TRANSFER(T
|
Facility
|
OP
|
$5,648.25
|
|
|
Service Code
|
HCPCS 14060
|
| Hospital Charge Code |
761T0168
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,690.17 |
| 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 |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,405.64
|
| 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 |
$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 |
$1,690.17
|
| 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 |
$2,028.20
|
| 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 |
$4,518.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,913.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,897.29
|
| Rate for Payer: PHCS Commercial |
$5,422.32
|
| Rate for Payer: United Healthcare All Payer |
$4,970.46
|
|
|
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 |
$746.59 |
| Rate for Payer: Aetna Commercial |
$672.90
|
| Rate for Payer: Ambetter Exchange |
$428.42
|
| Rate for Payer: Anthem Medicaid |
$236.03
|
| Rate for Payer: Buckeye Individual/Medicaid |
$428.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$428.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$514.10
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$428.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$428.42
|
| 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 |
$556.95
|
| Rate for Payer: UHCCP Medicaid |
$350.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$238.39
|
| Rate for Payer: Wellcare Medicare Advantage |
$428.42
|
|
|
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 |
$3,290.44 |
| Max. Negotiated Rate |
$9,240.92 |
| Rate for Payer: Aetna Commercial |
$7,367.36
|
| Rate for Payer: Anthem Medicaid |
$3,290.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,600.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,463.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9,240.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,910.89
|
| 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 |
$6,600.66
|
| 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 |
$7,920.79
|
| 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 |
$7,654.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,324.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,601.92
|
| 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
|
IP
|
$8,568.00
|
|
|
Service Code
|
HCPCS 20693
|
| Hospital Charge Code |
761T0353
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,570.40 |
| 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 |
$6,854.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,454.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,911.92
|
| 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
|
IP
|
$9,568.00
|
|
|
Service Code
|
HCPCS 20693
|
| Hospital Charge Code |
76100353
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,870.40 |
| 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 |
$7,654.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,324.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,601.92
|
| 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 |
$2,946.54 |
| Max. Negotiated Rate |
$9,240.92 |
| Rate for Payer: Aetna Commercial |
$6,597.36
|
| Rate for Payer: Anthem Medicaid |
$2,946.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,600.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,683.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9,240.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,910.89
|
| 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 |
$6,600.66
|
| 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 |
$7,920.79
|
| 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 |
$6,854.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,454.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,911.92
|
| Rate for Payer: PHCS Commercial |
$8,225.28
|
| Rate for Payer: United Healthcare All Payer |
$7,539.84
|
|
|
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 |
$5,740.80 |
| Rate for Payer: Aetna Commercial |
$672.90
|
| Rate for Payer: Ambetter Exchange |
$428.42
|
| Rate for Payer: Anthem Medicaid |
$236.03
|
| Rate for Payer: Buckeye Individual/Medicaid |
$428.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$428.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$514.10
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$428.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$428.42
|
| 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 |
$556.95
|
| Rate for Payer: UHCCP Medicaid |
$3,348.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$238.39
|
| Rate for Payer: Wellcare Medicare Advantage |
$428.42
|
|
|
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 |
$1,690.17 |
| 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 |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,457.56
|
| 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 |
$2,857.41
|
| 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 |
$1,690.17
|
| 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 |
$2,028.20
|
| 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 |
$4,286.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,571.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,971.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,943.23
|
| 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
|
Facility
|
IP
|
$5,714.82
|
|
|
Service Code
|
HCPCS 14041
|
| Hospital Charge Code |
761T0167
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,714.45 |
| 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 |
$4,286.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,571.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,971.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,943.23
|
| 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
|
Facility
|
OP
|
$7,214.82
|
|
|
Service Code
|
HCPCS 14041
|
| Hospital Charge Code |
76100167
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,690.17 |
| 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 |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,627.56
|
| 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 |
$3,607.41
|
| 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 |
$1,690.17
|
| 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 |
$2,028.20
|
| 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 |
$5,411.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,771.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,276.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,978.23
|
| 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 |
$2,164.45 |
| 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 |
$5,411.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,771.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,276.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,978.23
|
| 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
|
$1,500.00
|
|
|
Service Code
|
HCPCS 14041
|
| Hospital Charge Code |
761P0167
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$384.45 |
| Max. Negotiated Rate |
$1,204.11 |
| Rate for Payer: Aetna Commercial |
$1,130.23
|
| Rate for Payer: Ambetter Exchange |
$716.03
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$384.45
|
| Rate for Payer: Anthem Medicaid |
$551.29
|
| Rate for Payer: Buckeye Individual/Medicaid |
$716.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$716.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$859.24
|
| 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 |
$551.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$992.69
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$716.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$716.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$562.32
|
| Rate for Payer: Molina Healthcare Passport |
$551.29
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$930.84
|
| Rate for Payer: UHCCP Medicaid |
$403.67
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$556.80
|
| Rate for Payer: Wellcare Medicare Advantage |
$716.03
|
|
|
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 |
$4,328.89 |
| Rate for Payer: Aetna Commercial |
$1,130.23
|
| Rate for Payer: Ambetter Exchange |
$716.03
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$384.45
|
| Rate for Payer: Anthem Medicaid |
$551.29
|
| Rate for Payer: Buckeye Individual/Medicaid |
$716.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$716.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$859.24
|
| 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 |
$551.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$992.69
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$716.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$716.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$562.32
|
| Rate for Payer: Molina Healthcare Passport |
$551.29
|
| Rate for Payer: Multiplan PHCS |
$4,328.89
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$930.84
|
| Rate for Payer: UHCCP Medicaid |
$403.67
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$556.80
|
| Rate for Payer: Wellcare Medicare Advantage |
$716.03
|
|
|
ADM FEE VAC 1ST SHOT
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
HCPCS 90471
|
| Hospital Charge Code |
77000001
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$26.82 |
| Max. Negotiated Rate |
$92.06 |
| Rate for Payer: Aetna Commercial |
$60.06
|
| Rate for Payer: Anthem Medicaid |
$26.82
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$65.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$92.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$88.78
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$64.74
|
| Rate for Payer: First Health Commercial |
$74.10
|
| Rate for Payer: Humana Commercial |
$66.30
|
| Rate for Payer: Humana KY Medicaid |
$26.82
|
| Rate for Payer: Humana Medicare Advantage |
$65.76
|
| Rate for Payer: Kentucky WC Medicaid |
$27.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.64
|
| Rate for Payer: Ohio Health Group HMO |
$58.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.82
|
| Rate for Payer: PHCS Commercial |
$74.88
|
| Rate for Payer: United Healthcare All Payer |
$68.64
|
|
|
ADM FEE VAC 1ST SHOT
|
Professional
|
Both
|
$78.00
|
|
|
Service Code
|
HCPCS 90471
|
| Hospital Charge Code |
77000001
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$18.80 |
| Max. Negotiated Rate |
$46.80 |
| Rate for Payer: Ambetter Exchange |
$18.80
|
| Rate for Payer: Anthem Medicaid |
$27.49
|
| Rate for Payer: Buckeye Individual/Medicaid |
$18.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$18.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$22.56
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$28.79
|
| Rate for Payer: Healthspan PPO |
$23.94
|
| Rate for Payer: Humana Medicaid |
$27.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$24.58
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$18.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$28.04
|
| Rate for Payer: Molina Healthcare Passport |
$27.49
|
| Rate for Payer: Multiplan PHCS |
$46.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$24.44
|
| Rate for Payer: UHCCP Medicaid |
$27.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$27.76
|
| Rate for Payer: Wellcare Medicare Advantage |
$18.80
|
|
|
ADM FEE VAC 1ST SHOT
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
HCPCS 90471
|
| Hospital Charge Code |
77000001
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$23.40 |
| Max. Negotiated Rate |
$74.88 |
| Rate for Payer: Aetna Commercial |
$60.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.84
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$64.74
|
| Rate for Payer: First Health Commercial |
$74.10
|
| Rate for Payer: Humana Commercial |
$66.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.64
|
| Rate for Payer: Ohio Health Group HMO |
$58.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.82
|
| Rate for Payer: PHCS Commercial |
$74.88
|
| Rate for Payer: United Healthcare All Payer |
$68.64
|
|
|
ADM FEE VAC 1ST SHOT(T
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
HCPCS 90471
|
| Hospital Charge Code |
770T0001
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$23.40 |
| Max. Negotiated Rate |
$74.88 |
| Rate for Payer: Aetna Commercial |
$60.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.84
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$64.74
|
| Rate for Payer: First Health Commercial |
$74.10
|
| Rate for Payer: Humana Commercial |
$66.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.64
|
| Rate for Payer: Ohio Health Group HMO |
$58.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.82
|
| Rate for Payer: PHCS Commercial |
$74.88
|
| Rate for Payer: United Healthcare All Payer |
$68.64
|
|
|
ADM FEE VAC 1ST SHOT(T
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
HCPCS 90471
|
| Hospital Charge Code |
770T0001
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$26.82 |
| Max. Negotiated Rate |
$92.06 |
| Rate for Payer: Aetna Commercial |
$60.06
|
| Rate for Payer: Anthem Medicaid |
$26.82
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$65.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$92.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$88.78
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$64.74
|
| Rate for Payer: First Health Commercial |
$74.10
|
| Rate for Payer: Humana Commercial |
$66.30
|
| Rate for Payer: Humana KY Medicaid |
$26.82
|
| Rate for Payer: Humana Medicare Advantage |
$65.76
|
| Rate for Payer: Kentucky WC Medicaid |
$27.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.64
|
| Rate for Payer: Ohio Health Group HMO |
$58.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.82
|
| Rate for Payer: PHCS Commercial |
$74.88
|
| Rate for Payer: United Healthcare All Payer |
$68.64
|
|
|
ADM FEE VAC 2+ SHOTS
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
HCPCS 90472
|
| Hospital Charge Code |
77000002
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$13.44 |
| Rate for Payer: Aetna Commercial |
$10.78
|
| Rate for Payer: Anthem Medicaid |
$4.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10.92
|
| Rate for Payer: Cash Price |
$7.00
|
| Rate for Payer: Cigna Commercial |
$11.62
|
| Rate for Payer: First Health Commercial |
$13.30
|
| Rate for Payer: Humana Commercial |
$11.90
|
| Rate for Payer: Humana KY Medicaid |
$4.81
|
| Rate for Payer: Kentucky WC Medicaid |
$4.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$12.32
|
| Rate for Payer: Ohio Health Group HMO |
$10.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.66
|
| Rate for Payer: PHCS Commercial |
$13.44
|
| Rate for Payer: United Healthcare All Payer |
$12.32
|
|
|
ADM FEE VAC 2+ SHOTS
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
HCPCS 90472
|
| Hospital Charge Code |
77000002
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$13.44 |
| Rate for Payer: Aetna Commercial |
$10.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10.92
|
| Rate for Payer: Cash Price |
$7.00
|
| Rate for Payer: Cigna Commercial |
$11.62
|
| Rate for Payer: First Health Commercial |
$13.30
|
| Rate for Payer: Humana Commercial |
$11.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$12.32
|
| Rate for Payer: Ohio Health Group HMO |
$10.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.66
|
| Rate for Payer: PHCS Commercial |
$13.44
|
| Rate for Payer: United Healthcare All Payer |
$12.32
|
|
