|
FRESH FROZEN PLASMA 24H EA UN
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
HCPCS P9059
|
| Hospital Charge Code |
38000019
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$18.72 |
| Max. Negotiated Rate |
$138.24 |
| Rate for Payer: Aetna Commercial |
$110.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.32
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$119.52
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: Humana Commercial |
$122.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.72
|
| Rate for Payer: Ohio Health Group HMO |
$108.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.64
|
| Rate for Payer: PHCS Commercial |
$138.24
|
| Rate for Payer: United Healthcare All Payer |
$126.72
|
|
|
FRESH FROZEN PLASMA EA UNIT
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
HCPCS P9017
|
| Hospital Charge Code |
38000009
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$115.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$124.50
|
| Rate for Payer: First Health Commercial |
$142.50
|
| Rate for Payer: Humana Commercial |
$127.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.00
|
| Rate for Payer: Ohio Health Group HMO |
$112.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.50
|
| Rate for Payer: PHCS Commercial |
$144.00
|
| Rate for Payer: United Healthcare All Payer |
$132.00
|
|
|
FRESH FROZEN PLASMA EA UNIT
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
HCPCS P9017
|
| Hospital Charge Code |
38000009
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$115.50
|
| Rate for Payer: Anthem Medicaid |
$51.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$72.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$101.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$97.97
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$124.50
|
| Rate for Payer: First Health Commercial |
$142.50
|
| Rate for Payer: Humana Commercial |
$127.50
|
| Rate for Payer: Humana KY Medicaid |
$51.58
|
| Rate for Payer: Humana Medicare Advantage |
$72.57
|
| Rate for Payer: Kentucky WC Medicaid |
$52.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$52.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.00
|
| Rate for Payer: Ohio Health Group HMO |
$112.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.50
|
| Rate for Payer: PHCS Commercial |
$144.00
|
| Rate for Payer: United Healthcare All Payer |
$132.00
|
|
|
FSH FOLLICLE STIM HORMONE
|
Professional
|
Both
|
$166.00
|
|
|
Service Code
|
HCPCS 83001
|
| Hospital Charge Code |
30000353
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.15 |
| Max. Negotiated Rate |
$166.00 |
| Rate for Payer: Aetna Commercial |
$31.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$166.00
|
| Rate for Payer: Cash Price |
$83.00
|
| Rate for Payer: Cash Price |
$83.00
|
| Rate for Payer: Cigna Commercial |
$16.53
|
| Rate for Payer: Healthspan PPO |
$19.48
|
| Rate for Payer: Multiplan PHCS |
$99.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$116.20
|
| Rate for Payer: UHCCP Medicaid |
$58.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$11.15
|
|
|
FSH FOLLICLE STIM HORMONE
|
Facility
|
OP
|
$166.00
|
|
|
Service Code
|
HCPCS 83001
|
| Hospital Charge Code |
30000353
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.58 |
| Max. Negotiated Rate |
$159.36 |
| Rate for Payer: Aetna Commercial |
$127.82
|
| Rate for Payer: Anthem Medicaid |
$18.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$18.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$133.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$26.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$18.58
|
| Rate for Payer: Cash Price |
$83.00
|
| Rate for Payer: Cash Price |
$83.00
|
| Rate for Payer: Cigna Commercial |
$137.78
|
| Rate for Payer: First Health Commercial |
$157.70
|
| Rate for Payer: Humana Commercial |
$141.10
|
| Rate for Payer: Humana KY Medicaid |
$18.58
|
| Rate for Payer: Humana Medicare Advantage |
$18.58
|
| Rate for Payer: Kentucky WC Medicaid |
$18.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$136.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$122.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$18.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$146.08
|
| Rate for Payer: Ohio Health Group HMO |
$124.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.46
|
| Rate for Payer: PHCS Commercial |
$159.36
|
| Rate for Payer: United Healthcare All Payer |
$146.08
|
|
|
FSH FOLLICLE STIM HORMONE
|
Facility
|
IP
|
$166.00
|
|
|
Service Code
|
HCPCS 83001
|
| Hospital Charge Code |
30000353
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.58 |
| Max. Negotiated Rate |
$159.36 |
| Rate for Payer: Aetna Commercial |
$127.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$133.30
|
| Rate for Payer: Cash Price |
$83.00
|
| Rate for Payer: Cigna Commercial |
$137.78
|
| Rate for Payer: First Health Commercial |
$157.70
|
| Rate for Payer: Humana Commercial |
$141.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$136.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$122.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$146.08
|
| Rate for Payer: Ohio Health Group HMO |
$124.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.46
|
| Rate for Payer: PHCS Commercial |
$159.36
|
| Rate for Payer: United Healthcare All Payer |
$146.08
|
|
|
FSP FIBRIN SPL PROD SEMI Q
|
Facility
|
OP
|
$132.00
|
|
|
Service Code
|
HCPCS 85362
|
| Hospital Charge Code |
30000599
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.89 |
| Max. Negotiated Rate |
$126.72 |
| Rate for Payer: Aetna Commercial |
$101.64
|
| Rate for Payer: Anthem Medicaid |
$6.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$106.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$6.89
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$109.56
|
| Rate for Payer: First Health Commercial |
$125.40
|
| Rate for Payer: Humana Commercial |
$112.20
|
| Rate for Payer: Humana KY Medicaid |
$6.89
|
| Rate for Payer: Humana Medicare Advantage |
$6.89
|
| Rate for Payer: Kentucky WC Medicaid |
$6.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$108.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$97.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$116.16
|
| Rate for Payer: Ohio Health Group HMO |
$99.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.92
|
| Rate for Payer: PHCS Commercial |
$126.72
|
| Rate for Payer: United Healthcare All Payer |
$116.16
|
|
|
FSP FIBRIN SPL PROD SEMI Q
|
Facility
|
IP
|
$132.00
|
|
|
Service Code
|
HCPCS 85362
|
| Hospital Charge Code |
30000599
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$126.72 |
| Rate for Payer: Aetna Commercial |
$101.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$106.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cigna Commercial |
$109.56
|
| Rate for Payer: First Health Commercial |
$125.40
|
| Rate for Payer: Humana Commercial |
$112.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$108.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$97.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$116.16
|
| Rate for Payer: Ohio Health Group HMO |
$99.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.92
|
| Rate for Payer: PHCS Commercial |
$126.72
|
| Rate for Payer: United Healthcare All Payer |
$116.16
|
|
|
FULL LEG LASER HAIR REMOVAL
|
Professional
|
Both
|
$650.00
|
|
| Hospital Charge Code |
22200189
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$650.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$650.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Multiplan PHCS |
$390.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$455.00
|
| Rate for Payer: UHCCP Medicaid |
$227.50
|
|
|
Full Leg Lsr Hair Rem-PP#1 50%
|
Professional
|
Both
|
$829.00
|
|
| Hospital Charge Code |
22200353
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$290.15 |
| Max. Negotiated Rate |
$829.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$829.00
|
| Rate for Payer: Cash Price |
$414.50
|
| Rate for Payer: Multiplan PHCS |
$497.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$580.30
|
| Rate for Payer: UHCCP Medicaid |
$290.15
|
|
|
Full LegLsr HairRem-PP#2/3 25%
|
Professional
|
Both
|
$414.00
|
|
| Hospital Charge Code |
22200469
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$144.90 |
| Max. Negotiated Rate |
$414.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$414.00
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Multiplan PHCS |
$248.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$289.80
|
| Rate for Payer: UHCCP Medicaid |
$144.90
|
|
|
FULL MASTOPEXY WITH BIL
|
Professional
|
Both
|
$2,240.00
|
|
| Hospital Charge Code |
22200366
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$784.00 |
| Max. Negotiated Rate |
$2,240.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$2,240.00
|
| Rate for Payer: Cash Price |
$1,120.00
|
| Rate for Payer: Multiplan PHCS |
$1,344.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,568.00
|
| Rate for Payer: UHCCP Medicaid |
$784.00
|
|
|
FULL MASTOPEXY WITH BIL - 80
|
Professional
|
Both
|
$1,120.00
|
|
| Hospital Charge Code |
22200687
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$392.00 |
| Max. Negotiated Rate |
$1,120.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$1,120.00
|
| Rate for Payer: Cash Price |
$560.00
|
| Rate for Payer: Multiplan PHCS |
$672.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$784.00
|
| Rate for Payer: UHCCP Medicaid |
$392.00
|
|
|
FULL TERM NEONATE WITH MAJOR PROBLEMS
|
Facility
|
IP
|
$49,241.25
|
|
|
Service Code
|
MSDRG 793
|
| Min. Negotiated Rate |
$33,413.70 |
| Max. Negotiated Rate |
$49,241.25 |
| Rate for Payer: Anthem Medicaid |
$33,413.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$35,172.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$49,241.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$47,482.63
|
| Rate for Payer: Humana KY Medicaid |
$33,413.70
|
| Rate for Payer: Humana Medicare Advantage |
$35,172.32
|
| Rate for Payer: Kentucky WC Medicaid |
$33,747.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42,206.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$34,081.98
|
|
|
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY
|
Facility
|
IP
|
$24,478.48
|
|
|
Service Code
|
MSDRG 934
|
| Min. Negotiated Rate |
$16,610.40 |
| Max. Negotiated Rate |
$24,478.48 |
| Rate for Payer: Anthem Medicaid |
$16,610.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$17,484.63
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$24,478.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$23,604.25
|
| Rate for Payer: Humana KY Medicaid |
$16,610.40
|
| Rate for Payer: Humana Medicare Advantage |
$17,484.63
|
| Rate for Payer: Kentucky WC Medicaid |
$16,776.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,981.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$16,942.61
|
|
|
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC
|
Facility
|
IP
|
$80,948.07
|
|
|
Service Code
|
MSDRG 928
|
| Min. Negotiated Rate |
$54,929.05 |
| Max. Negotiated Rate |
$80,948.07 |
| Rate for Payer: Anthem Medicaid |
$54,929.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$57,820.05
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$80,948.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$78,057.07
|
| Rate for Payer: Humana KY Medicaid |
$54,929.05
|
| Rate for Payer: Humana Medicare Advantage |
$57,820.05
|
| Rate for Payer: Kentucky WC Medicaid |
$55,478.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$69,384.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$56,027.63
|
|
|
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC
|
Facility
|
IP
|
$37,615.59
|
|
|
Service Code
|
MSDRG 929
|
| Min. Negotiated Rate |
$25,524.87 |
| Max. Negotiated Rate |
$37,615.59 |
| Rate for Payer: Anthem Medicaid |
$25,524.87
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$26,868.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$37,615.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$36,272.18
|
| Rate for Payer: Humana KY Medicaid |
$25,524.87
|
| Rate for Payer: Humana Medicare Advantage |
$26,868.28
|
| Rate for Payer: Kentucky WC Medicaid |
$25,780.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32,241.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$26,035.36
|
|
|
FULL THICKNESS GRAFT
|
Professional
|
Both
|
$5,980.33
|
|
|
Service Code
|
HCPCS 15260
|
| Hospital Charge Code |
76100188
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$426.52 |
| Max. Negotiated Rate |
$5,980.33 |
| Rate for Payer: Aetna Commercial |
$1,207.11
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$426.52
|
| Rate for Payer: Anthem Medicaid |
$504.67
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,980.33
|
| Rate for Payer: Cash Price |
$2,990.16
|
| Rate for Payer: Cash Price |
$2,990.16
|
| Rate for Payer: Cigna Commercial |
$1,128.38
|
| Rate for Payer: Healthspan PPO |
$1,097.43
|
| Rate for Payer: Humana Medicaid |
$504.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,080.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$514.76
|
| Rate for Payer: Molina Healthcare Passport |
$504.67
|
| Rate for Payer: Multiplan PHCS |
$3,588.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,186.23
|
| Rate for Payer: UHCCP Medicaid |
$447.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$509.72
|
|
|
FULL THICKNESS GRAFT
|
Facility
|
OP
|
$5,980.33
|
|
|
Service Code
|
HCPCS 15260
|
| Hospital Charge Code |
76100188
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$777.44 |
| Max. Negotiated Rate |
$5,741.12 |
| Rate for Payer: Aetna Commercial |
$4,604.85
|
| Rate for Payer: Anthem Medicaid |
$2,056.64
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,664.66
|
| 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 |
$2,990.16
|
| Rate for Payer: Cash Price |
$2,990.16
|
| Rate for Payer: Cigna Commercial |
$4,963.67
|
| Rate for Payer: First Health Commercial |
$5,681.31
|
| Rate for Payer: Humana Commercial |
$5,083.28
|
| Rate for Payer: Humana KY Medicaid |
$2,056.64
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,077.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,903.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,413.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,097.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,262.69
|
| Rate for Payer: Ohio Health Group HMO |
$4,485.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,196.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$777.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,853.90
|
| Rate for Payer: PHCS Commercial |
$5,741.12
|
| Rate for Payer: United Healthcare All Payer |
$5,262.69
|
|
|
FULL THICKNESS GRAFT
|
Facility
|
IP
|
$5,980.33
|
|
|
Service Code
|
HCPCS 15260
|
| Hospital Charge Code |
76100188
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$777.44 |
| Max. Negotiated Rate |
$5,741.12 |
| Rate for Payer: Aetna Commercial |
$4,604.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,664.66
|
| Rate for Payer: Cash Price |
$2,990.16
|
| Rate for Payer: Cigna Commercial |
$4,963.67
|
| Rate for Payer: First Health Commercial |
$5,681.31
|
| Rate for Payer: Humana Commercial |
$5,083.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,903.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,413.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,794.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,262.69
|
| Rate for Payer: Ohio Health Group HMO |
$4,485.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,196.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$777.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,853.90
|
| Rate for Payer: PHCS Commercial |
$5,741.12
|
| Rate for Payer: United Healthcare All Payer |
$5,262.69
|
|
|
FULL THICKNESS GRAFT - CLOSU(P
|
Professional
|
Both
|
$1,025.00
|
|
|
Service Code
|
HCPCS 15220
|
| Hospital Charge Code |
761P0184
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$308.52 |
| Max. Negotiated Rate |
$1,025.00 |
| Rate for Payer: Aetna Commercial |
$882.69
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$308.52
|
| Rate for Payer: Anthem Medicaid |
$368.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,025.00
|
| Rate for Payer: Cash Price |
$512.50
|
| Rate for Payer: Cash Price |
$512.50
|
| Rate for Payer: Cigna Commercial |
$838.65
|
| Rate for Payer: Healthspan PPO |
$849.59
|
| Rate for Payer: Humana Medicaid |
$368.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$773.65
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$375.56
|
| Rate for Payer: Molina Healthcare Passport |
$368.20
|
| Rate for Payer: Multiplan PHCS |
$615.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$717.50
|
| Rate for Payer: UHCCP Medicaid |
$323.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$371.88
|
|
|
FULL THICKNESS GRAFT - CLOSUR
|
Professional
|
Both
|
$5,110.65
|
|
|
Service Code
|
HCPCS 15220
|
| Hospital Charge Code |
76100184
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$308.52 |
| Max. Negotiated Rate |
$5,110.65 |
| Rate for Payer: Aetna Commercial |
$882.69
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$308.52
|
| Rate for Payer: Anthem Medicaid |
$368.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,110.65
|
| Rate for Payer: Cash Price |
$2,555.32
|
| Rate for Payer: Cash Price |
$2,555.32
|
| Rate for Payer: Cigna Commercial |
$838.65
|
| Rate for Payer: Healthspan PPO |
$849.59
|
| Rate for Payer: Humana Medicaid |
$368.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$773.65
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$375.56
|
| Rate for Payer: Molina Healthcare Passport |
$368.20
|
| Rate for Payer: Multiplan PHCS |
$3,066.39
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,577.46
|
| Rate for Payer: UHCCP Medicaid |
$323.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$371.88
|
|
|
FULL THICKNESS GRAFT - CLOSUR
|
Facility
|
IP
|
$5,110.65
|
|
|
Service Code
|
HCPCS 15220
|
| Hospital Charge Code |
76100184
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$664.38 |
| Max. Negotiated Rate |
$4,906.22 |
| Rate for Payer: Aetna Commercial |
$3,935.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,986.31
|
| Rate for Payer: Cash Price |
$2,555.32
|
| Rate for Payer: Cigna Commercial |
$4,241.84
|
| Rate for Payer: First Health Commercial |
$4,855.12
|
| Rate for Payer: Humana Commercial |
$4,344.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,190.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,771.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,533.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,497.37
|
| Rate for Payer: Ohio Health Group HMO |
$3,832.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,022.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$664.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,584.30
|
| Rate for Payer: PHCS Commercial |
$4,906.22
|
| Rate for Payer: United Healthcare All Payer |
$4,497.37
|
|
|
FULL THICKNESS GRAFT - CLOSUR
|
Facility
|
OP
|
$5,110.65
|
|
|
Service Code
|
HCPCS 15220
|
| Hospital Charge Code |
76100184
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$664.38 |
| Max. Negotiated Rate |
$4,906.22 |
| Rate for Payer: Aetna Commercial |
$3,935.20
|
| Rate for Payer: Anthem Medicaid |
$1,757.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,986.31
|
| 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 |
$2,555.32
|
| Rate for Payer: Cash Price |
$2,555.32
|
| Rate for Payer: Cigna Commercial |
$4,241.84
|
| Rate for Payer: First Health Commercial |
$4,855.12
|
| Rate for Payer: Humana Commercial |
$4,344.05
|
| Rate for Payer: Humana KY Medicaid |
$1,757.55
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,775.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,190.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,771.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,792.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,497.37
|
| Rate for Payer: Ohio Health Group HMO |
$3,832.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,022.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$664.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,584.30
|
| Rate for Payer: PHCS Commercial |
$4,906.22
|
| Rate for Payer: United Healthcare All Payer |
$4,497.37
|
|
|
FULL THICKNESS GRAFT - CLOSU(T
|
Facility
|
IP
|
$4,085.65
|
|
|
Service Code
|
HCPCS 15220
|
| Hospital Charge Code |
761T0184
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$531.13 |
| Max. Negotiated Rate |
$3,922.22 |
| Rate for Payer: Aetna Commercial |
$3,145.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,186.81
|
| Rate for Payer: Cash Price |
$2,042.83
|
| Rate for Payer: Cigna Commercial |
$3,391.09
|
| Rate for Payer: First Health Commercial |
$3,881.37
|
| Rate for Payer: Humana Commercial |
$3,472.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,350.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,015.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,225.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,595.37
|
| Rate for Payer: Ohio Health Group HMO |
$3,064.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$817.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$531.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,266.55
|
| Rate for Payer: PHCS Commercial |
$3,922.22
|
| Rate for Payer: United Healthcare All Payer |
$3,595.37
|
|
