|
OZARK MANOR SUBSEQ UNSTABLE 60 MIN
|
Facility
|
OP
|
$310.00
|
|
|
Service Code
|
CPT 99350
|
| Hospital Charge Code |
9799337
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$173.53 |
| Max. Negotiated Rate |
$221.34 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$183.52
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$221.34
|
| Rate for Payer: Cash Price |
$279.00
|
| Rate for Payer: Cash Price |
$279.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$206.77
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$173.53
|
|
|
OZARK MANOR SUBSEQ UNSTABLE 60 MIN
|
Facility
|
IP
|
$310.00
|
|
|
Service Code
|
CPT 99350
|
| Hospital Charge Code |
9799337
|
|
Hospital Revenue Code
|
521
|
| Rate for Payer: Cash Price |
$279.00
|
|
|
OZARK NEW 30 MIN
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
CPT 99342
|
| Hospital Charge Code |
4299325
|
|
Hospital Revenue Code
|
525
|
| Rate for Payer: Cash Price |
$157.50
|
|
|
OZARK NEW 30 MIN
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
CPT 99342
|
| Hospital Charge Code |
4299325
|
|
Hospital Revenue Code
|
525
|
| Min. Negotiated Rate |
$103.60 |
| Max. Negotiated Rate |
$173.53 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$103.60
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$124.95
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$116.72
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$173.53
|
|
|
OZARK NEW ADMIT 45 MIN
|
Facility
|
OP
|
$245.00
|
|
|
Service Code
|
CPT 99342
|
| Hospital Charge Code |
4299326
|
|
Hospital Revenue Code
|
525
|
| Min. Negotiated Rate |
$145.04 |
| Max. Negotiated Rate |
$174.93 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$145.04
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$174.93
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$163.41
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$173.53
|
|
|
OZARK NEW ADMIT 45 MIN
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
CPT 99342
|
| Hospital Charge Code |
4299326
|
|
Hospital Revenue Code
|
525
|
| Rate for Payer: Cash Price |
$220.50
|
|
|
OZARK NEW ADMIT 60 MIN
|
Facility
|
IP
|
$330.00
|
|
|
Service Code
|
CPT 99344
|
| Hospital Charge Code |
4299327
|
|
Hospital Revenue Code
|
525
|
| Rate for Payer: Cash Price |
$297.00
|
|
|
OZARK NEW ADMIT 60 MIN
|
Facility
|
OP
|
$330.00
|
|
|
Service Code
|
CPT 99344
|
| Hospital Charge Code |
4299327
|
|
Hospital Revenue Code
|
525
|
| Min. Negotiated Rate |
$173.53 |
| Max. Negotiated Rate |
$235.62 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$195.36
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$235.62
|
| Rate for Payer: Cash Price |
$297.00
|
| Rate for Payer: Cash Price |
$297.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$220.11
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$173.53
|
|
|
OZARK NEW ADMIT 75 MIN
|
Facility
|
OP
|
$415.00
|
|
|
Service Code
|
CPT 99345
|
| Hospital Charge Code |
4299328
|
|
Hospital Revenue Code
|
525
|
| Min. Negotiated Rate |
$173.53 |
| Max. Negotiated Rate |
$296.31 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$245.68
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$296.31
|
| Rate for Payer: Cash Price |
$373.50
|
| Rate for Payer: Cash Price |
$373.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$276.81
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$173.53
|
|
|
OZARK NEW ADMIT 75 MIN
|
Facility
|
IP
|
$415.00
|
|
|
Service Code
|
CPT 99345
|
| Hospital Charge Code |
4299328
|
|
Hospital Revenue Code
|
525
|
| Rate for Payer: Cash Price |
$373.50
|
|
|
OZARK NEW BRIEF VISIT
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 99341
|
| Hospital Charge Code |
4299324
|
|
Hospital Revenue Code
|
525
|
| Min. Negotiated Rate |
$71.04 |
| Max. Negotiated Rate |
$173.53 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$71.04
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$85.68
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$80.04
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$173.53
|
|
|
OZARK NEW BRIEF VISIT
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 99341
|
| Hospital Charge Code |
4299324
|
|
Hospital Revenue Code
|
525
|
| Rate for Payer: Cash Price |
$108.00
|
|
|
PA CHEST X-RAY
|
Facility
|
OP
|
$360.00
|
|
|
Service Code
|
CPT 71045
|
| Hospital Charge Code |
323139
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$78.45 |
| Max. Negotiated Rate |
$257.04 |
| Rate for Payer: Aetna Better Health Medicaid/QHP |
$78.45
|
| Rate for Payer: Aetna Medicare Advantage |
$88.91
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$213.12
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$257.04
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Cigna Commercial HMO & PPO |
$88.91
|
| Rate for Payer: Healthy Blue CHP/Medicaid Managed Care |
$78.45
|
| Rate for Payer: Home State Health Plan Medicaid Managed Care |
$83.94
|
| Rate for Payer: Home State Health Plan Medicare Advantage |
$88.91
|
| Rate for Payer: Humana Commercial |
$177.82
|
| Rate for Payer: Humana Medicare Advantage |
$88.91
|
| Rate for Payer: UnitedHealthcare Commercial |
$175.00
|
| Rate for Payer: UnitedHealthcare Medicaid Managed Care |
$78.45
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$129.60
|
|
|
PA CHEST X-RAY
|
Facility
|
IP
|
$360.00
|
|
|
Service Code
|
CPT 71045
|
| Hospital Charge Code |
323139
|
|
Hospital Revenue Code
|
324
|
| Rate for Payer: Cash Price |
$324.00
|
|
|
PACK, #1 (LITH)
|
Facility
|
OP
|
$187.00
|
|
| Hospital Charge Code |
1216042
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$67.32 |
| Max. Negotiated Rate |
$133.52 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$110.70
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$133.52
|
| Rate for Payer: Cash Price |
$168.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$124.73
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$67.32
|
|
|
PACK, #1 (LITH)
|
Facility
|
IP
|
$187.00
|
|
| Hospital Charge Code |
1216042
|
|
Hospital Revenue Code
|
271
|
| Rate for Payer: Cash Price |
$168.30
|
|
|
PACK, #2 TRANS
|
Facility
|
IP
|
$187.00
|
|
| Hospital Charge Code |
1216047
|
|
Hospital Revenue Code
|
271
|
| Rate for Payer: Cash Price |
$168.30
|
|
|
PACK, #2 TRANS
|
Facility
|
OP
|
$187.00
|
|
| Hospital Charge Code |
1216047
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$67.32 |
| Max. Negotiated Rate |
$133.52 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$110.70
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$133.52
|
| Rate for Payer: Cash Price |
$168.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$124.73
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$67.32
|
|
|
PACK, BASIK #5
|
Facility
|
IP
|
$208.00
|
|
| Hospital Charge Code |
2816040
|
|
Hospital Revenue Code
|
271
|
| Rate for Payer: Cash Price |
$187.20
|
|
|
PACK, BASIK #5
|
Facility
|
OP
|
$208.00
|
|
| Hospital Charge Code |
2816040
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$74.88 |
| Max. Negotiated Rate |
$148.51 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$123.14
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$148.51
|
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$138.74
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$74.88
|
|
|
PACK, COLD
|
Facility
|
OP
|
$42.00
|
|
| Hospital Charge Code |
2816268
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$29.99 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$24.86
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$29.99
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$28.01
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$15.12
|
|
|
PACK, COLD
|
Facility
|
IP
|
$42.00
|
|
| Hospital Charge Code |
2816268
|
|
Hospital Revenue Code
|
271
|
| Rate for Payer: Cash Price |
$37.80
|
|
|
PACK, LAP
|
Facility
|
OP
|
$208.00
|
|
| Hospital Charge Code |
2816042
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$74.88 |
| Max. Negotiated Rate |
$148.51 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$123.14
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$148.51
|
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$138.74
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$74.88
|
|
|
PACK, LAP
|
Facility
|
IP
|
$208.00
|
|
| Hospital Charge Code |
2816042
|
|
Hospital Revenue Code
|
271
|
| Rate for Payer: Cash Price |
$187.20
|
|
|
PACK, LAP #4 MID 88241
|
Facility
|
IP
|
$244.00
|
|
| Hospital Charge Code |
1216038
|
|
Hospital Revenue Code
|
272
|
| Rate for Payer: Cash Price |
$219.60
|
|
