|
NEW PT HIGH LEVEL 4(T
|
Facility
|
IP
|
$430.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
510T0004
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$55.90 |
| Max. Negotiated Rate |
$412.80 |
| Rate for Payer: Aetna Commercial |
$331.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$335.40
|
| Rate for Payer: Cash Price |
$215.00
|
| Rate for Payer: Cigna Commercial |
$356.90
|
| Rate for Payer: First Health Commercial |
$408.50
|
| Rate for Payer: Humana Commercial |
$365.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$352.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$317.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$129.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$378.40
|
| Rate for Payer: Ohio Health Group HMO |
$322.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$86.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$55.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$133.30
|
| Rate for Payer: PHCS Commercial |
$412.80
|
| Rate for Payer: United Healthcare All Payer |
$378.40
|
|
|
NEW PT HIGH LEVEL 4(T
|
Facility
|
OP
|
$430.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
510T0004
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$55.90 |
| Max. Negotiated Rate |
$412.80 |
| Rate for Payer: Aetna Commercial |
$331.10
|
| Rate for Payer: Anthem Medicaid |
$147.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$114.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$335.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$160.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$154.32
|
| Rate for Payer: Cash Price |
$215.00
|
| Rate for Payer: Cash Price |
$215.00
|
| Rate for Payer: Cigna Commercial |
$356.90
|
| Rate for Payer: First Health Commercial |
$408.50
|
| Rate for Payer: Humana Commercial |
$365.50
|
| Rate for Payer: Humana KY Medicaid |
$147.88
|
| Rate for Payer: Humana Medicare Advantage |
$114.31
|
| Rate for Payer: Kentucky WC Medicaid |
$149.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$352.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$317.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$150.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$378.40
|
| Rate for Payer: Ohio Health Group HMO |
$322.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$86.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$55.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$133.30
|
| Rate for Payer: PHCS Commercial |
$412.80
|
| Rate for Payer: United Healthcare All Payer |
$378.40
|
|
|
NEW PT HIGH LEVEL 4 TELEHEALTH
|
Professional
|
Both
|
$635.00
|
|
|
Service Code
|
HCPCS 99204
|
| Hospital Charge Code |
51000284
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$68.35 |
| Max. Negotiated Rate |
$635.00 |
| Rate for Payer: Aetna Commercial |
$180.94
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$68.35
|
| Rate for Payer: Anthem Medicaid |
$102.79
|
| Rate for Payer: Buckeye Medicare Advantage |
$635.00
|
| Rate for Payer: Cash Price |
$317.50
|
| Rate for Payer: Cash Price |
$317.50
|
| Rate for Payer: Cigna Commercial |
$211.74
|
| Rate for Payer: Healthspan PPO |
$165.14
|
| Rate for Payer: Humana Medicaid |
$102.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$168.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$104.85
|
| Rate for Payer: Molina Healthcare Passport |
$102.79
|
| Rate for Payer: Multiplan PHCS |
$381.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$444.50
|
| Rate for Payer: UHCCP Medicaid |
$71.77
|
| Rate for Payer: United Healthcare Non-Options |
$124.61
|
| Rate for Payer: United Healthcare Options |
$102.01
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$103.82
|
|
|
NEW PT HIGH LEVEL 5
|
Facility
|
OP
|
$797.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000005
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$103.61 |
| Max. Negotiated Rate |
$765.12 |
| Rate for Payer: Aetna Commercial |
$613.69
|
| Rate for Payer: Anthem Medicaid |
$274.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$114.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$621.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$160.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$154.32
|
| Rate for Payer: Cash Price |
$398.50
|
| Rate for Payer: Cash Price |
$398.50
|
| Rate for Payer: Cigna Commercial |
$661.51
|
| Rate for Payer: First Health Commercial |
$757.15
|
| Rate for Payer: Humana Commercial |
$677.45
|
| Rate for Payer: Humana KY Medicaid |
$274.09
|
| Rate for Payer: Humana Medicare Advantage |
$114.31
|
| Rate for Payer: Kentucky WC Medicaid |
$276.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$653.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$588.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$279.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$701.36
|
| Rate for Payer: Ohio Health Group HMO |
$597.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$247.07
|
| Rate for Payer: PHCS Commercial |
$765.12
|
| Rate for Payer: United Healthcare All Payer |
$701.36
|
|
|
NEW PT HIGH LEVEL 5
|
Facility
|
IP
|
$797.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000005
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$103.61 |
| Max. Negotiated Rate |
$765.12 |
| Rate for Payer: Aetna Commercial |
$613.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$621.66
|
| Rate for Payer: Cash Price |
$398.50
|
| Rate for Payer: Cigna Commercial |
$661.51
|
| Rate for Payer: First Health Commercial |
$757.15
|
| Rate for Payer: Humana Commercial |
$677.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$653.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$588.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$239.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$701.36
|
| Rate for Payer: Ohio Health Group HMO |
$597.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$247.07
|
| Rate for Payer: PHCS Commercial |
$765.12
|
| Rate for Payer: United Healthcare All Payer |
$701.36
|
|
|
NEW PT HIGH LEVEL 5
|
Professional
|
Both
|
$797.00
|
|
|
Service Code
|
HCPCS 99205
|
| Hospital Charge Code |
51000005
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$92.75 |
| Max. Negotiated Rate |
$797.00 |
| Rate for Payer: Aetna Commercial |
$235.26
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$92.75
|
| Rate for Payer: Anthem Medicaid |
$131.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$797.00
|
| Rate for Payer: Cash Price |
$398.50
|
| Rate for Payer: Cash Price |
$398.50
|
| Rate for Payer: Cigna Commercial |
$266.06
|
| Rate for Payer: Healthspan PPO |
$208.70
|
| Rate for Payer: Humana Medicaid |
$131.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$218.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$134.62
|
| Rate for Payer: Molina Healthcare Passport |
$131.98
|
| Rate for Payer: Multiplan PHCS |
$478.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$557.90
|
| Rate for Payer: UHCCP Medicaid |
$97.39
|
| Rate for Payer: United Healthcare Non-Options |
$162.03
|
| Rate for Payer: United Healthcare Options |
$132.63
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$133.30
|
|
|
NEW PT HIGH LEVEL 5(P
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 99205
|
| Hospital Charge Code |
510P0005
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$92.75 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Aetna Commercial |
$235.26
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$92.75
|
| Rate for Payer: Anthem Medicaid |
$131.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$300.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$266.06
|
| Rate for Payer: Healthspan PPO |
$208.70
|
| Rate for Payer: Humana Medicaid |
$131.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$218.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$134.62
|
| Rate for Payer: Molina Healthcare Passport |
$131.98
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$210.00
|
| Rate for Payer: UHCCP Medicaid |
$97.39
|
| Rate for Payer: United Healthcare Non-Options |
$162.03
|
| Rate for Payer: United Healthcare Options |
$132.63
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$133.30
|
|
|
NEW PT HIGH LEVEL 5(T
|
Facility
|
OP
|
$497.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
510T0005
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$64.61 |
| Max. Negotiated Rate |
$477.12 |
| Rate for Payer: Aetna Commercial |
$382.69
|
| Rate for Payer: Anthem Medicaid |
$170.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$114.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$387.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$160.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$154.32
|
| Rate for Payer: Cash Price |
$248.50
|
| Rate for Payer: Cash Price |
$248.50
|
| Rate for Payer: Cigna Commercial |
$412.51
|
| Rate for Payer: First Health Commercial |
$472.15
|
| Rate for Payer: Humana Commercial |
$422.45
|
| Rate for Payer: Humana KY Medicaid |
$170.92
|
| Rate for Payer: Humana Medicare Advantage |
$114.31
|
| Rate for Payer: Kentucky WC Medicaid |
$172.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$407.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$366.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$174.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$437.36
|
| Rate for Payer: Ohio Health Group HMO |
$372.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$154.07
|
| Rate for Payer: PHCS Commercial |
$477.12
|
| Rate for Payer: United Healthcare All Payer |
$437.36
|
|
|
NEW PT HIGH LEVEL 5(T
|
Facility
|
IP
|
$497.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
510T0005
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$64.61 |
| Max. Negotiated Rate |
$477.12 |
| Rate for Payer: Aetna Commercial |
$382.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$387.66
|
| Rate for Payer: Cash Price |
$248.50
|
| Rate for Payer: Cigna Commercial |
$412.51
|
| Rate for Payer: First Health Commercial |
$472.15
|
| Rate for Payer: Humana Commercial |
$422.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$407.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$366.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$149.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$437.36
|
| Rate for Payer: Ohio Health Group HMO |
$372.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$154.07
|
| Rate for Payer: PHCS Commercial |
$477.12
|
| Rate for Payer: United Healthcare All Payer |
$437.36
|
|
|
NEW PT HIGH LEVEL 5 TELEHEALTH
|
Professional
|
Both
|
$745.00
|
|
|
Service Code
|
HCPCS 99205
|
| Hospital Charge Code |
51000285
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$92.75 |
| Max. Negotiated Rate |
$745.00 |
| Rate for Payer: Aetna Commercial |
$235.26
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$92.75
|
| Rate for Payer: Anthem Medicaid |
$131.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$745.00
|
| Rate for Payer: Cash Price |
$372.50
|
| Rate for Payer: Cash Price |
$372.50
|
| Rate for Payer: Cigna Commercial |
$266.06
|
| Rate for Payer: Healthspan PPO |
$208.70
|
| Rate for Payer: Humana Medicaid |
$131.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$218.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$134.62
|
| Rate for Payer: Molina Healthcare Passport |
$131.98
|
| Rate for Payer: Multiplan PHCS |
$447.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$521.50
|
| Rate for Payer: UHCCP Medicaid |
$97.39
|
| Rate for Payer: United Healthcare Non-Options |
$162.03
|
| Rate for Payer: United Healthcare Options |
$132.63
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$133.30
|
|
|
NEW PT LOW LEVEL 2
|
Professional
|
Both
|
$423.00
|
|
|
Service Code
|
HCPCS 99202
|
| Hospital Charge Code |
51000002
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$423.00 |
| Rate for Payer: Aetna Commercial |
$71.49
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$24.75
|
| Rate for Payer: Anthem Medicaid |
$39.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$423.00
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cigna Commercial |
$93.60
|
| Rate for Payer: Healthspan PPO |
$73.43
|
| Rate for Payer: Humana Medicaid |
$39.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$66.50
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$40.52
|
| Rate for Payer: Molina Healthcare Passport |
$39.73
|
| Rate for Payer: Multiplan PHCS |
$253.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$296.10
|
| Rate for Payer: UHCCP Medicaid |
$25.99
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$40.13
|
|
|
NEW PT LOW LEVEL 2
|
Facility
|
OP
|
$423.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000002
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$54.99 |
| Max. Negotiated Rate |
$406.08 |
| Rate for Payer: Aetna Commercial |
$325.71
|
| Rate for Payer: Anthem Medicaid |
$145.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$114.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$329.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$160.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$154.32
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cigna Commercial |
$351.09
|
| Rate for Payer: First Health Commercial |
$401.85
|
| Rate for Payer: Humana Commercial |
$359.55
|
| Rate for Payer: Humana KY Medicaid |
$145.47
|
| Rate for Payer: Humana Medicare Advantage |
$114.31
|
| Rate for Payer: Kentucky WC Medicaid |
$146.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$346.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$312.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$148.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$372.24
|
| Rate for Payer: Ohio Health Group HMO |
$317.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$84.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$131.13
|
| Rate for Payer: PHCS Commercial |
$406.08
|
| Rate for Payer: United Healthcare All Payer |
$372.24
|
|
|
NEW PT LOW LEVEL 2
|
Facility
|
IP
|
$423.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000002
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$54.99 |
| Max. Negotiated Rate |
$406.08 |
| Rate for Payer: Aetna Commercial |
$325.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$329.94
|
| Rate for Payer: Cash Price |
$211.50
|
| Rate for Payer: Cigna Commercial |
$351.09
|
| Rate for Payer: First Health Commercial |
$401.85
|
| Rate for Payer: Humana Commercial |
$359.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$346.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$312.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$126.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$372.24
|
| Rate for Payer: Ohio Health Group HMO |
$317.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$84.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$131.13
|
| Rate for Payer: PHCS Commercial |
$406.08
|
| Rate for Payer: United Healthcare All Payer |
$372.24
|
|
|
NEW PT LOW LEVEL 2(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 99202
|
| Hospital Charge Code |
510P0002
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Aetna Commercial |
$71.49
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$24.75
|
| Rate for Payer: Anthem Medicaid |
$39.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$150.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$93.60
|
| Rate for Payer: Healthspan PPO |
$73.43
|
| Rate for Payer: Humana Medicaid |
$39.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$66.50
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$40.52
|
| Rate for Payer: Molina Healthcare Passport |
$39.73
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$25.99
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$40.13
|
|
|
NEW PT LOW LEVEL 2(T
|
Facility
|
OP
|
$273.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
510T0002
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$35.49 |
| Max. Negotiated Rate |
$262.08 |
| Rate for Payer: Aetna Commercial |
$210.21
|
| Rate for Payer: Anthem Medicaid |
$93.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$114.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$212.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$160.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$154.32
|
| Rate for Payer: Cash Price |
$136.50
|
| Rate for Payer: Cash Price |
$136.50
|
| Rate for Payer: Cigna Commercial |
$226.59
|
| Rate for Payer: First Health Commercial |
$259.35
|
| Rate for Payer: Humana Commercial |
$232.05
|
| Rate for Payer: Humana KY Medicaid |
$93.88
|
| Rate for Payer: Humana Medicare Advantage |
$114.31
|
| Rate for Payer: Kentucky WC Medicaid |
$94.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$223.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$201.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$95.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$240.24
|
| Rate for Payer: Ohio Health Group HMO |
$204.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$54.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.63
|
| Rate for Payer: PHCS Commercial |
$262.08
|
| Rate for Payer: United Healthcare All Payer |
$240.24
|
|
|
NEW PT LOW LEVEL 2(T
|
Facility
|
IP
|
$273.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
510T0002
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$35.49 |
| Max. Negotiated Rate |
$262.08 |
| Rate for Payer: Aetna Commercial |
$210.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$212.94
|
| Rate for Payer: Cash Price |
$136.50
|
| Rate for Payer: Cigna Commercial |
$226.59
|
| Rate for Payer: First Health Commercial |
$259.35
|
| Rate for Payer: Humana Commercial |
$232.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$223.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$201.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$81.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$240.24
|
| Rate for Payer: Ohio Health Group HMO |
$204.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$54.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.63
|
| Rate for Payer: PHCS Commercial |
$262.08
|
| Rate for Payer: United Healthcare All Payer |
$240.24
|
|
|
NEW PT LOW LEVEL 2 TELEHEALTH
|
Professional
|
Both
|
$395.00
|
|
|
Service Code
|
HCPCS 99202
|
| Hospital Charge Code |
51000161
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$395.00 |
| Rate for Payer: Aetna Commercial |
$71.49
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$24.75
|
| Rate for Payer: Anthem Medicaid |
$39.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$395.00
|
| Rate for Payer: Cash Price |
$197.50
|
| Rate for Payer: Cash Price |
$197.50
|
| Rate for Payer: Cigna Commercial |
$93.60
|
| Rate for Payer: Healthspan PPO |
$73.43
|
| Rate for Payer: Humana Medicaid |
$39.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$66.50
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$40.52
|
| Rate for Payer: Molina Healthcare Passport |
$39.73
|
| Rate for Payer: Multiplan PHCS |
$237.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$276.50
|
| Rate for Payer: UHCCP Medicaid |
$25.99
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$40.13
|
|
|
NEW PT LOW LEVEL 3 TELEHEALTH
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 99203
|
| Hospital Charge Code |
51000179
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.22 |
| Max. Negotiated Rate |
$27,517.35 |
| Rate for Payer: Aetna Commercial |
$108.39
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$42.22
|
| Rate for Payer: Anthem Medicaid |
$60.57
|
| Rate for Payer: Buckeye Medicare Advantage |
$450.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$138.86
|
| Rate for Payer: Healthspan PPO |
$106.83
|
| Rate for Payer: Humana Medicaid |
$60.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$100.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$61.78
|
| Rate for Payer: Molina Healthcare Passport |
$60.57
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$315.00
|
| Rate for Payer: UHCCP Medicaid |
$44.33
|
| Rate for Payer: United Healthcare Non-Options |
$27,517.35
|
| Rate for Payer: United Healthcare Options |
$61.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$61.18
|
|
|
NEW PT MID LEVEL 3
|
Professional
|
Both
|
$484.00
|
|
|
Service Code
|
HCPCS 99203
|
| Hospital Charge Code |
51000003
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.22 |
| Max. Negotiated Rate |
$27,517.35 |
| Rate for Payer: Aetna Commercial |
$108.39
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$42.22
|
| Rate for Payer: Anthem Medicaid |
$60.57
|
| Rate for Payer: Buckeye Medicare Advantage |
$484.00
|
| Rate for Payer: Cash Price |
$242.00
|
| Rate for Payer: Cash Price |
$242.00
|
| Rate for Payer: Cigna Commercial |
$138.86
|
| Rate for Payer: Healthspan PPO |
$106.83
|
| Rate for Payer: Humana Medicaid |
$60.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$100.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$61.78
|
| Rate for Payer: Molina Healthcare Passport |
$60.57
|
| Rate for Payer: Multiplan PHCS |
$290.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$338.80
|
| Rate for Payer: UHCCP Medicaid |
$44.33
|
| Rate for Payer: United Healthcare Non-Options |
$27,517.35
|
| Rate for Payer: United Healthcare Options |
$61.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$61.18
|
|
|
NEW PT MID LEVEL 3
|
Facility
|
IP
|
$484.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000003
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$62.92 |
| Max. Negotiated Rate |
$464.64 |
| Rate for Payer: Aetna Commercial |
$372.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$377.52
|
| Rate for Payer: Cash Price |
$242.00
|
| Rate for Payer: Cigna Commercial |
$401.72
|
| Rate for Payer: First Health Commercial |
$459.80
|
| Rate for Payer: Humana Commercial |
$411.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$396.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$357.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$145.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$425.92
|
| Rate for Payer: Ohio Health Group HMO |
$363.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$150.04
|
| Rate for Payer: PHCS Commercial |
$464.64
|
| Rate for Payer: United Healthcare All Payer |
$425.92
|
|
|
NEW PT MID LEVEL 3
|
Facility
|
OP
|
$484.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000003
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$62.92 |
| Max. Negotiated Rate |
$464.64 |
| Rate for Payer: Aetna Commercial |
$372.68
|
| Rate for Payer: Anthem Medicaid |
$166.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$114.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$377.52
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$160.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$154.32
|
| Rate for Payer: Cash Price |
$242.00
|
| Rate for Payer: Cash Price |
$242.00
|
| Rate for Payer: Cigna Commercial |
$401.72
|
| Rate for Payer: First Health Commercial |
$459.80
|
| Rate for Payer: Humana Commercial |
$411.40
|
| Rate for Payer: Humana KY Medicaid |
$166.45
|
| Rate for Payer: Humana Medicare Advantage |
$114.31
|
| Rate for Payer: Kentucky WC Medicaid |
$168.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$396.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$357.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$169.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$425.92
|
| Rate for Payer: Ohio Health Group HMO |
$363.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$150.04
|
| Rate for Payer: PHCS Commercial |
$464.64
|
| Rate for Payer: United Healthcare All Payer |
$425.92
|
|
|
NEW PT MID LEVEL 3(P
|
Professional
|
Both
|
$160.00
|
|
|
Service Code
|
HCPCS 99203
|
| Hospital Charge Code |
510P0003
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.22 |
| Max. Negotiated Rate |
$27,517.35 |
| Rate for Payer: Aetna Commercial |
$108.39
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$42.22
|
| Rate for Payer: Anthem Medicaid |
$60.57
|
| Rate for Payer: Buckeye Medicare Advantage |
$160.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cigna Commercial |
$138.86
|
| Rate for Payer: Healthspan PPO |
$106.83
|
| Rate for Payer: Humana Medicaid |
$60.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$100.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$61.78
|
| Rate for Payer: Molina Healthcare Passport |
$60.57
|
| Rate for Payer: Multiplan PHCS |
$96.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$112.00
|
| Rate for Payer: UHCCP Medicaid |
$44.33
|
| Rate for Payer: United Healthcare Non-Options |
$27,517.35
|
| Rate for Payer: United Healthcare Options |
$61.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$61.18
|
|
|
NEW PT MID LEVEL 3(T
|
Facility
|
OP
|
$324.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
510T0003
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.12 |
| Max. Negotiated Rate |
$311.04 |
| Rate for Payer: Aetna Commercial |
$249.48
|
| Rate for Payer: Anthem Medicaid |
$111.42
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$114.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$252.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$160.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$154.32
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cigna Commercial |
$268.92
|
| Rate for Payer: First Health Commercial |
$307.80
|
| Rate for Payer: Humana Commercial |
$275.40
|
| Rate for Payer: Humana KY Medicaid |
$111.42
|
| Rate for Payer: Humana Medicare Advantage |
$114.31
|
| Rate for Payer: Kentucky WC Medicaid |
$112.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$265.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$239.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$113.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$285.12
|
| Rate for Payer: Ohio Health Group HMO |
$243.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$100.44
|
| Rate for Payer: PHCS Commercial |
$311.04
|
| Rate for Payer: United Healthcare All Payer |
$285.12
|
|
|
NEW PT MID LEVEL 3(T
|
Facility
|
IP
|
$324.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
510T0003
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.12 |
| Max. Negotiated Rate |
$311.04 |
| Rate for Payer: Aetna Commercial |
$249.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$252.72
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cigna Commercial |
$268.92
|
| Rate for Payer: First Health Commercial |
$307.80
|
| Rate for Payer: Humana Commercial |
$275.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$265.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$239.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$285.12
|
| Rate for Payer: Ohio Health Group HMO |
$243.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$100.44
|
| Rate for Payer: PHCS Commercial |
$311.04
|
| Rate for Payer: United Healthcare All Payer |
$285.12
|
|
|
NEW SKIN (COMBINATION) SPR 1OZ
|
Facility
|
IP
|
$11.73
|
|
|
Service Code
|
NDC 16864044001
|
| Hospital Charge Code |
25001070
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$11.26 |
| Rate for Payer: Aetna Commercial |
$9.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.15
|
| Rate for Payer: Cash Price |
$5.86
|
| Rate for Payer: Cigna Commercial |
$9.74
|
| Rate for Payer: First Health Commercial |
$11.14
|
| Rate for Payer: Humana Commercial |
$9.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.32
|
| Rate for Payer: Ohio Health Group HMO |
$8.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.64
|
| Rate for Payer: PHCS Commercial |
$11.26
|
| Rate for Payer: United Healthcare All Payer |
$10.32
|
|
