|
NEUROPLASTY; NERVE HAND/FOOT
|
Facility
|
IP
|
$1,160.00
|
|
|
Service Code
|
HCPCS 64704
|
| Hospital Charge Code |
76102360
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$348.00 |
| Max. Negotiated Rate |
$1,113.60 |
| Rate for Payer: Aetna Commercial |
$893.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$904.80
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cigna Commercial |
$962.80
|
| Rate for Payer: First Health Commercial |
$1,102.00
|
| Rate for Payer: Humana Commercial |
$986.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$951.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$856.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$348.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,020.80
|
| Rate for Payer: Ohio Health Group HMO |
$870.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$928.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,009.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$800.40
|
| Rate for Payer: PHCS Commercial |
$1,113.60
|
| Rate for Payer: United Healthcare All Payer |
$1,020.80
|
|
|
NEUROPLASTY; NERVE HAND/FOOT
|
Professional
|
Both
|
$1,160.00
|
|
|
Service Code
|
HCPCS 64704
|
| Hospital Charge Code |
76102360
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$292.57 |
| Max. Negotiated Rate |
$696.00 |
| Rate for Payer: Aetna Commercial |
$529.75
|
| Rate for Payer: Ambetter Exchange |
$308.62
|
| Rate for Payer: Anthem Medicaid |
$292.57
|
| Rate for Payer: Buckeye Individual/Medicaid |
$308.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$308.62
|
| Rate for Payer: CareSource Just4Me Medicare |
$370.34
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cigna Commercial |
$481.06
|
| Rate for Payer: Healthspan PPO |
$413.61
|
| Rate for Payer: Humana Medicaid |
$292.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$408.44
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$308.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$308.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$298.42
|
| Rate for Payer: Molina Healthcare Passport |
$292.57
|
| Rate for Payer: Multiplan PHCS |
$696.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$401.21
|
| Rate for Payer: UHCCP Medicaid |
$406.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$295.50
|
| Rate for Payer: Wellcare Medicare Advantage |
$308.62
|
|
|
NEUROPLASTY; NERVE HAND/FOOT
|
Facility
|
OP
|
$1,160.00
|
|
|
Service Code
|
HCPCS 64704
|
| Hospital Charge Code |
76102360
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$398.92 |
| Max. Negotiated Rate |
$2,526.05 |
| Rate for Payer: Aetna Commercial |
$893.20
|
| Rate for Payer: Anthem Medicaid |
$398.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,804.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$904.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,526.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,435.83
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cigna Commercial |
$962.80
|
| Rate for Payer: First Health Commercial |
$1,102.00
|
| Rate for Payer: Humana Commercial |
$986.00
|
| Rate for Payer: Humana KY Medicaid |
$398.92
|
| Rate for Payer: Humana Medicare Advantage |
$1,804.32
|
| Rate for Payer: Kentucky WC Medicaid |
$402.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$951.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$856.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,165.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$406.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,020.80
|
| Rate for Payer: Ohio Health Group HMO |
$870.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$928.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,009.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$800.40
|
| Rate for Payer: PHCS Commercial |
$1,113.60
|
| Rate for Payer: United Healthcare All Payer |
$1,020.80
|
|
|
NEUROPLASTY; NERVE HAND/FOOT(P
|
Professional
|
Both
|
$1,160.00
|
|
|
Service Code
|
HCPCS 64704
|
| Hospital Charge Code |
761P2360
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$292.57 |
| Max. Negotiated Rate |
$696.00 |
| Rate for Payer: Aetna Commercial |
$529.75
|
| Rate for Payer: Ambetter Exchange |
$308.62
|
| Rate for Payer: Anthem Medicaid |
$292.57
|
| Rate for Payer: Buckeye Individual/Medicaid |
$308.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$308.62
|
| Rate for Payer: CareSource Just4Me Medicare |
$370.34
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cigna Commercial |
$481.06
|
| Rate for Payer: Healthspan PPO |
$413.61
|
| Rate for Payer: Humana Medicaid |
$292.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$408.44
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$308.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$308.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$298.42
|
| Rate for Payer: Molina Healthcare Passport |
$292.57
|
| Rate for Payer: Multiplan PHCS |
$696.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$401.21
|
| Rate for Payer: UHCCP Medicaid |
$406.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$295.50
|
| Rate for Payer: Wellcare Medicare Advantage |
$308.62
|
|
|
NEUROPLASTY(P
|
Professional
|
Both
|
$1,200.00
|
|
|
Service Code
|
HCPCS 64721
|
| Hospital Charge Code |
761P2364
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$263.04 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Aetna Commercial |
$640.03
|
| Rate for Payer: Ambetter Exchange |
$415.73
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$263.04
|
| Rate for Payer: Anthem Medicaid |
$284.77
|
| Rate for Payer: Buckeye Individual/Medicaid |
$415.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$415.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.88
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$609.80
|
| Rate for Payer: Healthspan PPO |
$501.51
|
| Rate for Payer: Humana Medicaid |
$284.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$530.73
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$415.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$415.73
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$290.47
|
| Rate for Payer: Molina Healthcare Passport |
$284.77
|
| Rate for Payer: Multiplan PHCS |
$720.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$540.45
|
| Rate for Payer: UHCCP Medicaid |
$276.19
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$287.62
|
| Rate for Payer: Wellcare Medicare Advantage |
$415.73
|
|
|
NEUROSTIMULATOR 3058
|
Facility
|
IP
|
$73,884.00
|
|
|
Service Code
|
HCPCS C1767
|
| Hospital Charge Code |
27000081
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,165.20 |
| Max. Negotiated Rate |
$70,928.64 |
| Rate for Payer: Aetna Commercial |
$56,890.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,629.52
|
| Rate for Payer: Cash Price |
$36,942.00
|
| Rate for Payer: Cigna Commercial |
$61,323.72
|
| Rate for Payer: First Health Commercial |
$70,189.80
|
| Rate for Payer: Humana Commercial |
$62,801.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,584.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,526.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,165.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$65,017.92
|
| Rate for Payer: Ohio Health Group HMO |
$55,413.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$59,107.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64,279.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,979.96
|
| Rate for Payer: PHCS Commercial |
$70,928.64
|
| Rate for Payer: United Healthcare All Payer |
$65,017.92
|
|
|
NEUROSTIMULATOR 3058
|
Facility
|
OP
|
$73,884.00
|
|
|
Service Code
|
HCPCS C1767
|
| Hospital Charge Code |
27000081
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,165.20 |
| Max. Negotiated Rate |
$70,928.64 |
| Rate for Payer: Aetna Commercial |
$56,890.68
|
| Rate for Payer: Anthem Medicaid |
$25,408.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,629.52
|
| Rate for Payer: Cash Price |
$36,942.00
|
| Rate for Payer: Cigna Commercial |
$61,323.72
|
| Rate for Payer: First Health Commercial |
$70,189.80
|
| Rate for Payer: Humana Commercial |
$62,801.40
|
| Rate for Payer: Humana KY Medicaid |
$25,408.71
|
| Rate for Payer: Kentucky WC Medicaid |
$25,667.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,584.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,526.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,165.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$25,918.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$65,017.92
|
| Rate for Payer: Ohio Health Group HMO |
$55,413.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$59,107.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64,279.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,979.96
|
| Rate for Payer: PHCS Commercial |
$70,928.64
|
| Rate for Payer: United Healthcare All Payer |
$65,017.92
|
|
|
NEUTRA-PHOS POWDER 1.25GM/1EA
|
Facility
|
OP
|
$4.74
|
|
|
Service Code
|
NDC 60258000601
|
| Hospital Charge Code |
25001069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$4.55 |
| Rate for Payer: Aetna Commercial |
$3.65
|
| Rate for Payer: Anthem Medicaid |
$1.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Cigna Commercial |
$3.93
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: Humana Commercial |
$4.03
|
| Rate for Payer: Humana KY Medicaid |
$1.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.17
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.27
|
| Rate for Payer: PHCS Commercial |
$4.55
|
| Rate for Payer: United Healthcare All Payer |
$4.17
|
|
|
NEUTRA-PHOS POWDER 1.25GM/1EA
|
Facility
|
IP
|
$4.74
|
|
|
Service Code
|
NDC 60258000601
|
| Hospital Charge Code |
25001069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$4.55 |
| Rate for Payer: Aetna Commercial |
$3.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.70
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Cigna Commercial |
$3.93
|
| Rate for Payer: First Health Commercial |
$4.50
|
| Rate for Payer: Humana Commercial |
$4.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.17
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.27
|
| Rate for Payer: PHCS Commercial |
$4.55
|
| Rate for Payer: United Healthcare All Payer |
$4.17
|
|
|
NEVANAC 0.1% EYE DROPS 3ML
|
Facility
|
IP
|
$15.57
|
|
|
Service Code
|
NDC 82667050003
|
| Hospital Charge Code |
25003268
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.67 |
| Max. Negotiated Rate |
$14.95 |
| Rate for Payer: Aetna Commercial |
$11.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12.14
|
| Rate for Payer: Cash Price |
$7.78
|
| Rate for Payer: Cigna Commercial |
$12.92
|
| Rate for Payer: First Health Commercial |
$14.79
|
| Rate for Payer: Humana Commercial |
$13.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$13.70
|
| Rate for Payer: Ohio Health Group HMO |
$11.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.74
|
| Rate for Payer: PHCS Commercial |
$14.95
|
| Rate for Payer: United Healthcare All Payer |
$13.70
|
|
|
NEVANAC 0.1% EYE DROPS 3ML
|
Facility
|
OP
|
$15.57
|
|
|
Service Code
|
NDC 82667050003
|
| Hospital Charge Code |
25003268
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.67 |
| Max. Negotiated Rate |
$14.95 |
| Rate for Payer: Aetna Commercial |
$11.99
|
| Rate for Payer: Anthem Medicaid |
$5.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12.14
|
| Rate for Payer: Cash Price |
$7.78
|
| Rate for Payer: Cigna Commercial |
$12.92
|
| Rate for Payer: First Health Commercial |
$14.79
|
| Rate for Payer: Humana Commercial |
$13.23
|
| Rate for Payer: Humana KY Medicaid |
$5.35
|
| Rate for Payer: Kentucky WC Medicaid |
$5.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$13.70
|
| Rate for Payer: Ohio Health Group HMO |
$11.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.74
|
| Rate for Payer: PHCS Commercial |
$14.95
|
| Rate for Payer: United Healthcare All Payer |
$13.70
|
|
|
NEWBORN METABOLIC SCREEN PKU
|
Facility
|
OP
|
$135.00
|
|
|
Service Code
|
HCPCS 84030
|
| Hospital Charge Code |
30000469
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$129.60 |
| Rate for Payer: Aetna Commercial |
$103.95
|
| Rate for Payer: Anthem Medicaid |
$5.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$108.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$112.05
|
| Rate for Payer: First Health Commercial |
$128.25
|
| Rate for Payer: Humana Commercial |
$114.75
|
| Rate for Payer: Humana KY Medicaid |
$5.50
|
| Rate for Payer: Humana Medicare Advantage |
$5.50
|
| Rate for Payer: Kentucky WC Medicaid |
$5.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$110.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$99.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$118.80
|
| Rate for Payer: Ohio Health Group HMO |
$101.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$93.15
|
| Rate for Payer: PHCS Commercial |
$129.60
|
| Rate for Payer: United Healthcare All Payer |
$118.80
|
|
|
NEWBORN METABOLIC SCREEN PKU
|
Facility
|
IP
|
$135.00
|
|
|
Service Code
|
HCPCS 84030
|
| Hospital Charge Code |
30000469
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$40.50 |
| Max. Negotiated Rate |
$129.60 |
| Rate for Payer: Aetna Commercial |
$103.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$108.41
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$112.05
|
| Rate for Payer: First Health Commercial |
$128.25
|
| Rate for Payer: Humana Commercial |
$114.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$110.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$99.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$118.80
|
| Rate for Payer: Ohio Health Group HMO |
$101.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$93.15
|
| Rate for Payer: PHCS Commercial |
$129.60
|
| Rate for Payer: United Healthcare All Payer |
$118.80
|
|
|
NEW PT HIGH LEVEL 4
|
Facility
|
IP
|
$692.00
|
|
|
Service Code
|
HCPCS 99204
|
| Hospital Charge Code |
51000004
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$207.60 |
| Max. Negotiated Rate |
$664.32 |
| Rate for Payer: Aetna Commercial |
$532.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$539.76
|
| Rate for Payer: Cash Price |
$346.00
|
| Rate for Payer: Cigna Commercial |
$574.36
|
| Rate for Payer: First Health Commercial |
$657.40
|
| Rate for Payer: Humana Commercial |
$588.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$567.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$510.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$608.96
|
| Rate for Payer: Ohio Health Group HMO |
$519.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$553.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$602.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$477.48
|
| Rate for Payer: PHCS Commercial |
$664.32
|
| Rate for Payer: United Healthcare All Payer |
$608.96
|
|
|
NEW PT HIGH LEVEL 4
|
Facility
|
IP
|
$692.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000004
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$207.60 |
| Max. Negotiated Rate |
$664.32 |
| Rate for Payer: Aetna Commercial |
$532.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$539.76
|
| Rate for Payer: Cash Price |
$346.00
|
| Rate for Payer: Cigna Commercial |
$574.36
|
| Rate for Payer: First Health Commercial |
$657.40
|
| Rate for Payer: Humana Commercial |
$588.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$567.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$510.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$608.96
|
| Rate for Payer: Ohio Health Group HMO |
$519.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$553.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$602.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$477.48
|
| Rate for Payer: PHCS Commercial |
$664.32
|
| Rate for Payer: United Healthcare All Payer |
$608.96
|
|
|
NEW PT HIGH LEVEL 4
|
Facility
|
OP
|
$692.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000004
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$119.07 |
| Max. Negotiated Rate |
$664.32 |
| Rate for Payer: Aetna Commercial |
$532.84
|
| Rate for Payer: Anthem Medicaid |
$237.98
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$539.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.74
|
| Rate for Payer: Cash Price |
$346.00
|
| Rate for Payer: Cash Price |
$346.00
|
| Rate for Payer: Cigna Commercial |
$574.36
|
| Rate for Payer: First Health Commercial |
$657.40
|
| Rate for Payer: Humana Commercial |
$588.20
|
| Rate for Payer: Humana KY Medicaid |
$237.98
|
| Rate for Payer: Humana Medicare Advantage |
$119.07
|
| Rate for Payer: Kentucky WC Medicaid |
$240.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$567.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$510.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$242.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$608.96
|
| Rate for Payer: Ohio Health Group HMO |
$519.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$553.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$602.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$477.48
|
| Rate for Payer: PHCS Commercial |
$664.32
|
| Rate for Payer: United Healthcare All Payer |
$608.96
|
|
|
NEW PT HIGH LEVEL 4
|
Professional
|
Both
|
$692.00
|
|
|
Service Code
|
HCPCS 99204
|
| Hospital Charge Code |
51000004
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$68.35 |
| Max. Negotiated Rate |
$415.20 |
| Rate for Payer: Aetna Commercial |
$180.94
|
| Rate for Payer: Ambetter Exchange |
$126.01
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$68.35
|
| Rate for Payer: Anthem Medicaid |
$112.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$126.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$126.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$151.21
|
| Rate for Payer: Cash Price |
$346.00
|
| Rate for Payer: Cash Price |
$346.00
|
| Rate for Payer: Cigna Commercial |
$211.74
|
| Rate for Payer: Healthspan PPO |
$165.14
|
| Rate for Payer: Humana Medicaid |
$112.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$168.30
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$126.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$126.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$114.52
|
| Rate for Payer: Molina Healthcare Passport |
$112.27
|
| Rate for Payer: Multiplan PHCS |
$415.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$163.81
|
| 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 |
$113.39
|
| Rate for Payer: Wellcare Medicare Advantage |
$126.01
|
|
|
NEW PT HIGH LEVEL 4
|
Facility
|
OP
|
$692.00
|
|
|
Service Code
|
HCPCS 99204
|
| Hospital Charge Code |
51000004
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$207.60 |
| Max. Negotiated Rate |
$664.32 |
| Rate for Payer: Aetna Commercial |
$532.84
|
| Rate for Payer: Anthem Medicaid |
$237.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$539.76
|
| Rate for Payer: Cash Price |
$346.00
|
| Rate for Payer: Cigna Commercial |
$574.36
|
| Rate for Payer: First Health Commercial |
$657.40
|
| Rate for Payer: Humana Commercial |
$588.20
|
| Rate for Payer: Humana KY Medicaid |
$237.98
|
| Rate for Payer: Kentucky WC Medicaid |
$240.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$567.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$510.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$242.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$608.96
|
| Rate for Payer: Ohio Health Group HMO |
$519.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$553.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$602.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$477.48
|
| Rate for Payer: PHCS Commercial |
$664.32
|
| Rate for Payer: United Healthcare All Payer |
$608.96
|
|
|
NEW PT HIGH LEVEL 4(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 99204
|
| Hospital Charge Code |
510P0004
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$68.35 |
| Max. Negotiated Rate |
$211.74 |
| Rate for Payer: Aetna Commercial |
$180.94
|
| Rate for Payer: Ambetter Exchange |
$126.01
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$68.35
|
| Rate for Payer: Anthem Medicaid |
$112.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$126.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$126.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$151.21
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$211.74
|
| Rate for Payer: Healthspan PPO |
$165.14
|
| Rate for Payer: Humana Medicaid |
$112.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$168.30
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$126.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$126.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$114.52
|
| Rate for Payer: Molina Healthcare Passport |
$112.27
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$163.81
|
| 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 |
$113.39
|
| Rate for Payer: Wellcare Medicare Advantage |
$126.01
|
|
|
NEW PT HIGH LEVEL 4(T
|
Facility
|
IP
|
$442.00
|
|
|
Service Code
|
HCPCS 99204
|
| Hospital Charge Code |
510T0004
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$132.60 |
| Max. Negotiated Rate |
$424.32 |
| Rate for Payer: Aetna Commercial |
$340.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$344.76
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cigna Commercial |
$366.86
|
| Rate for Payer: First Health Commercial |
$419.90
|
| Rate for Payer: Humana Commercial |
$375.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$362.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$326.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$388.96
|
| Rate for Payer: Ohio Health Group HMO |
$331.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$353.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$384.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$304.98
|
| Rate for Payer: PHCS Commercial |
$424.32
|
| Rate for Payer: United Healthcare All Payer |
$388.96
|
|
|
NEW PT HIGH LEVEL 4(T
|
Facility
|
OP
|
$442.00
|
|
|
Service Code
|
HCPCS 99204
|
| Hospital Charge Code |
510T0004
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$132.60 |
| Max. Negotiated Rate |
$424.32 |
| Rate for Payer: Aetna Commercial |
$340.34
|
| Rate for Payer: Anthem Medicaid |
$152.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$344.76
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cigna Commercial |
$366.86
|
| Rate for Payer: First Health Commercial |
$419.90
|
| Rate for Payer: Humana Commercial |
$375.70
|
| Rate for Payer: Humana KY Medicaid |
$152.00
|
| Rate for Payer: Kentucky WC Medicaid |
$153.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$362.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$326.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$155.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$388.96
|
| Rate for Payer: Ohio Health Group HMO |
$331.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$353.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$384.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$304.98
|
| Rate for Payer: PHCS Commercial |
$424.32
|
| Rate for Payer: United Healthcare All Payer |
$388.96
|
|
|
NEW PT HIGH LEVEL 4(T
|
Facility
|
OP
|
$442.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
510T0004
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$119.07 |
| Max. Negotiated Rate |
$424.32 |
| Rate for Payer: Aetna Commercial |
$340.34
|
| Rate for Payer: Anthem Medicaid |
$152.00
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$344.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.74
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cigna Commercial |
$366.86
|
| Rate for Payer: First Health Commercial |
$419.90
|
| Rate for Payer: Humana Commercial |
$375.70
|
| Rate for Payer: Humana KY Medicaid |
$152.00
|
| Rate for Payer: Humana Medicare Advantage |
$119.07
|
| Rate for Payer: Kentucky WC Medicaid |
$153.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$362.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$326.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$155.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$388.96
|
| Rate for Payer: Ohio Health Group HMO |
$331.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$353.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$384.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$304.98
|
| Rate for Payer: PHCS Commercial |
$424.32
|
| Rate for Payer: United Healthcare All Payer |
$388.96
|
|
|
NEW PT HIGH LEVEL 4(T
|
Facility
|
IP
|
$442.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
510T0004
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$132.60 |
| Max. Negotiated Rate |
$424.32 |
| Rate for Payer: Aetna Commercial |
$340.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$344.76
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cigna Commercial |
$366.86
|
| Rate for Payer: First Health Commercial |
$419.90
|
| Rate for Payer: Humana Commercial |
$375.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$362.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$326.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$388.96
|
| Rate for Payer: Ohio Health Group HMO |
$331.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$353.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$384.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$304.98
|
| Rate for Payer: PHCS Commercial |
$424.32
|
| Rate for Payer: United Healthcare All Payer |
$388.96
|
|
|
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 |
$381.00 |
| Rate for Payer: Aetna Commercial |
$180.94
|
| Rate for Payer: Ambetter Exchange |
$126.01
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$68.35
|
| Rate for Payer: Anthem Medicaid |
$112.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$126.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$126.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$151.21
|
| 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 |
$112.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$168.30
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$126.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$126.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$114.52
|
| Rate for Payer: Molina Healthcare Passport |
$112.27
|
| Rate for Payer: Multiplan PHCS |
$381.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$163.81
|
| 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 |
$113.39
|
| Rate for Payer: Wellcare Medicare Advantage |
$126.01
|
|
|
NEW PT HIGH LEVEL 5
|
Facility
|
OP
|
$811.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000005
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$119.07 |
| Max. Negotiated Rate |
$778.56 |
| Rate for Payer: Aetna Commercial |
$624.47
|
| Rate for Payer: Anthem Medicaid |
$278.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$632.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.74
|
| Rate for Payer: Cash Price |
$405.50
|
| Rate for Payer: Cash Price |
$405.50
|
| Rate for Payer: Cigna Commercial |
$673.13
|
| Rate for Payer: First Health Commercial |
$770.45
|
| Rate for Payer: Humana Commercial |
$689.35
|
| Rate for Payer: Humana KY Medicaid |
$278.90
|
| Rate for Payer: Humana Medicare Advantage |
$119.07
|
| Rate for Payer: Kentucky WC Medicaid |
$281.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$665.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$598.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$284.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$713.68
|
| Rate for Payer: Ohio Health Group HMO |
$608.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$648.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$705.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$559.59
|
| Rate for Payer: PHCS Commercial |
$778.56
|
| Rate for Payer: United Healthcare All Payer |
$713.68
|
|
