|
SEGMNTAL FEM/TIB M/M PROV 90MM
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
SEIZURES WITH MCC
|
Facility
|
IP
|
$23,191.69
|
|
|
Service Code
|
MSDRG 100
|
| Min. Negotiated Rate |
$15,737.22 |
| Max. Negotiated Rate |
$23,191.69 |
| Rate for Payer: Anthem Medicaid |
$15,737.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$16,565.49
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$23,191.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$22,363.41
|
| Rate for Payer: Humana KY Medicaid |
$15,737.22
|
| Rate for Payer: Humana Medicare Advantage |
$16,565.49
|
| Rate for Payer: Kentucky WC Medicaid |
$15,894.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19,878.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$16,051.96
|
|
|
SEIZURES WITHOUT MCC
|
Facility
|
IP
|
$10,640.67
|
|
|
Service Code
|
MSDRG 101
|
| Min. Negotiated Rate |
$7,220.46 |
| Max. Negotiated Rate |
$10,640.67 |
| Rate for Payer: Anthem Medicaid |
$7,220.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7,600.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10,640.67
|
| Rate for Payer: CareSource Just4Me Medicare |
$10,260.65
|
| Rate for Payer: Humana KY Medicaid |
$7,220.46
|
| Rate for Payer: Humana Medicare Advantage |
$7,600.48
|
| Rate for Payer: Kentucky WC Medicaid |
$7,292.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,120.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,364.87
|
|
|
SEL CATH ART EA 1ST THOR BRACH
|
Facility
|
OP
|
$2,985.00
|
|
|
Service Code
|
HCPCS 36215
|
| Hospital Charge Code |
761T1439
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$388.05 |
| Max. Negotiated Rate |
$2,865.60 |
| Rate for Payer: Aetna Commercial |
$2,298.45
|
| Rate for Payer: Anthem Medicaid |
$1,026.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,328.30
|
| Rate for Payer: Cash Price |
$1,492.50
|
| Rate for Payer: Cigna Commercial |
$2,477.55
|
| Rate for Payer: First Health Commercial |
$2,835.75
|
| Rate for Payer: Humana Commercial |
$2,537.25
|
| Rate for Payer: Humana KY Medicaid |
$1,026.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1,036.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,447.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,202.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$895.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,047.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,626.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,238.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$597.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$388.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$925.35
|
| Rate for Payer: PHCS Commercial |
$2,865.60
|
| Rate for Payer: United Healthcare All Payer |
$2,626.80
|
|
|
SEL CATH ART EA 1ST THOR BRACH
|
Facility
|
IP
|
$4,650.00
|
|
|
Service Code
|
HCPCS 36215
|
| Hospital Charge Code |
76101439
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$604.50 |
| Max. Negotiated Rate |
$4,464.00 |
| Rate for Payer: Aetna Commercial |
$3,580.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,627.00
|
| Rate for Payer: Cash Price |
$2,325.00
|
| Rate for Payer: Cigna Commercial |
$3,859.50
|
| Rate for Payer: First Health Commercial |
$4,417.50
|
| Rate for Payer: Humana Commercial |
$3,952.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,813.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,431.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,395.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,092.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$930.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$604.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,441.50
|
| Rate for Payer: PHCS Commercial |
$4,464.00
|
| Rate for Payer: United Healthcare All Payer |
$4,092.00
|
|
|
SEL CATH ART EA 1ST THOR BRACH
|
Facility
|
OP
|
$4,650.00
|
|
|
Service Code
|
HCPCS 36215
|
| Hospital Charge Code |
76101439
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$604.50 |
| Max. Negotiated Rate |
$4,464.00 |
| Rate for Payer: Aetna Commercial |
$3,580.50
|
| Rate for Payer: Anthem Medicaid |
$1,599.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,627.00
|
| Rate for Payer: Cash Price |
$2,325.00
|
| Rate for Payer: Cigna Commercial |
$3,859.50
|
| Rate for Payer: First Health Commercial |
$4,417.50
|
| Rate for Payer: Humana Commercial |
$3,952.50
|
| Rate for Payer: Humana KY Medicaid |
$1,599.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,615.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,813.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,431.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,395.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,631.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,092.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$930.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$604.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,441.50
|
| Rate for Payer: PHCS Commercial |
$4,464.00
|
| Rate for Payer: United Healthcare All Payer |
$4,092.00
|
|
|
SEL CATH ART EA 1ST THOR BRACH
|
Facility
|
IP
|
$1,469.00
|
|
|
Service Code
|
HCPCS 36215
|
| Hospital Charge Code |
48100011
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$190.97 |
| Max. Negotiated Rate |
$1,410.24 |
| Rate for Payer: Aetna Commercial |
$1,131.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,145.82
|
| Rate for Payer: Cash Price |
$734.50
|
| Rate for Payer: Cigna Commercial |
$1,219.27
|
| Rate for Payer: First Health Commercial |
$1,395.55
|
| Rate for Payer: Humana Commercial |
$1,248.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,204.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,084.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$440.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,292.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,101.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$293.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$190.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$455.39
|
| Rate for Payer: PHCS Commercial |
$1,410.24
|
| Rate for Payer: United Healthcare All Payer |
$1,292.72
|
|
|
SEL CATH ART EA 1ST THOR BRACH
|
Facility
|
OP
|
$1,469.00
|
|
|
Service Code
|
HCPCS 36215
|
| Hospital Charge Code |
48100011
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$190.97 |
| Max. Negotiated Rate |
$1,410.24 |
| Rate for Payer: Aetna Commercial |
$1,131.13
|
| Rate for Payer: Anthem Medicaid |
$505.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,145.82
|
| Rate for Payer: Cash Price |
$734.50
|
| Rate for Payer: Cigna Commercial |
$1,219.27
|
| Rate for Payer: First Health Commercial |
$1,395.55
|
| Rate for Payer: Humana Commercial |
$1,248.65
|
| Rate for Payer: Humana KY Medicaid |
$505.19
|
| Rate for Payer: Kentucky WC Medicaid |
$510.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,204.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,084.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$440.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$515.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,292.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,101.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$293.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$190.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$455.39
|
| Rate for Payer: PHCS Commercial |
$1,410.24
|
| Rate for Payer: United Healthcare All Payer |
$1,292.72
|
|
|
SEL CATH ART EA 1ST THOR BRACH
|
Professional
|
Both
|
$4,650.00
|
|
|
Service Code
|
HCPCS 36215
|
| Hospital Charge Code |
76101439
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$166.05 |
| Max. Negotiated Rate |
$4,650.00 |
| Rate for Payer: Aetna Commercial |
$420.64
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$166.05
|
| Rate for Payer: Anthem Medicaid |
$211.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,650.00
|
| Rate for Payer: Cash Price |
$2,325.00
|
| Rate for Payer: Cash Price |
$2,325.00
|
| Rate for Payer: Cigna Commercial |
$385.06
|
| Rate for Payer: Healthspan PPO |
$1,773.13
|
| Rate for Payer: Humana Medicaid |
$211.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$324.29
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$215.55
|
| Rate for Payer: Molina Healthcare Passport |
$211.32
|
| Rate for Payer: Multiplan PHCS |
$2,790.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,255.00
|
| Rate for Payer: UHCCP Medicaid |
$174.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$213.43
|
|
|
SEL CATH ART EA 1ST THOR BRACH
|
Facility
|
IP
|
$2,985.00
|
|
|
Service Code
|
HCPCS 36215
|
| Hospital Charge Code |
761T1439
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$388.05 |
| Max. Negotiated Rate |
$2,865.60 |
| Rate for Payer: Aetna Commercial |
$2,298.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,328.30
|
| Rate for Payer: Cash Price |
$1,492.50
|
| Rate for Payer: Cigna Commercial |
$2,477.55
|
| Rate for Payer: First Health Commercial |
$2,835.75
|
| Rate for Payer: Humana Commercial |
$2,537.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,447.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,202.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$895.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,626.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,238.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$597.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$388.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$925.35
|
| Rate for Payer: PHCS Commercial |
$2,865.60
|
| Rate for Payer: United Healthcare All Payer |
$2,626.80
|
|
|
SEL CATH ART EA 1ST THOR BRACH
|
Professional
|
Both
|
$1,665.00
|
|
|
Service Code
|
HCPCS 36215
|
| Hospital Charge Code |
761P1439
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$166.05 |
| Max. Negotiated Rate |
$1,773.13 |
| Rate for Payer: Aetna Commercial |
$420.64
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$166.05
|
| Rate for Payer: Anthem Medicaid |
$211.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,665.00
|
| Rate for Payer: Cash Price |
$832.50
|
| Rate for Payer: Cash Price |
$832.50
|
| Rate for Payer: Cigna Commercial |
$385.06
|
| Rate for Payer: Healthspan PPO |
$1,773.13
|
| Rate for Payer: Humana Medicaid |
$211.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$324.29
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$215.55
|
| Rate for Payer: Molina Healthcare Passport |
$211.32
|
| Rate for Payer: Multiplan PHCS |
$999.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,165.50
|
| Rate for Payer: UHCCP Medicaid |
$174.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$213.43
|
|
|
SEL CATHART INI 2ND THOR BRACH
|
Facility
|
OP
|
$2,995.26
|
|
|
Service Code
|
HCPCS 36216
|
| Hospital Charge Code |
761T1440
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$389.38 |
| Max. Negotiated Rate |
$2,875.45 |
| Rate for Payer: Aetna Commercial |
$2,306.35
|
| Rate for Payer: Anthem Medicaid |
$1,030.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,336.30
|
| Rate for Payer: Cash Price |
$1,497.63
|
| Rate for Payer: Cigna Commercial |
$2,486.07
|
| Rate for Payer: First Health Commercial |
$2,845.50
|
| Rate for Payer: Humana Commercial |
$2,545.97
|
| Rate for Payer: Humana KY Medicaid |
$1,030.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,040.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,456.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,210.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$898.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,050.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,635.83
|
| Rate for Payer: Ohio Health Group HMO |
$2,246.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$599.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$389.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$928.53
|
| Rate for Payer: PHCS Commercial |
$2,875.45
|
| Rate for Payer: United Healthcare All Payer |
$2,635.83
|
|
|
SEL CATHART INI 2ND THOR BRACH
|
Facility
|
IP
|
$2,995.26
|
|
|
Service Code
|
HCPCS 36216
|
| Hospital Charge Code |
761T1440
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$389.38 |
| Max. Negotiated Rate |
$2,875.45 |
| Rate for Payer: Aetna Commercial |
$2,306.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,336.30
|
| Rate for Payer: Cash Price |
$1,497.63
|
| Rate for Payer: Cigna Commercial |
$2,486.07
|
| Rate for Payer: First Health Commercial |
$2,845.50
|
| Rate for Payer: Humana Commercial |
$2,545.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,456.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,210.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$898.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,635.83
|
| Rate for Payer: Ohio Health Group HMO |
$2,246.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$599.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$389.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$928.53
|
| Rate for Payer: PHCS Commercial |
$2,875.45
|
| Rate for Payer: United Healthcare All Payer |
$2,635.83
|
|
|
SEL CATHART INI 2ND THOR BRACH
|
Facility
|
OP
|
$1,469.00
|
|
|
Service Code
|
HCPCS 36216
|
| Hospital Charge Code |
48100012
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$190.97 |
| Max. Negotiated Rate |
$1,410.24 |
| Rate for Payer: Aetna Commercial |
$1,131.13
|
| Rate for Payer: Anthem Medicaid |
$505.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,145.82
|
| Rate for Payer: Cash Price |
$734.50
|
| Rate for Payer: Cigna Commercial |
$1,219.27
|
| Rate for Payer: First Health Commercial |
$1,395.55
|
| Rate for Payer: Humana Commercial |
$1,248.65
|
| Rate for Payer: Humana KY Medicaid |
$505.19
|
| Rate for Payer: Kentucky WC Medicaid |
$510.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,204.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,084.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$440.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$515.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,292.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,101.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$293.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$190.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$455.39
|
| Rate for Payer: PHCS Commercial |
$1,410.24
|
| Rate for Payer: United Healthcare All Payer |
$1,292.72
|
|
|
SEL CATHART INI 2ND THOR BRACH
|
Professional
|
Both
|
$4,798.26
|
|
|
Service Code
|
HCPCS 36216
|
| Hospital Charge Code |
76101440
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$177.02 |
| Max. Negotiated Rate |
$4,798.26 |
| Rate for Payer: Aetna Commercial |
$474.44
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$177.02
|
| Rate for Payer: Anthem Medicaid |
$249.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,798.26
|
| Rate for Payer: Cash Price |
$2,399.13
|
| Rate for Payer: Cash Price |
$2,399.13
|
| Rate for Payer: Cigna Commercial |
$432.36
|
| Rate for Payer: Healthspan PPO |
$1,939.12
|
| Rate for Payer: Humana Medicaid |
$249.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$366.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$254.73
|
| Rate for Payer: Molina Healthcare Passport |
$249.74
|
| Rate for Payer: Multiplan PHCS |
$2,878.96
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,358.78
|
| Rate for Payer: UHCCP Medicaid |
$185.87
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$252.24
|
|
|
SEL CATHART INI 2ND THOR BRACH
|
Professional
|
Both
|
$1,803.00
|
|
|
Service Code
|
HCPCS 36216
|
| Hospital Charge Code |
761P1440
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$177.02 |
| Max. Negotiated Rate |
$1,939.12 |
| Rate for Payer: Aetna Commercial |
$474.44
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$177.02
|
| Rate for Payer: Anthem Medicaid |
$249.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,803.00
|
| Rate for Payer: Cash Price |
$901.50
|
| Rate for Payer: Cash Price |
$901.50
|
| Rate for Payer: Cigna Commercial |
$432.36
|
| Rate for Payer: Healthspan PPO |
$1,939.12
|
| Rate for Payer: Humana Medicaid |
$249.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$366.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$254.73
|
| Rate for Payer: Molina Healthcare Passport |
$249.74
|
| Rate for Payer: Multiplan PHCS |
$1,081.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,262.10
|
| Rate for Payer: UHCCP Medicaid |
$185.87
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$252.24
|
|
|
SEL CATHART INI 2ND THOR BRACH
|
Facility
|
IP
|
$4,798.26
|
|
|
Service Code
|
HCPCS 36216
|
| Hospital Charge Code |
76101440
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$623.77 |
| Max. Negotiated Rate |
$4,606.33 |
| Rate for Payer: Aetna Commercial |
$3,694.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,742.64
|
| Rate for Payer: Cash Price |
$2,399.13
|
| Rate for Payer: Cigna Commercial |
$3,982.56
|
| Rate for Payer: First Health Commercial |
$4,558.35
|
| Rate for Payer: Humana Commercial |
$4,078.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,934.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,541.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,439.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,222.47
|
| Rate for Payer: Ohio Health Group HMO |
$3,598.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$959.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$623.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,487.46
|
| Rate for Payer: PHCS Commercial |
$4,606.33
|
| Rate for Payer: United Healthcare All Payer |
$4,222.47
|
|
|
SEL CATHART INI 2ND THOR BRACH
|
Facility
|
OP
|
$4,798.26
|
|
|
Service Code
|
HCPCS 36216
|
| Hospital Charge Code |
76101440
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$623.77 |
| Max. Negotiated Rate |
$4,606.33 |
| Rate for Payer: Aetna Commercial |
$3,694.66
|
| Rate for Payer: Anthem Medicaid |
$1,650.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,742.64
|
| Rate for Payer: Cash Price |
$2,399.13
|
| Rate for Payer: Cigna Commercial |
$3,982.56
|
| Rate for Payer: First Health Commercial |
$4,558.35
|
| Rate for Payer: Humana Commercial |
$4,078.52
|
| Rate for Payer: Humana KY Medicaid |
$1,650.12
|
| Rate for Payer: Kentucky WC Medicaid |
$1,666.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,934.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,541.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,439.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,683.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,222.47
|
| Rate for Payer: Ohio Health Group HMO |
$3,598.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$959.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$623.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,487.46
|
| Rate for Payer: PHCS Commercial |
$4,606.33
|
| Rate for Payer: United Healthcare All Payer |
$4,222.47
|
|
|
SEL CATHART INI 2ND THOR BRACH
|
Facility
|
IP
|
$1,469.00
|
|
|
Service Code
|
HCPCS 36216
|
| Hospital Charge Code |
48100012
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$190.97 |
| Max. Negotiated Rate |
$1,410.24 |
| Rate for Payer: Aetna Commercial |
$1,131.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,145.82
|
| Rate for Payer: Cash Price |
$734.50
|
| Rate for Payer: Cigna Commercial |
$1,219.27
|
| Rate for Payer: First Health Commercial |
$1,395.55
|
| Rate for Payer: Humana Commercial |
$1,248.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,204.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,084.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$440.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,292.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,101.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$293.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$190.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$455.39
|
| Rate for Payer: PHCS Commercial |
$1,410.24
|
| Rate for Payer: United Healthcare All Payer |
$1,292.72
|
|
|
SEL CATH EA 3RD ORDER ABD/PELV
|
Facility
|
IP
|
$3,992.00
|
|
|
Service Code
|
HCPCS 36247
|
| Hospital Charge Code |
48100023
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$518.96 |
| Max. Negotiated Rate |
$3,832.32 |
| Rate for Payer: Aetna Commercial |
$3,073.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,113.76
|
| Rate for Payer: Cash Price |
$1,996.00
|
| Rate for Payer: Cigna Commercial |
$3,313.36
|
| Rate for Payer: First Health Commercial |
$3,792.40
|
| Rate for Payer: Humana Commercial |
$3,393.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,273.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,946.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,197.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,512.96
|
| Rate for Payer: Ohio Health Group HMO |
$2,994.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$798.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$518.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,237.52
|
| Rate for Payer: PHCS Commercial |
$3,832.32
|
| Rate for Payer: United Healthcare All Payer |
$3,512.96
|
|
|
SEL CATH EA 3RD ORDER ABD/PELV
|
Facility
|
IP
|
$1,241.00
|
|
|
Service Code
|
HCPCS 36247
|
| Hospital Charge Code |
761T1453
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$161.33 |
| Max. Negotiated Rate |
$1,191.36 |
| Rate for Payer: Aetna Commercial |
$955.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$967.98
|
| Rate for Payer: Cash Price |
$620.50
|
| Rate for Payer: Cigna Commercial |
$1,030.03
|
| Rate for Payer: First Health Commercial |
$1,178.95
|
| Rate for Payer: Humana Commercial |
$1,054.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,017.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$915.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$372.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,092.08
|
| Rate for Payer: Ohio Health Group HMO |
$930.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$248.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$161.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$384.71
|
| Rate for Payer: PHCS Commercial |
$1,191.36
|
| Rate for Payer: United Healthcare All Payer |
$1,092.08
|
|
|
SEL CATH EA 3RD ORDER ABD/PELV
|
Facility
|
OP
|
$4,149.00
|
|
|
Service Code
|
HCPCS 36247
|
| Hospital Charge Code |
76101453
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$539.37 |
| Max. Negotiated Rate |
$3,983.04 |
| Rate for Payer: Aetna Commercial |
$3,194.73
|
| Rate for Payer: Anthem Medicaid |
$1,426.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,236.22
|
| Rate for Payer: Cash Price |
$2,074.50
|
| Rate for Payer: Cigna Commercial |
$3,443.67
|
| Rate for Payer: First Health Commercial |
$3,941.55
|
| Rate for Payer: Humana Commercial |
$3,526.65
|
| Rate for Payer: Humana KY Medicaid |
$1,426.84
|
| Rate for Payer: Kentucky WC Medicaid |
$1,441.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,402.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,061.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,244.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,455.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,651.12
|
| Rate for Payer: Ohio Health Group HMO |
$3,111.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$829.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$539.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,286.19
|
| Rate for Payer: PHCS Commercial |
$3,983.04
|
| Rate for Payer: United Healthcare All Payer |
$3,651.12
|
|
|
SEL CATH EA 3RD ORDER ABD/PELV
|
Facility
|
OP
|
$1,241.00
|
|
|
Service Code
|
HCPCS 36247
|
| Hospital Charge Code |
761T1453
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$161.33 |
| Max. Negotiated Rate |
$1,191.36 |
| Rate for Payer: Aetna Commercial |
$955.57
|
| Rate for Payer: Anthem Medicaid |
$426.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$967.98
|
| Rate for Payer: Cash Price |
$620.50
|
| Rate for Payer: Cigna Commercial |
$1,030.03
|
| Rate for Payer: First Health Commercial |
$1,178.95
|
| Rate for Payer: Humana Commercial |
$1,054.85
|
| Rate for Payer: Humana KY Medicaid |
$426.78
|
| Rate for Payer: Kentucky WC Medicaid |
$431.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,017.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$915.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$372.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$435.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,092.08
|
| Rate for Payer: Ohio Health Group HMO |
$930.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$248.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$161.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$384.71
|
| Rate for Payer: PHCS Commercial |
$1,191.36
|
| Rate for Payer: United Healthcare All Payer |
$1,092.08
|
|
|
SEL CATH EA 3RD ORDER ABD/PELV
|
Facility
|
OP
|
$3,992.00
|
|
|
Service Code
|
HCPCS 36247
|
| Hospital Charge Code |
48100023
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$518.96 |
| Max. Negotiated Rate |
$3,832.32 |
| Rate for Payer: Aetna Commercial |
$3,073.84
|
| Rate for Payer: Anthem Medicaid |
$1,372.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,113.76
|
| Rate for Payer: Cash Price |
$1,996.00
|
| Rate for Payer: Cigna Commercial |
$3,313.36
|
| Rate for Payer: First Health Commercial |
$3,792.40
|
| Rate for Payer: Humana Commercial |
$3,393.20
|
| Rate for Payer: Humana KY Medicaid |
$1,372.85
|
| Rate for Payer: Kentucky WC Medicaid |
$1,386.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,273.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,946.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,197.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,400.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,512.96
|
| Rate for Payer: Ohio Health Group HMO |
$2,994.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$798.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$518.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,237.52
|
| Rate for Payer: PHCS Commercial |
$3,832.32
|
| Rate for Payer: United Healthcare All Payer |
$3,512.96
|
|
|
SEL CATH EA 3RD ORDER ABD/PELV
|
Facility
|
IP
|
$4,149.00
|
|
|
Service Code
|
HCPCS 36247
|
| Hospital Charge Code |
76101453
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$539.37 |
| Max. Negotiated Rate |
$3,983.04 |
| Rate for Payer: Aetna Commercial |
$3,194.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,236.22
|
| Rate for Payer: Cash Price |
$2,074.50
|
| Rate for Payer: Cigna Commercial |
$3,443.67
|
| Rate for Payer: First Health Commercial |
$3,941.55
|
| Rate for Payer: Humana Commercial |
$3,526.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,402.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,061.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,244.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,651.12
|
| Rate for Payer: Ohio Health Group HMO |
$3,111.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$829.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$539.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,286.19
|
| Rate for Payer: PHCS Commercial |
$3,983.04
|
| Rate for Payer: United Healthcare All Payer |
$3,651.12
|
|
