|
TISS XPNDR PLMT BRST RCNSTJ
|
Facility
|
OP
|
$22,842.00
|
|
|
Service Code
|
HCPCS 19357
|
| Hospital Charge Code |
76100315
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,969.46 |
| Max. Negotiated Rate |
$21,928.32 |
| Rate for Payer: Aetna Commercial |
$17,588.34
|
| Rate for Payer: Anthem Medicaid |
$7,855.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$15,238.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,816.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$21,334.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$20,572.12
|
| Rate for Payer: Cash Price |
$11,421.00
|
| Rate for Payer: Cash Price |
$11,421.00
|
| Rate for Payer: Cigna Commercial |
$18,958.86
|
| Rate for Payer: First Health Commercial |
$21,699.90
|
| Rate for Payer: Humana Commercial |
$19,415.70
|
| Rate for Payer: Humana KY Medicaid |
$7,855.36
|
| Rate for Payer: Humana Medicare Advantage |
$15,238.61
|
| Rate for Payer: Kentucky WC Medicaid |
$7,935.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,730.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,857.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18,286.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,012.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,100.96
|
| Rate for Payer: Ohio Health Group HMO |
$17,131.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,568.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,969.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,081.02
|
| Rate for Payer: PHCS Commercial |
$21,928.32
|
| Rate for Payer: United Healthcare All Payer |
$20,100.96
|
|
|
TISS XPNDR PLMT BRST RCNSTJ
|
Professional
|
Both
|
$22,842.00
|
|
|
Service Code
|
HCPCS 19357
|
| Hospital Charge Code |
76100315
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$874.10 |
| Max. Negotiated Rate |
$22,842.00 |
| Rate for Payer: Aetna Commercial |
$2,233.83
|
| Rate for Payer: Anthem Medicaid |
$874.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$22,842.00
|
| Rate for Payer: Cash Price |
$11,421.00
|
| Rate for Payer: Cash Price |
$11,421.00
|
| Rate for Payer: Cigna Commercial |
$2,124.05
|
| Rate for Payer: Healthspan PPO |
$1,786.15
|
| Rate for Payer: Humana Medicaid |
$874.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,889.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$891.58
|
| Rate for Payer: Molina Healthcare Passport |
$874.10
|
| Rate for Payer: Multiplan PHCS |
$13,705.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$15,989.40
|
| Rate for Payer: UHCCP Medicaid |
$7,994.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$882.84
|
|
|
TISS XPNDR PLMT BRST RCNSTJ
|
Facility
|
IP
|
$22,842.00
|
|
|
Service Code
|
HCPCS 19357
|
| Hospital Charge Code |
76100315
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,969.46 |
| Max. Negotiated Rate |
$21,928.32 |
| Rate for Payer: Aetna Commercial |
$17,588.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,816.76
|
| Rate for Payer: Cash Price |
$11,421.00
|
| Rate for Payer: Cigna Commercial |
$18,958.86
|
| Rate for Payer: First Health Commercial |
$21,699.90
|
| Rate for Payer: Humana Commercial |
$19,415.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,730.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,857.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,852.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,100.96
|
| Rate for Payer: Ohio Health Group HMO |
$17,131.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,568.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,969.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,081.02
|
| Rate for Payer: PHCS Commercial |
$21,928.32
|
| Rate for Payer: United Healthcare All Payer |
$20,100.96
|
|
|
TISS XPNDR PLMT BRST RCNSTJ (P
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 19357
|
| Hospital Charge Code |
761P0315
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$874.10 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$2,233.83
|
| Rate for Payer: Anthem Medicaid |
$874.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,000.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,124.05
|
| Rate for Payer: Healthspan PPO |
$1,786.15
|
| Rate for Payer: Humana Medicaid |
$874.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,889.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$891.58
|
| Rate for Payer: Molina Healthcare Passport |
$874.10
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,100.00
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$882.84
|
|
|
TISS XPNDR PLMT BRST RCNSTJ (T
|
Facility
|
OP
|
$19,842.00
|
|
|
Service Code
|
HCPCS 19357
|
| Hospital Charge Code |
761T0315
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,579.46 |
| Max. Negotiated Rate |
$21,334.05 |
| Rate for Payer: Aetna Commercial |
$15,278.34
|
| Rate for Payer: Anthem Medicaid |
$6,823.66
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$15,238.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,476.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$21,334.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$20,572.12
|
| Rate for Payer: Cash Price |
$9,921.00
|
| Rate for Payer: Cash Price |
$9,921.00
|
| Rate for Payer: Cigna Commercial |
$16,468.86
|
| Rate for Payer: First Health Commercial |
$18,849.90
|
| Rate for Payer: Humana Commercial |
$16,865.70
|
| Rate for Payer: Humana KY Medicaid |
$6,823.66
|
| Rate for Payer: Humana Medicare Advantage |
$15,238.61
|
| Rate for Payer: Kentucky WC Medicaid |
$6,893.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,270.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,643.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18,286.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,960.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,460.96
|
| Rate for Payer: Ohio Health Group HMO |
$14,881.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,968.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,579.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,151.02
|
| Rate for Payer: PHCS Commercial |
$19,048.32
|
| Rate for Payer: United Healthcare All Payer |
$17,460.96
|
|
|
TISS XPNDR PLMT BRST RCNSTJ (T
|
Facility
|
IP
|
$19,842.00
|
|
|
Service Code
|
HCPCS 19357
|
| Hospital Charge Code |
761T0315
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,579.46 |
| Max. Negotiated Rate |
$19,048.32 |
| Rate for Payer: Aetna Commercial |
$15,278.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,476.76
|
| Rate for Payer: Cash Price |
$9,921.00
|
| Rate for Payer: Cigna Commercial |
$16,468.86
|
| Rate for Payer: First Health Commercial |
$18,849.90
|
| Rate for Payer: Humana Commercial |
$16,865.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,270.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,643.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,952.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,460.96
|
| Rate for Payer: Ohio Health Group HMO |
$14,881.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,968.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,579.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,151.02
|
| Rate for Payer: PHCS Commercial |
$19,048.32
|
| Rate for Payer: United Healthcare All Payer |
$17,460.96
|
|
|
TIS TRNFR ADDL 30 SQ CM
|
Professional
|
Both
|
$3,466.63
|
|
|
Service Code
|
HCPCS 14302
|
| Hospital Charge Code |
76100170
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$169.02 |
| Max. Negotiated Rate |
$3,466.63 |
| Rate for Payer: Aetna Commercial |
$357.37
|
| Rate for Payer: Anthem Medicaid |
$169.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,466.63
|
| Rate for Payer: Cash Price |
$1,733.32
|
| Rate for Payer: Cash Price |
$1,733.32
|
| Rate for Payer: Cigna Commercial |
$360.42
|
| Rate for Payer: Healthspan PPO |
$224.81
|
| Rate for Payer: Humana Medicaid |
$169.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$294.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$172.40
|
| Rate for Payer: Molina Healthcare Passport |
$169.02
|
| Rate for Payer: Multiplan PHCS |
$2,079.98
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,426.64
|
| Rate for Payer: UHCCP Medicaid |
$1,213.32
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$170.71
|
|
|
TIS TRNFR ADDL 30 SQ CM
|
Facility
|
IP
|
$3,466.63
|
|
|
Service Code
|
HCPCS 14302
|
| Hospital Charge Code |
76100170
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$450.66 |
| Max. Negotiated Rate |
$3,327.96 |
| Rate for Payer: Aetna Commercial |
$2,669.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,703.97
|
| Rate for Payer: Cash Price |
$1,733.32
|
| Rate for Payer: Cigna Commercial |
$2,877.30
|
| Rate for Payer: First Health Commercial |
$3,293.30
|
| Rate for Payer: Humana Commercial |
$2,946.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,842.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,558.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,039.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,050.63
|
| Rate for Payer: Ohio Health Group HMO |
$2,599.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$693.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$450.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,074.66
|
| Rate for Payer: PHCS Commercial |
$3,327.96
|
| Rate for Payer: United Healthcare All Payer |
$3,050.63
|
|
|
TIS TRNFR ADDL 30 SQ CM
|
Facility
|
OP
|
$3,466.63
|
|
|
Service Code
|
HCPCS 14302
|
| Hospital Charge Code |
76100170
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$450.66 |
| Max. Negotiated Rate |
$3,327.96 |
| Rate for Payer: Aetna Commercial |
$2,669.31
|
| Rate for Payer: Anthem Medicaid |
$1,192.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,703.97
|
| Rate for Payer: Cash Price |
$1,733.32
|
| Rate for Payer: Cigna Commercial |
$2,877.30
|
| Rate for Payer: First Health Commercial |
$3,293.30
|
| Rate for Payer: Humana Commercial |
$2,946.64
|
| Rate for Payer: Humana KY Medicaid |
$1,192.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,204.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,842.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,558.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,039.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,216.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,050.63
|
| Rate for Payer: Ohio Health Group HMO |
$2,599.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$693.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$450.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,074.66
|
| Rate for Payer: PHCS Commercial |
$3,327.96
|
| Rate for Payer: United Healthcare All Payer |
$3,050.63
|
|
|
TIS TRNFR ADDL 30 SQ CM(P
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 14302
|
| Hospital Charge Code |
761P0170
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$169.02 |
| Max. Negotiated Rate |
$500.00 |
| Rate for Payer: Aetna Commercial |
$357.37
|
| Rate for Payer: Anthem Medicaid |
$169.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$500.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$360.42
|
| Rate for Payer: Healthspan PPO |
$224.81
|
| Rate for Payer: Humana Medicaid |
$169.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$294.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$172.40
|
| Rate for Payer: Molina Healthcare Passport |
$169.02
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$350.00
|
| Rate for Payer: UHCCP Medicaid |
$175.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$170.71
|
|
|
TIS TRNFR ADDL 30 SQ CM(T
|
Facility
|
OP
|
$2,966.63
|
|
|
Service Code
|
HCPCS 14302
|
| Hospital Charge Code |
761T0170
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$385.66 |
| Max. Negotiated Rate |
$2,847.96 |
| Rate for Payer: Aetna Commercial |
$2,284.31
|
| Rate for Payer: Anthem Medicaid |
$1,020.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,313.97
|
| Rate for Payer: Cash Price |
$1,483.32
|
| Rate for Payer: Cigna Commercial |
$2,462.30
|
| Rate for Payer: First Health Commercial |
$2,818.30
|
| Rate for Payer: Humana Commercial |
$2,521.64
|
| Rate for Payer: Humana KY Medicaid |
$1,020.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1,030.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,432.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,189.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$889.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,040.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,610.63
|
| Rate for Payer: Ohio Health Group HMO |
$2,224.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$593.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$385.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$919.66
|
| Rate for Payer: PHCS Commercial |
$2,847.96
|
| Rate for Payer: United Healthcare All Payer |
$2,610.63
|
|
|
TIS TRNFR ADDL 30 SQ CM(T
|
Facility
|
IP
|
$2,966.63
|
|
|
Service Code
|
HCPCS 14302
|
| Hospital Charge Code |
761T0170
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$385.66 |
| Max. Negotiated Rate |
$2,847.96 |
| Rate for Payer: Aetna Commercial |
$2,284.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,313.97
|
| Rate for Payer: Cash Price |
$1,483.32
|
| Rate for Payer: Cigna Commercial |
$2,462.30
|
| Rate for Payer: First Health Commercial |
$2,818.30
|
| Rate for Payer: Humana Commercial |
$2,521.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,432.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,189.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$889.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,610.63
|
| Rate for Payer: Ohio Health Group HMO |
$2,224.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$593.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$385.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$919.66
|
| Rate for Payer: PHCS Commercial |
$2,847.96
|
| Rate for Payer: United Healthcare All Payer |
$2,610.63
|
|
|
TIS TRNFR ANY 30.1-60 SQ CM
|
Facility
|
OP
|
$7,290.93
|
|
|
Service Code
|
HCPCS 14301
|
| Hospital Charge Code |
76100169
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$947.82 |
| Max. Negotiated Rate |
$6,999.29 |
| Rate for Payer: Aetna Commercial |
$5,614.02
|
| Rate for Payer: Anthem Medicaid |
$2,507.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,102.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,686.93
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,343.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,188.25
|
| Rate for Payer: Cash Price |
$3,645.47
|
| Rate for Payer: Cash Price |
$3,645.47
|
| Rate for Payer: Cigna Commercial |
$6,051.47
|
| Rate for Payer: First Health Commercial |
$6,926.38
|
| Rate for Payer: Humana Commercial |
$6,197.29
|
| Rate for Payer: Humana KY Medicaid |
$2,507.35
|
| Rate for Payer: Humana Medicare Advantage |
$3,102.41
|
| Rate for Payer: Kentucky WC Medicaid |
$2,532.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,978.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,380.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,557.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,416.02
|
| Rate for Payer: Ohio Health Group HMO |
$5,468.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,458.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$947.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,260.19
|
| Rate for Payer: PHCS Commercial |
$6,999.29
|
| Rate for Payer: United Healthcare All Payer |
$6,416.02
|
|
|
TIS TRNFR ANY 30.1-60 SQ CM
|
Professional
|
Both
|
$7,290.93
|
|
|
Service Code
|
HCPCS 14301
|
| Hospital Charge Code |
76100169
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$440.71 |
| Max. Negotiated Rate |
$7,290.93 |
| Rate for Payer: Aetna Commercial |
$1,366.41
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$440.71
|
| Rate for Payer: Anthem Medicaid |
$647.04
|
| Rate for Payer: Buckeye Medicare Advantage |
$7,290.93
|
| Rate for Payer: Cash Price |
$3,645.47
|
| Rate for Payer: Cash Price |
$3,645.47
|
| Rate for Payer: Cigna Commercial |
$1,381.65
|
| Rate for Payer: Healthspan PPO |
$1,008.01
|
| Rate for Payer: Humana Medicaid |
$647.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,147.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$659.98
|
| Rate for Payer: Molina Healthcare Passport |
$647.04
|
| Rate for Payer: Multiplan PHCS |
$4,374.56
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5,103.65
|
| Rate for Payer: UHCCP Medicaid |
$462.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$653.51
|
|
|
TIS TRNFR ANY 30.1-60 SQ CM
|
Facility
|
IP
|
$7,290.93
|
|
|
Service Code
|
HCPCS 14301
|
| Hospital Charge Code |
76100169
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$947.82 |
| Max. Negotiated Rate |
$6,999.29 |
| Rate for Payer: Aetna Commercial |
$5,614.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,686.93
|
| Rate for Payer: Cash Price |
$3,645.47
|
| Rate for Payer: Cigna Commercial |
$6,051.47
|
| Rate for Payer: First Health Commercial |
$6,926.38
|
| Rate for Payer: Humana Commercial |
$6,197.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,978.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,380.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,187.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,416.02
|
| Rate for Payer: Ohio Health Group HMO |
$5,468.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,458.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$947.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,260.19
|
| Rate for Payer: PHCS Commercial |
$6,999.29
|
| Rate for Payer: United Healthcare All Payer |
$6,416.02
|
|
|
TIS TRNFR ANY 30.1-60 SQ CM(P
|
Professional
|
Both
|
$1,550.00
|
|
|
Service Code
|
HCPCS 14301
|
| Hospital Charge Code |
761P0169
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$440.71 |
| Max. Negotiated Rate |
$1,550.00 |
| Rate for Payer: Aetna Commercial |
$1,366.41
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$440.71
|
| Rate for Payer: Anthem Medicaid |
$647.04
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,550.00
|
| Rate for Payer: Cash Price |
$775.00
|
| Rate for Payer: Cash Price |
$775.00
|
| Rate for Payer: Cigna Commercial |
$1,381.65
|
| Rate for Payer: Healthspan PPO |
$1,008.01
|
| Rate for Payer: Humana Medicaid |
$647.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,147.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$659.98
|
| Rate for Payer: Molina Healthcare Passport |
$647.04
|
| Rate for Payer: Multiplan PHCS |
$930.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,085.00
|
| Rate for Payer: UHCCP Medicaid |
$462.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$653.51
|
|
|
TIS TRNFR ANY 30.1-60 SQ CM(T
|
Facility
|
IP
|
$5,740.93
|
|
|
Service Code
|
HCPCS 14301
|
| Hospital Charge Code |
761T0169
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$746.32 |
| Max. Negotiated Rate |
$5,511.29 |
| Rate for Payer: Aetna Commercial |
$4,420.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,477.93
|
| Rate for Payer: Cash Price |
$2,870.47
|
| Rate for Payer: Cigna Commercial |
$4,764.97
|
| Rate for Payer: First Health Commercial |
$5,453.88
|
| Rate for Payer: Humana Commercial |
$4,879.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,707.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,236.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,722.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,052.02
|
| Rate for Payer: Ohio Health Group HMO |
$4,305.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,148.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$746.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,779.69
|
| Rate for Payer: PHCS Commercial |
$5,511.29
|
| Rate for Payer: United Healthcare All Payer |
$5,052.02
|
|
|
TIS TRNFR ANY 30.1-60 SQ CM(T
|
Facility
|
OP
|
$5,740.93
|
|
|
Service Code
|
HCPCS 14301
|
| Hospital Charge Code |
761T0169
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$746.32 |
| Max. Negotiated Rate |
$5,511.29 |
| Rate for Payer: Aetna Commercial |
$4,420.52
|
| Rate for Payer: Anthem Medicaid |
$1,974.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,102.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,477.93
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,343.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,188.25
|
| Rate for Payer: Cash Price |
$2,870.47
|
| Rate for Payer: Cash Price |
$2,870.47
|
| Rate for Payer: Cigna Commercial |
$4,764.97
|
| Rate for Payer: First Health Commercial |
$5,453.88
|
| Rate for Payer: Humana Commercial |
$4,879.79
|
| Rate for Payer: Humana KY Medicaid |
$1,974.31
|
| Rate for Payer: Humana Medicare Advantage |
$3,102.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1,994.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,707.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,236.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,013.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,052.02
|
| Rate for Payer: Ohio Health Group HMO |
$4,305.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,148.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$746.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,779.69
|
| Rate for Payer: PHCS Commercial |
$5,511.29
|
| Rate for Payer: United Healthcare All Payer |
$5,052.02
|
|
|
TIS TRNFR E/N/E/L10.1-30SQCM
|
Professional
|
Both
|
$1,170.00
|
|
|
Service Code
|
HCPCS 14061
|
| Hospital Charge Code |
76102692
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$445.57 |
| Max. Negotiated Rate |
$1,304.64 |
| Rate for Payer: Aetna Commercial |
$1,204.55
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$445.57
|
| Rate for Payer: Anthem Medicaid |
$506.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,170.00
|
| Rate for Payer: Cash Price |
$585.00
|
| Rate for Payer: Cash Price |
$585.00
|
| Rate for Payer: Cigna Commercial |
$1,304.64
|
| Rate for Payer: Healthspan PPO |
$1,130.47
|
| Rate for Payer: Humana Medicaid |
$506.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,059.17
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$516.77
|
| Rate for Payer: Molina Healthcare Passport |
$506.64
|
| Rate for Payer: Multiplan PHCS |
$702.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$819.00
|
| Rate for Payer: UHCCP Medicaid |
$467.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$511.71
|
|
|
TIS TRNFR S/A/L 10.1-30 SQCM
|
Professional
|
Both
|
$1,173.00
|
|
|
Service Code
|
HCPCS 14021
|
| Hospital Charge Code |
761P2598
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$358.35 |
| Max. Negotiated Rate |
$1,173.00 |
| Rate for Payer: Aetna Commercial |
$1,043.99
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$358.35
|
| Rate for Payer: Anthem Medicaid |
$464.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,173.00
|
| Rate for Payer: Cash Price |
$586.50
|
| Rate for Payer: Cash Price |
$586.50
|
| Rate for Payer: Cigna Commercial |
$1,103.60
|
| Rate for Payer: Healthspan PPO |
$971.29
|
| Rate for Payer: Humana Medicaid |
$464.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$914.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$473.64
|
| Rate for Payer: Molina Healthcare Passport |
$464.35
|
| Rate for Payer: Multiplan PHCS |
$703.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$821.10
|
| Rate for Payer: UHCCP Medicaid |
$376.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$468.99
|
|
|
TIS TRNFR S/A/L 10.1-30 SQCM
|
Facility
|
IP
|
$1,173.00
|
|
|
Service Code
|
HCPCS 14021
|
| Hospital Charge Code |
76102598
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$152.49 |
| Max. Negotiated Rate |
$1,126.08 |
| Rate for Payer: Aetna Commercial |
$903.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$914.94
|
| Rate for Payer: Cash Price |
$586.50
|
| Rate for Payer: Cigna Commercial |
$973.59
|
| Rate for Payer: First Health Commercial |
$1,114.35
|
| Rate for Payer: Humana Commercial |
$997.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$961.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$865.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$351.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,032.24
|
| Rate for Payer: Ohio Health Group HMO |
$879.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$234.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$152.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$363.63
|
| Rate for Payer: PHCS Commercial |
$1,126.08
|
| Rate for Payer: United Healthcare All Payer |
$1,032.24
|
|
|
TIS TRNFR S/A/L 10.1-30 SQCM
|
Facility
|
OP
|
$1,173.00
|
|
|
Service Code
|
HCPCS 14021
|
| Hospital Charge Code |
76102598
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$152.49 |
| Max. Negotiated Rate |
$2,207.77 |
| Rate for Payer: Aetna Commercial |
$903.21
|
| Rate for Payer: Anthem Medicaid |
$403.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$914.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$586.50
|
| Rate for Payer: Cash Price |
$586.50
|
| Rate for Payer: Cigna Commercial |
$973.59
|
| Rate for Payer: First Health Commercial |
$1,114.35
|
| Rate for Payer: Humana Commercial |
$997.05
|
| Rate for Payer: Humana KY Medicaid |
$403.39
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$407.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$961.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$865.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$411.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,032.24
|
| Rate for Payer: Ohio Health Group HMO |
$879.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$234.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$152.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$363.63
|
| Rate for Payer: PHCS Commercial |
$1,126.08
|
| Rate for Payer: United Healthcare All Payer |
$1,032.24
|
|
|
TIS TRNFR S/A/L 10.1-30 SQCM
|
Professional
|
Both
|
$1,173.00
|
|
|
Service Code
|
HCPCS 14021
|
| Hospital Charge Code |
76102598
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$358.35 |
| Max. Negotiated Rate |
$1,173.00 |
| Rate for Payer: Aetna Commercial |
$1,043.99
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$358.35
|
| Rate for Payer: Anthem Medicaid |
$464.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,173.00
|
| Rate for Payer: Cash Price |
$586.50
|
| Rate for Payer: Cash Price |
$586.50
|
| Rate for Payer: Cigna Commercial |
$1,103.60
|
| Rate for Payer: Healthspan PPO |
$971.29
|
| Rate for Payer: Humana Medicaid |
$464.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$914.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$473.64
|
| Rate for Payer: Molina Healthcare Passport |
$464.35
|
| Rate for Payer: Multiplan PHCS |
$703.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$821.10
|
| Rate for Payer: UHCCP Medicaid |
$376.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$468.99
|
|
|
TITAL CHP 100 LEGTH 16 THRD
|
Facility
|
OP
|
$3,452.12
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$448.78 |
| Max. Negotiated Rate |
$3,314.04 |
| Rate for Payer: Aetna Commercial |
$2,658.13
|
| Rate for Payer: Anthem Medicaid |
$1,187.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,692.65
|
| Rate for Payer: Cash Price |
$1,726.06
|
| Rate for Payer: Cigna Commercial |
$2,865.26
|
| Rate for Payer: First Health Commercial |
$3,279.51
|
| Rate for Payer: Humana Commercial |
$2,934.30
|
| Rate for Payer: Humana KY Medicaid |
$1,187.18
|
| Rate for Payer: Kentucky WC Medicaid |
$1,199.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,830.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,547.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,035.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,211.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,037.87
|
| Rate for Payer: Ohio Health Group HMO |
$2,589.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$690.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$448.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,070.16
|
| Rate for Payer: PHCS Commercial |
$3,314.04
|
| Rate for Payer: United Healthcare All Payer |
$3,037.87
|
|
|
TITAL CHP 100 LEGTH 16 THRD
|
Facility
|
IP
|
$3,452.12
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$448.78 |
| Max. Negotiated Rate |
$3,314.04 |
| Rate for Payer: Aetna Commercial |
$2,658.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,692.65
|
| Rate for Payer: Cash Price |
$1,726.06
|
| Rate for Payer: Cigna Commercial |
$2,865.26
|
| Rate for Payer: First Health Commercial |
$3,279.51
|
| Rate for Payer: Humana Commercial |
$2,934.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,830.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,547.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,035.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,037.87
|
| Rate for Payer: Ohio Health Group HMO |
$2,589.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$690.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$448.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,070.16
|
| Rate for Payer: PHCS Commercial |
$3,314.04
|
| Rate for Payer: United Healthcare All Payer |
$3,037.87
|
|
