|
CLTX DSTL PHLNGL FX FNGR/THM(P
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 26750
|
| Hospital Charge Code |
761P0743
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$71.64 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna Commercial |
$232.79
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$97.42
|
| Rate for Payer: Anthem Medicaid |
$71.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$400.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$269.08
|
| Rate for Payer: Healthspan PPO |
$216.18
|
| Rate for Payer: Humana Medicaid |
$71.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$211.69
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$73.07
|
| Rate for Payer: Molina Healthcare Passport |
$71.64
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$102.29
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.36
|
|
|
CLTX FEM FX DST MED/LAT COND
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 27508
|
| Hospital Charge Code |
76100861
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$281.86 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Aetna Commercial |
$699.41
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$295.86
|
| Rate for Payer: Anthem Medicaid |
$281.86
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,000.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$818.04
|
| Rate for Payer: Healthspan PPO |
$667.45
|
| Rate for Payer: Humana Medicaid |
$281.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$601.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$287.50
|
| Rate for Payer: Molina Healthcare Passport |
$281.86
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$310.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$284.68
|
|
|
CLTX FEM FX DST MED/LAT COND
|
Facility
|
OP
|
$1,000.00
|
|
|
Service Code
|
HCPCS 27508
|
| Hospital Charge Code |
76100861
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$130.00 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$770.00
|
| Rate for Payer: Anthem Medicaid |
$343.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$203.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$780.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$285.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$275.31
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$830.00
|
| Rate for Payer: First Health Commercial |
$950.00
|
| Rate for Payer: Humana Commercial |
$850.00
|
| Rate for Payer: Humana KY Medicaid |
$343.90
|
| Rate for Payer: Humana Medicare Advantage |
$203.93
|
| Rate for Payer: Kentucky WC Medicaid |
$347.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$820.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$738.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$244.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$350.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$880.00
|
| Rate for Payer: Ohio Health Group HMO |
$750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$310.00
|
| Rate for Payer: PHCS Commercial |
$960.00
|
| Rate for Payer: United Healthcare All Payer |
$880.00
|
|
|
CLTX FEM FX DST MED/LAT COND
|
Facility
|
IP
|
$1,000.00
|
|
|
Service Code
|
HCPCS 27508
|
| Hospital Charge Code |
76100861
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$130.00 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$770.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$780.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$830.00
|
| Rate for Payer: First Health Commercial |
$950.00
|
| Rate for Payer: Humana Commercial |
$850.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$820.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$738.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$300.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$880.00
|
| Rate for Payer: Ohio Health Group HMO |
$750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$310.00
|
| Rate for Payer: PHCS Commercial |
$960.00
|
| Rate for Payer: United Healthcare All Payer |
$880.00
|
|
|
CLTX FEM FX DST MED/LAT COND(P
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 27508
|
| Hospital Charge Code |
761P0861
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$281.86 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Aetna Commercial |
$699.41
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$295.86
|
| Rate for Payer: Anthem Medicaid |
$281.86
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,000.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$818.04
|
| Rate for Payer: Healthspan PPO |
$667.45
|
| Rate for Payer: Humana Medicaid |
$281.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$601.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$287.50
|
| Rate for Payer: Molina Healthcare Passport |
$281.86
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$310.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$284.68
|
|
|
CLTX FEM FX PROX NCK WO MAN
|
Facility
|
IP
|
$860.00
|
|
|
Service Code
|
HCPCS 27230
|
| Hospital Charge Code |
76100788
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$111.80 |
| Max. Negotiated Rate |
$825.60 |
| Rate for Payer: Aetna Commercial |
$662.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$670.80
|
| Rate for Payer: Cash Price |
$430.00
|
| Rate for Payer: Cigna Commercial |
$713.80
|
| Rate for Payer: First Health Commercial |
$817.00
|
| Rate for Payer: Humana Commercial |
$731.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$705.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$634.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$258.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$756.80
|
| Rate for Payer: Ohio Health Group HMO |
$645.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$172.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$111.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$266.60
|
| Rate for Payer: PHCS Commercial |
$825.60
|
| Rate for Payer: United Healthcare All Payer |
$756.80
|
|
|
CLTX FEM FX PROX NCK WO MAN
|
Professional
|
Both
|
$860.00
|
|
|
Service Code
|
HCPCS 27230
|
| Hospital Charge Code |
76100788
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$243.73 |
| Max. Negotiated Rate |
$860.00 |
| Rate for Payer: Aetna Commercial |
$664.23
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$262.44
|
| Rate for Payer: Anthem Medicaid |
$243.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$860.00
|
| Rate for Payer: Cash Price |
$430.00
|
| Rate for Payer: Cash Price |
$430.00
|
| Rate for Payer: Cigna Commercial |
$737.93
|
| Rate for Payer: Healthspan PPO |
$608.93
|
| Rate for Payer: Humana Medicaid |
$243.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$571.86
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$248.60
|
| Rate for Payer: Molina Healthcare Passport |
$243.73
|
| Rate for Payer: Multiplan PHCS |
$516.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$602.00
|
| Rate for Payer: UHCCP Medicaid |
$275.56
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$246.17
|
|
|
CLTX FEM FX PROX NCK WO MAN
|
Facility
|
OP
|
$860.00
|
|
|
Service Code
|
HCPCS 27230
|
| Hospital Charge Code |
76100788
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$111.80 |
| Max. Negotiated Rate |
$825.60 |
| Rate for Payer: Aetna Commercial |
$662.20
|
| Rate for Payer: Anthem Medicaid |
$295.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$203.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$670.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$285.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$275.31
|
| Rate for Payer: Cash Price |
$430.00
|
| Rate for Payer: Cash Price |
$430.00
|
| Rate for Payer: Cigna Commercial |
$713.80
|
| Rate for Payer: First Health Commercial |
$817.00
|
| Rate for Payer: Humana Commercial |
$731.00
|
| Rate for Payer: Humana KY Medicaid |
$295.75
|
| Rate for Payer: Humana Medicare Advantage |
$203.93
|
| Rate for Payer: Kentucky WC Medicaid |
$298.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$705.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$634.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$244.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$301.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$756.80
|
| Rate for Payer: Ohio Health Group HMO |
$645.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$172.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$111.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$266.60
|
| Rate for Payer: PHCS Commercial |
$825.60
|
| Rate for Payer: United Healthcare All Payer |
$756.80
|
|
|
CLTX FEM FX PROX NCK WO MAN(P
|
Professional
|
Both
|
$860.00
|
|
|
Service Code
|
HCPCS 27230
|
| Hospital Charge Code |
761P0788
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$243.73 |
| Max. Negotiated Rate |
$860.00 |
| Rate for Payer: Aetna Commercial |
$664.23
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$262.44
|
| Rate for Payer: Anthem Medicaid |
$243.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$860.00
|
| Rate for Payer: Cash Price |
$430.00
|
| Rate for Payer: Cash Price |
$430.00
|
| Rate for Payer: Cigna Commercial |
$737.93
|
| Rate for Payer: Healthspan PPO |
$608.93
|
| Rate for Payer: Humana Medicaid |
$243.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$571.86
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$248.60
|
| Rate for Payer: Molina Healthcare Passport |
$243.73
|
| Rate for Payer: Multiplan PHCS |
$516.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$602.00
|
| Rate for Payer: UHCCP Medicaid |
$275.56
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$246.17
|
|
|
CLTX FEM FX PRX END NCK W/WO
|
Facility
|
IP
|
$950.00
|
|
|
Service Code
|
HCPCS 27232
|
| Hospital Charge Code |
76100789
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$123.50 |
| Max. Negotiated Rate |
$912.00 |
| Rate for Payer: Aetna Commercial |
$731.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$741.00
|
| Rate for Payer: Cash Price |
$475.00
|
| Rate for Payer: Cigna Commercial |
$788.50
|
| Rate for Payer: First Health Commercial |
$902.50
|
| Rate for Payer: Humana Commercial |
$807.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$779.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$701.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$285.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$836.00
|
| Rate for Payer: Ohio Health Group HMO |
$712.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$190.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$123.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$294.50
|
| Rate for Payer: PHCS Commercial |
$912.00
|
| Rate for Payer: United Healthcare All Payer |
$836.00
|
|
|
CLTX FEM FX PRX END NCK W/WO
|
Facility
|
OP
|
$950.00
|
|
|
Service Code
|
HCPCS 27232
|
| Hospital Charge Code |
76100789
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$123.50 |
| Max. Negotiated Rate |
$912.00 |
| Rate for Payer: Aetna Commercial |
$731.50
|
| Rate for Payer: Anthem Medicaid |
$326.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$741.00
|
| Rate for Payer: Cash Price |
$475.00
|
| Rate for Payer: Cigna Commercial |
$788.50
|
| Rate for Payer: First Health Commercial |
$902.50
|
| Rate for Payer: Humana Commercial |
$807.50
|
| Rate for Payer: Humana KY Medicaid |
$326.70
|
| Rate for Payer: Kentucky WC Medicaid |
$330.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$779.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$701.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$285.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$333.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$836.00
|
| Rate for Payer: Ohio Health Group HMO |
$712.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$190.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$123.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$294.50
|
| Rate for Payer: PHCS Commercial |
$912.00
|
| Rate for Payer: United Healthcare All Payer |
$836.00
|
|
|
CLTX FEM FX PRX END NCK W/WO
|
Professional
|
Both
|
$950.00
|
|
|
Service Code
|
HCPCS 27232
|
| Hospital Charge Code |
76100789
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$332.50 |
| Max. Negotiated Rate |
$1,248.14 |
| Rate for Payer: Aetna Commercial |
$1,157.68
|
| Rate for Payer: Anthem Medicaid |
$549.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$950.00
|
| Rate for Payer: Cash Price |
$475.00
|
| Rate for Payer: Cash Price |
$475.00
|
| Rate for Payer: Cigna Commercial |
$1,248.14
|
| Rate for Payer: Healthspan PPO |
$1,048.61
|
| Rate for Payer: Humana Medicaid |
$549.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$958.97
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$560.82
|
| Rate for Payer: Molina Healthcare Passport |
$549.82
|
| Rate for Payer: Multiplan PHCS |
$570.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$665.00
|
| Rate for Payer: UHCCP Medicaid |
$332.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$555.32
|
|
|
CLTX FEM FX PRX END NCK W/WO(P
|
Professional
|
Both
|
$950.00
|
|
|
Service Code
|
HCPCS 27232
|
| Hospital Charge Code |
761P0789
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$332.50 |
| Max. Negotiated Rate |
$1,248.14 |
| Rate for Payer: Aetna Commercial |
$1,157.68
|
| Rate for Payer: Anthem Medicaid |
$549.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$950.00
|
| Rate for Payer: Cash Price |
$475.00
|
| Rate for Payer: Cash Price |
$475.00
|
| Rate for Payer: Cigna Commercial |
$1,248.14
|
| Rate for Payer: Healthspan PPO |
$1,048.61
|
| Rate for Payer: Humana Medicaid |
$549.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$958.97
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$560.82
|
| Rate for Payer: Molina Healthcare Passport |
$549.82
|
| Rate for Payer: Multiplan PHCS |
$570.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$665.00
|
| Rate for Payer: UHCCP Medicaid |
$332.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$555.32
|
|
|
CLTX FX GRT TOE PHLX/PHLG
|
Facility
|
OP
|
$500.00
|
|
|
Service Code
|
HCPCS 28490
|
| Hospital Charge Code |
76101023
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$65.00 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Aetna Commercial |
$385.00
|
| Rate for Payer: Anthem Medicaid |
$171.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$203.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$390.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$285.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$275.31
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$415.00
|
| Rate for Payer: First Health Commercial |
$475.00
|
| Rate for Payer: Humana Commercial |
$425.00
|
| Rate for Payer: Humana KY Medicaid |
$171.95
|
| Rate for Payer: Humana Medicare Advantage |
$203.93
|
| Rate for Payer: Kentucky WC Medicaid |
$173.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$410.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$369.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$244.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$175.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$440.00
|
| Rate for Payer: Ohio Health Group HMO |
$375.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$155.00
|
| Rate for Payer: PHCS Commercial |
$480.00
|
| Rate for Payer: United Healthcare All Payer |
$440.00
|
|
|
CLTX FX GRT TOE PHLX/PHLG
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 28490
|
| Hospital Charge Code |
76101023
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$44.14 |
| Max. Negotiated Rate |
$500.00 |
| Rate for Payer: Aetna Commercial |
$162.40
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$63.85
|
| Rate for Payer: Anthem Medicaid |
$44.14
|
| 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 |
$203.54
|
| Rate for Payer: Healthspan PPO |
$166.49
|
| Rate for Payer: Humana Medicaid |
$44.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$145.14
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$45.02
|
| Rate for Payer: Molina Healthcare Passport |
$44.14
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$350.00
|
| Rate for Payer: UHCCP Medicaid |
$67.04
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$44.58
|
|
|
CLTX FX GRT TOE PHLX/PHLG
|
Facility
|
IP
|
$500.00
|
|
|
Service Code
|
HCPCS 28490
|
| Hospital Charge Code |
76101023
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$65.00 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Aetna Commercial |
$385.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$390.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$415.00
|
| Rate for Payer: First Health Commercial |
$475.00
|
| Rate for Payer: Humana Commercial |
$425.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$410.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$369.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$150.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$440.00
|
| Rate for Payer: Ohio Health Group HMO |
$375.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$155.00
|
| Rate for Payer: PHCS Commercial |
$480.00
|
| Rate for Payer: United Healthcare All Payer |
$440.00
|
|
|
CLTX FX GRT TOE PHLX/PHLG(P
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 28490
|
| Hospital Charge Code |
761P1023
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$44.14 |
| Max. Negotiated Rate |
$500.00 |
| Rate for Payer: Aetna Commercial |
$162.40
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$63.85
|
| Rate for Payer: Anthem Medicaid |
$44.14
|
| 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 |
$203.54
|
| Rate for Payer: Healthspan PPO |
$166.49
|
| Rate for Payer: Humana Medicaid |
$44.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$145.14
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$45.02
|
| Rate for Payer: Molina Healthcare Passport |
$44.14
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$350.00
|
| Rate for Payer: UHCCP Medicaid |
$67.04
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$44.58
|
|
|
CLTX FX PHLX/PHLG NOT GRT TOE
|
Facility
|
IP
|
$760.00
|
|
|
Service Code
|
HCPCS 28510
|
| Hospital Charge Code |
76101026
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$98.80 |
| Max. Negotiated Rate |
$729.60 |
| Rate for Payer: Aetna Commercial |
$585.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$592.80
|
| Rate for Payer: Cash Price |
$380.00
|
| Rate for Payer: Cigna Commercial |
$630.80
|
| Rate for Payer: First Health Commercial |
$722.00
|
| Rate for Payer: Humana Commercial |
$646.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$623.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$560.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$228.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$668.80
|
| Rate for Payer: Ohio Health Group HMO |
$570.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$235.60
|
| Rate for Payer: PHCS Commercial |
$729.60
|
| Rate for Payer: United Healthcare All Payer |
$668.80
|
|
|
CLTX FX PHLX/PHLG NOT GRT TOE
|
Facility
|
OP
|
$760.00
|
|
|
Service Code
|
HCPCS 28510
|
| Hospital Charge Code |
76101026
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$98.80 |
| Max. Negotiated Rate |
$729.60 |
| Rate for Payer: Aetna Commercial |
$585.20
|
| Rate for Payer: Anthem Medicaid |
$261.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$203.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$592.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$285.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$275.31
|
| Rate for Payer: Cash Price |
$380.00
|
| Rate for Payer: Cash Price |
$380.00
|
| Rate for Payer: Cigna Commercial |
$630.80
|
| Rate for Payer: First Health Commercial |
$722.00
|
| Rate for Payer: Humana Commercial |
$646.00
|
| Rate for Payer: Humana KY Medicaid |
$261.36
|
| Rate for Payer: Humana Medicare Advantage |
$203.93
|
| Rate for Payer: Kentucky WC Medicaid |
$264.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$623.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$560.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$244.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$266.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$668.80
|
| Rate for Payer: Ohio Health Group HMO |
$570.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$235.60
|
| Rate for Payer: PHCS Commercial |
$729.60
|
| Rate for Payer: United Healthcare All Payer |
$668.80
|
|
|
CLTX FX PHLX/PHLG NOT GRT TOE
|
Professional
|
Both
|
$760.00
|
|
|
Service Code
|
HCPCS 28510
|
| Hospital Charge Code |
76101026
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$43.76 |
| Max. Negotiated Rate |
$760.00 |
| Rate for Payer: Aetna Commercial |
$158.11
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$60.91
|
| Rate for Payer: Anthem Medicaid |
$43.76
|
| Rate for Payer: Buckeye Medicare Advantage |
$760.00
|
| Rate for Payer: Cash Price |
$380.00
|
| Rate for Payer: Cash Price |
$380.00
|
| Rate for Payer: Cigna Commercial |
$174.24
|
| Rate for Payer: Healthspan PPO |
$145.64
|
| Rate for Payer: Humana Medicaid |
$43.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$139.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$44.64
|
| Rate for Payer: Molina Healthcare Passport |
$43.76
|
| Rate for Payer: Multiplan PHCS |
$456.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$532.00
|
| Rate for Payer: UHCCP Medicaid |
$63.96
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$44.20
|
|
|
CLTX FX PHLX/PHLG NOT GRT TO(P
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
HCPCS 28510
|
| Hospital Charge Code |
761P1026
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$43.76 |
| Max. Negotiated Rate |
$350.00 |
| Rate for Payer: Aetna Commercial |
$158.11
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$60.91
|
| Rate for Payer: Anthem Medicaid |
$43.76
|
| Rate for Payer: Buckeye Medicare Advantage |
$350.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna Commercial |
$174.24
|
| Rate for Payer: Healthspan PPO |
$145.64
|
| Rate for Payer: Humana Medicaid |
$43.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$139.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$44.64
|
| Rate for Payer: Molina Healthcare Passport |
$43.76
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$245.00
|
| Rate for Payer: UHCCP Medicaid |
$63.96
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$44.20
|
|
|
CLTX FX PHLX/PHLG NOT GRT TO(T
|
Facility
|
IP
|
$410.00
|
|
|
Service Code
|
HCPCS 28510
|
| Hospital Charge Code |
761T1026
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$53.30 |
| Max. Negotiated Rate |
$393.60 |
| Rate for Payer: Aetna Commercial |
$315.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$319.80
|
| Rate for Payer: Cash Price |
$205.00
|
| Rate for Payer: Cigna Commercial |
$340.30
|
| Rate for Payer: First Health Commercial |
$389.50
|
| Rate for Payer: Humana Commercial |
$348.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$336.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$302.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$123.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$360.80
|
| Rate for Payer: Ohio Health Group HMO |
$307.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$82.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$127.10
|
| Rate for Payer: PHCS Commercial |
$393.60
|
| Rate for Payer: United Healthcare All Payer |
$360.80
|
|
|
CLTX FX PHLX/PHLG NOT GRT TO(T
|
Facility
|
OP
|
$410.00
|
|
|
Service Code
|
HCPCS 28510
|
| Hospital Charge Code |
761T1026
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$53.30 |
| Max. Negotiated Rate |
$393.60 |
| Rate for Payer: Aetna Commercial |
$315.70
|
| Rate for Payer: Anthem Medicaid |
$141.00
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$203.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$319.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$285.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$275.31
|
| Rate for Payer: Cash Price |
$205.00
|
| Rate for Payer: Cash Price |
$205.00
|
| Rate for Payer: Cigna Commercial |
$340.30
|
| Rate for Payer: First Health Commercial |
$389.50
|
| Rate for Payer: Humana Commercial |
$348.50
|
| Rate for Payer: Humana KY Medicaid |
$141.00
|
| Rate for Payer: Humana Medicare Advantage |
$203.93
|
| Rate for Payer: Kentucky WC Medicaid |
$142.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$336.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$302.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$244.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$143.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$360.80
|
| Rate for Payer: Ohio Health Group HMO |
$307.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$82.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$127.10
|
| Rate for Payer: PHCS Commercial |
$393.60
|
| Rate for Payer: United Healthcare All Payer |
$360.80
|
|
|
CLTX FX W8 BRG ARTCLR DSTTIB
|
Facility
|
IP
|
$720.00
|
|
|
Service Code
|
HCPCS 27824
|
| Hospital Charge Code |
76100946
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$93.60 |
| Max. Negotiated Rate |
$691.20 |
| Rate for Payer: Aetna Commercial |
$554.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$561.60
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cigna Commercial |
$597.60
|
| Rate for Payer: First Health Commercial |
$684.00
|
| Rate for Payer: Humana Commercial |
$612.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$590.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$531.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$216.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$633.60
|
| Rate for Payer: Ohio Health Group HMO |
$540.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$144.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$93.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$223.20
|
| Rate for Payer: PHCS Commercial |
$691.20
|
| Rate for Payer: United Healthcare All Payer |
$633.60
|
|
|
CLTX FX W8 BRG ARTCLR DSTTIB
|
Professional
|
Both
|
$720.00
|
|
|
Service Code
|
HCPCS 27824
|
| Hospital Charge Code |
76100946
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$185.96 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Aetna Commercial |
$406.77
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$197.04
|
| Rate for Payer: Anthem Medicaid |
$185.96
|
| Rate for Payer: Buckeye Medicare Advantage |
$720.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cigna Commercial |
$469.14
|
| Rate for Payer: Healthspan PPO |
$381.54
|
| Rate for Payer: Humana Medicaid |
$185.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$361.22
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$189.68
|
| Rate for Payer: Molina Healthcare Passport |
$185.96
|
| Rate for Payer: Multiplan PHCS |
$432.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$504.00
|
| Rate for Payer: UHCCP Medicaid |
$206.89
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$187.82
|
|
