|
CLSD TRTMNT FX WT BRNG ART PTN
|
Facility
|
IP
|
$1,130.00
|
|
|
Service Code
|
HCPCS 27825
|
| Hospital Charge Code |
76100947
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$339.00 |
| Max. Negotiated Rate |
$1,084.80 |
| Rate for Payer: Aetna Commercial |
$870.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$881.40
|
| Rate for Payer: Cash Price |
$565.00
|
| Rate for Payer: Cigna Commercial |
$937.90
|
| Rate for Payer: First Health Commercial |
$1,073.50
|
| Rate for Payer: Humana Commercial |
$960.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$926.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$833.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$339.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$994.40
|
| Rate for Payer: Ohio Health Group HMO |
$847.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$904.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$983.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$779.70
|
| Rate for Payer: PHCS Commercial |
$1,084.80
|
| Rate for Payer: United Healthcare All Payer |
$994.40
|
|
|
CLSD TRTMNT METATARS FX W/MAN
|
Facility
|
OP
|
$630.00
|
|
|
Service Code
|
HCPCS 28475
|
| Hospital Charge Code |
76101020
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$216.66 |
| Max. Negotiated Rate |
$604.80 |
| Rate for Payer: Aetna Commercial |
$485.10
|
| Rate for Payer: Anthem Medicaid |
$216.66
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$221.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$491.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$310.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$299.21
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cigna Commercial |
$522.90
|
| Rate for Payer: First Health Commercial |
$598.50
|
| Rate for Payer: Humana Commercial |
$535.50
|
| Rate for Payer: Humana KY Medicaid |
$216.66
|
| Rate for Payer: Humana Medicare Advantage |
$221.64
|
| Rate for Payer: Kentucky WC Medicaid |
$218.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$516.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$464.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$221.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$554.40
|
| Rate for Payer: Ohio Health Group HMO |
$472.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$504.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$548.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$434.70
|
| Rate for Payer: PHCS Commercial |
$604.80
|
| Rate for Payer: United Healthcare All Payer |
$554.40
|
|
|
CLSD TRTMNT METATARS FX W/MAN
|
Professional
|
Both
|
$630.00
|
|
|
Service Code
|
HCPCS 28475
|
| Hospital Charge Code |
76101020
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$141.77 |
| Max. Negotiated Rate |
$411.45 |
| Rate for Payer: Aetna Commercial |
$345.68
|
| Rate for Payer: Ambetter Exchange |
$220.56
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$141.77
|
| Rate for Payer: Anthem Medicaid |
$150.45
|
| Rate for Payer: Buckeye Individual/Medicaid |
$220.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$220.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$264.67
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cigna Commercial |
$411.45
|
| Rate for Payer: Healthspan PPO |
$336.39
|
| Rate for Payer: Humana Medicaid |
$150.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$281.49
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$220.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.56
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$153.46
|
| Rate for Payer: Molina Healthcare Passport |
$150.45
|
| Rate for Payer: Multiplan PHCS |
$378.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$286.73
|
| Rate for Payer: UHCCP Medicaid |
$148.86
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$151.95
|
| Rate for Payer: Wellcare Medicare Advantage |
$220.56
|
|
|
CLSD TRTMNT METATARS FX W/MAN
|
Facility
|
IP
|
$630.00
|
|
|
Service Code
|
HCPCS 28475
|
| Hospital Charge Code |
76101020
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$189.00 |
| Max. Negotiated Rate |
$604.80 |
| Rate for Payer: Aetna Commercial |
$485.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$491.40
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cigna Commercial |
$522.90
|
| Rate for Payer: First Health Commercial |
$598.50
|
| Rate for Payer: Humana Commercial |
$535.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$516.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$464.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$189.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$554.40
|
| Rate for Payer: Ohio Health Group HMO |
$472.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$504.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$548.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$434.70
|
| Rate for Payer: PHCS Commercial |
$604.80
|
| Rate for Payer: United Healthcare All Payer |
$554.40
|
|
|
CLSD TRTMNT METATARS FX W/MAN
|
Facility
|
IP
|
$322.00
|
|
|
Service Code
|
HCPCS 28475
|
| Hospital Charge Code |
45000178
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$96.60 |
| Max. Negotiated Rate |
$309.12 |
| Rate for Payer: Aetna Commercial |
$247.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$251.16
|
| Rate for Payer: Cash Price |
$161.00
|
| Rate for Payer: Cigna Commercial |
$267.26
|
| Rate for Payer: First Health Commercial |
$305.90
|
| Rate for Payer: Humana Commercial |
$273.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$264.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$237.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$283.36
|
| Rate for Payer: Ohio Health Group HMO |
$241.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$257.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$280.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$222.18
|
| Rate for Payer: PHCS Commercial |
$309.12
|
| Rate for Payer: United Healthcare All Payer |
$283.36
|
|
|
CLSD TRTMNT METATARS FX W/MAN
|
Facility
|
OP
|
$322.00
|
|
|
Service Code
|
HCPCS 28475
|
| Hospital Charge Code |
45000178
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$110.74 |
| Max. Negotiated Rate |
$310.30 |
| Rate for Payer: Aetna Commercial |
$247.94
|
| Rate for Payer: Anthem Medicaid |
$110.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$221.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$251.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$310.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$299.21
|
| Rate for Payer: Cash Price |
$161.00
|
| Rate for Payer: Cash Price |
$161.00
|
| Rate for Payer: Cigna Commercial |
$267.26
|
| Rate for Payer: First Health Commercial |
$305.90
|
| Rate for Payer: Humana Commercial |
$273.70
|
| Rate for Payer: Humana KY Medicaid |
$110.74
|
| Rate for Payer: Humana Medicare Advantage |
$221.64
|
| Rate for Payer: Kentucky WC Medicaid |
$111.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$264.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$237.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$112.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$283.36
|
| Rate for Payer: Ohio Health Group HMO |
$241.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$257.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$280.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$222.18
|
| Rate for Payer: PHCS Commercial |
$309.12
|
| Rate for Payer: United Healthcare All Payer |
$283.36
|
|
|
CLSD TRTMNT METATARS FX W/MA(P
|
Professional
|
Both
|
$630.00
|
|
|
Service Code
|
HCPCS 28475
|
| Hospital Charge Code |
761P1020
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$141.77 |
| Max. Negotiated Rate |
$411.45 |
| Rate for Payer: Aetna Commercial |
$345.68
|
| Rate for Payer: Ambetter Exchange |
$220.56
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$141.77
|
| Rate for Payer: Anthem Medicaid |
$150.45
|
| Rate for Payer: Buckeye Individual/Medicaid |
$220.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$220.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$264.67
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cigna Commercial |
$411.45
|
| Rate for Payer: Healthspan PPO |
$336.39
|
| Rate for Payer: Humana Medicaid |
$150.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$281.49
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$220.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.56
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$153.46
|
| Rate for Payer: Molina Healthcare Passport |
$150.45
|
| Rate for Payer: Multiplan PHCS |
$378.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$286.73
|
| Rate for Payer: UHCCP Medicaid |
$148.86
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$151.95
|
| Rate for Payer: Wellcare Medicare Advantage |
$220.56
|
|
|
CLSD TRTMNT TIB FX
|
Facility
|
OP
|
$2,248.00
|
|
|
Service Code
|
HCPCS 27752
|
| Hospital Charge Code |
45000165
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$773.09 |
| Max. Negotiated Rate |
$2,158.08 |
| Rate for Payer: Aetna Commercial |
$1,730.96
|
| Rate for Payer: Anthem Medicaid |
$773.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,478.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,753.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,070.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,996.31
|
| Rate for Payer: Cash Price |
$1,124.00
|
| Rate for Payer: Cash Price |
$1,124.00
|
| Rate for Payer: Cigna Commercial |
$1,865.84
|
| Rate for Payer: First Health Commercial |
$2,135.60
|
| Rate for Payer: Humana Commercial |
$1,910.80
|
| Rate for Payer: Humana KY Medicaid |
$773.09
|
| Rate for Payer: Humana Medicare Advantage |
$1,478.75
|
| Rate for Payer: Kentucky WC Medicaid |
$780.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,843.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,659.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,774.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$788.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,978.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,686.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,798.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,955.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,551.12
|
| Rate for Payer: PHCS Commercial |
$2,158.08
|
| Rate for Payer: United Healthcare All Payer |
$1,978.24
|
|
|
CLSD TRTMNT TIB FX
|
Facility
|
IP
|
$1,040.00
|
|
|
Service Code
|
HCPCS 27752
|
| Hospital Charge Code |
76100924
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$312.00 |
| Max. Negotiated Rate |
$998.40 |
| Rate for Payer: Aetna Commercial |
$800.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$811.20
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cigna Commercial |
$863.20
|
| Rate for Payer: First Health Commercial |
$988.00
|
| Rate for Payer: Humana Commercial |
$884.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$852.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$767.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$312.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$915.20
|
| Rate for Payer: Ohio Health Group HMO |
$780.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$832.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$904.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$717.60
|
| Rate for Payer: PHCS Commercial |
$998.40
|
| Rate for Payer: United Healthcare All Payer |
$915.20
|
|
|
CLSD TRTMNT TIB FX
|
Facility
|
OP
|
$1,040.00
|
|
|
Service Code
|
HCPCS 27752
|
| Hospital Charge Code |
76100924
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$357.66 |
| Max. Negotiated Rate |
$2,070.25 |
| Rate for Payer: Aetna Commercial |
$800.80
|
| Rate for Payer: Anthem Medicaid |
$357.66
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,478.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$811.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,070.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,996.31
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cigna Commercial |
$863.20
|
| Rate for Payer: First Health Commercial |
$988.00
|
| Rate for Payer: Humana Commercial |
$884.00
|
| Rate for Payer: Humana KY Medicaid |
$357.66
|
| Rate for Payer: Humana Medicare Advantage |
$1,478.75
|
| Rate for Payer: Kentucky WC Medicaid |
$361.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$852.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$767.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,774.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$364.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$915.20
|
| Rate for Payer: Ohio Health Group HMO |
$780.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$832.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$904.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$717.60
|
| Rate for Payer: PHCS Commercial |
$998.40
|
| Rate for Payer: United Healthcare All Payer |
$915.20
|
|
|
CLSD TRTMNT TIB FX
|
Professional
|
Both
|
$1,040.00
|
|
|
Service Code
|
HCPCS 27752
|
| Hospital Charge Code |
76100924
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$260.34 |
| Max. Negotiated Rate |
$779.13 |
| Rate for Payer: Aetna Commercial |
$711.12
|
| Rate for Payer: Ambetter Exchange |
$470.97
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$260.34
|
| Rate for Payer: Anthem Medicaid |
$307.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$470.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$470.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$565.16
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cigna Commercial |
$779.13
|
| Rate for Payer: Healthspan PPO |
$685.81
|
| Rate for Payer: Humana Medicaid |
$307.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$608.46
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$470.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$470.97
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$313.77
|
| Rate for Payer: Molina Healthcare Passport |
$307.62
|
| Rate for Payer: Multiplan PHCS |
$624.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$612.26
|
| Rate for Payer: UHCCP Medicaid |
$273.36
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$310.70
|
| Rate for Payer: Wellcare Medicare Advantage |
$470.97
|
|
|
CLSD TRTMNT TIB FX
|
Facility
|
IP
|
$2,248.00
|
|
|
Service Code
|
HCPCS 27752
|
| Hospital Charge Code |
45000165
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$674.40 |
| Max. Negotiated Rate |
$2,158.08 |
| Rate for Payer: Aetna Commercial |
$1,730.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,753.44
|
| Rate for Payer: Cash Price |
$1,124.00
|
| Rate for Payer: Cigna Commercial |
$1,865.84
|
| Rate for Payer: First Health Commercial |
$2,135.60
|
| Rate for Payer: Humana Commercial |
$1,910.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,843.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,659.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$674.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,978.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,686.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,798.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,955.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,551.12
|
| Rate for Payer: PHCS Commercial |
$2,158.08
|
| Rate for Payer: United Healthcare All Payer |
$1,978.24
|
|
|
CLSD TRTMNT TIB FX (P
|
Professional
|
Both
|
$1,040.00
|
|
|
Service Code
|
HCPCS 27752
|
| Hospital Charge Code |
761P0924
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$260.34 |
| Max. Negotiated Rate |
$779.13 |
| Rate for Payer: Aetna Commercial |
$711.12
|
| Rate for Payer: Ambetter Exchange |
$470.97
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$260.34
|
| Rate for Payer: Anthem Medicaid |
$307.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$470.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$470.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$565.16
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cigna Commercial |
$779.13
|
| Rate for Payer: Healthspan PPO |
$685.81
|
| Rate for Payer: Humana Medicaid |
$307.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$608.46
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$470.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$470.97
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$313.77
|
| Rate for Payer: Molina Healthcare Passport |
$307.62
|
| Rate for Payer: Multiplan PHCS |
$624.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$612.26
|
| Rate for Payer: UHCCP Medicaid |
$273.36
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$310.70
|
| Rate for Payer: Wellcare Medicare Advantage |
$470.97
|
|
|
CLSD TX ACRMCLVCLR DISLC WOMAN
|
Facility
|
OP
|
$900.00
|
|
|
Service Code
|
HCPCS 23540
|
| Hospital Charge Code |
761T0474
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$221.64 |
| Max. Negotiated Rate |
$864.00 |
| Rate for Payer: Aetna Commercial |
$693.00
|
| Rate for Payer: Anthem Medicaid |
$309.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$221.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$702.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$310.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$299.21
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$747.00
|
| Rate for Payer: First Health Commercial |
$855.00
|
| Rate for Payer: Humana Commercial |
$765.00
|
| Rate for Payer: Humana KY Medicaid |
$309.51
|
| Rate for Payer: Humana Medicare Advantage |
$221.64
|
| Rate for Payer: Kentucky WC Medicaid |
$312.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$738.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$664.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$315.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$792.00
|
| Rate for Payer: Ohio Health Group HMO |
$675.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$720.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$783.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$621.00
|
| Rate for Payer: PHCS Commercial |
$864.00
|
| Rate for Payer: United Healthcare All Payer |
$792.00
|
|
|
CLSD TX ACRMCLVCLR DISLC WOMAN
|
Facility
|
IP
|
$1,455.00
|
|
|
Service Code
|
HCPCS 23540
|
| Hospital Charge Code |
76100474
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$436.50 |
| Max. Negotiated Rate |
$1,396.80 |
| Rate for Payer: Aetna Commercial |
$1,120.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,134.90
|
| Rate for Payer: Cash Price |
$727.50
|
| Rate for Payer: Cigna Commercial |
$1,207.65
|
| Rate for Payer: First Health Commercial |
$1,382.25
|
| Rate for Payer: Humana Commercial |
$1,236.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,193.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,073.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$436.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,280.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,091.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,164.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,003.95
|
| Rate for Payer: PHCS Commercial |
$1,396.80
|
| Rate for Payer: United Healthcare All Payer |
$1,280.40
|
|
|
CLSD TX ACRMCLVCLR DISLC WOMAN
|
Professional
|
Both
|
$1,455.00
|
|
|
Service Code
|
HCPCS 23540
|
| Hospital Charge Code |
76100474
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$107.81 |
| Max. Negotiated Rate |
$873.00 |
| Rate for Payer: Aetna Commercial |
$291.43
|
| Rate for Payer: Ambetter Exchange |
$229.44
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$122.51
|
| Rate for Payer: Anthem Medicaid |
$107.81
|
| Rate for Payer: Buckeye Individual/Medicaid |
$229.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$229.44
|
| Rate for Payer: CareSource Just4Me Medicare |
$275.33
|
| Rate for Payer: Cash Price |
$727.50
|
| Rate for Payer: Cash Price |
$727.50
|
| Rate for Payer: Cigna Commercial |
$329.95
|
| Rate for Payer: Healthspan PPO |
$267.37
|
| Rate for Payer: Humana Medicaid |
$107.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$262.53
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$229.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$229.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$109.97
|
| Rate for Payer: Molina Healthcare Passport |
$107.81
|
| Rate for Payer: Multiplan PHCS |
$873.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$298.27
|
| Rate for Payer: UHCCP Medicaid |
$128.64
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$108.89
|
| Rate for Payer: Wellcare Medicare Advantage |
$229.44
|
|
|
CLSD TX ACRMCLVCLR DISLC WOMAN
|
Facility
|
OP
|
$1,455.00
|
|
|
Service Code
|
HCPCS 23540
|
| Hospital Charge Code |
76100474
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$221.64 |
| Max. Negotiated Rate |
$1,396.80 |
| Rate for Payer: Aetna Commercial |
$1,120.35
|
| Rate for Payer: Anthem Medicaid |
$500.37
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$221.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,134.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$310.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$299.21
|
| Rate for Payer: Cash Price |
$727.50
|
| Rate for Payer: Cash Price |
$727.50
|
| Rate for Payer: Cigna Commercial |
$1,207.65
|
| Rate for Payer: First Health Commercial |
$1,382.25
|
| Rate for Payer: Humana Commercial |
$1,236.75
|
| Rate for Payer: Humana KY Medicaid |
$500.37
|
| Rate for Payer: Humana Medicare Advantage |
$221.64
|
| Rate for Payer: Kentucky WC Medicaid |
$505.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,193.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,073.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$510.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,280.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,091.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,164.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,003.95
|
| Rate for Payer: PHCS Commercial |
$1,396.80
|
| Rate for Payer: United Healthcare All Payer |
$1,280.40
|
|
|
CLSD TX ACRMCLVCLR DISLC WOMAN
|
Professional
|
Both
|
$555.00
|
|
|
Service Code
|
HCPCS 23540
|
| Hospital Charge Code |
761P0474
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$107.81 |
| Max. Negotiated Rate |
$333.00 |
| Rate for Payer: Aetna Commercial |
$291.43
|
| Rate for Payer: Ambetter Exchange |
$229.44
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$122.51
|
| Rate for Payer: Anthem Medicaid |
$107.81
|
| Rate for Payer: Buckeye Individual/Medicaid |
$229.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$229.44
|
| Rate for Payer: CareSource Just4Me Medicare |
$275.33
|
| Rate for Payer: Cash Price |
$277.50
|
| Rate for Payer: Cash Price |
$277.50
|
| Rate for Payer: Cigna Commercial |
$329.95
|
| Rate for Payer: Healthspan PPO |
$267.37
|
| Rate for Payer: Humana Medicaid |
$107.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$262.53
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$229.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$229.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$109.97
|
| Rate for Payer: Molina Healthcare Passport |
$107.81
|
| Rate for Payer: Multiplan PHCS |
$333.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$298.27
|
| Rate for Payer: UHCCP Medicaid |
$128.64
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$108.89
|
| Rate for Payer: Wellcare Medicare Advantage |
$229.44
|
|
|
CLSD TX ACRMCLVCLR DISLC WOMAN
|
Facility
|
IP
|
$900.00
|
|
|
Service Code
|
HCPCS 23540
|
| Hospital Charge Code |
761T0474
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$270.00 |
| Max. Negotiated Rate |
$864.00 |
| Rate for Payer: Aetna Commercial |
$693.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$702.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$747.00
|
| Rate for Payer: First Health Commercial |
$855.00
|
| Rate for Payer: Humana Commercial |
$765.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$738.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$664.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$270.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$792.00
|
| Rate for Payer: Ohio Health Group HMO |
$675.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$720.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$783.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$621.00
|
| Rate for Payer: PHCS Commercial |
$864.00
|
| Rate for Payer: United Healthcare All Payer |
$792.00
|
|
|
CLSD TX ANKL DISLOCCATW ANES
|
Facility
|
IP
|
$2,185.00
|
|
|
Service Code
|
HCPCS 27842
|
| Hospital Charge Code |
45000172
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$655.50 |
| Max. Negotiated Rate |
$2,097.60 |
| Rate for Payer: Aetna Commercial |
$1,682.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,704.30
|
| Rate for Payer: Cash Price |
$1,092.50
|
| Rate for Payer: Cigna Commercial |
$1,813.55
|
| Rate for Payer: First Health Commercial |
$2,075.75
|
| Rate for Payer: Humana Commercial |
$1,857.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,791.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,612.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$655.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,922.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,638.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,748.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,900.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,507.65
|
| Rate for Payer: PHCS Commercial |
$2,097.60
|
| Rate for Payer: United Healthcare All Payer |
$1,922.80
|
|
|
CLSD TX ANKL DISLOCCATW ANES
|
Facility
|
OP
|
$2,185.00
|
|
|
Service Code
|
HCPCS 27842
|
| Hospital Charge Code |
45000172
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$751.42 |
| Max. Negotiated Rate |
$2,097.60 |
| Rate for Payer: Aetna Commercial |
$1,682.45
|
| Rate for Payer: Anthem Medicaid |
$751.42
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,478.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,704.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,070.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,996.31
|
| Rate for Payer: Cash Price |
$1,092.50
|
| Rate for Payer: Cash Price |
$1,092.50
|
| Rate for Payer: Cigna Commercial |
$1,813.55
|
| Rate for Payer: First Health Commercial |
$2,075.75
|
| Rate for Payer: Humana Commercial |
$1,857.25
|
| Rate for Payer: Humana KY Medicaid |
$751.42
|
| Rate for Payer: Humana Medicare Advantage |
$1,478.75
|
| Rate for Payer: Kentucky WC Medicaid |
$759.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,791.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,612.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,774.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$766.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,922.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,638.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,748.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,900.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,507.65
|
| Rate for Payer: PHCS Commercial |
$2,097.60
|
| Rate for Payer: United Healthcare All Payer |
$1,922.80
|
|
|
CLSD TX ANKL DISLOCCATW ANES
|
Facility
|
OP
|
$2,111.00
|
|
|
Service Code
|
HCPCS 27842
|
| Hospital Charge Code |
76100953
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$725.97 |
| Max. Negotiated Rate |
$2,070.25 |
| Rate for Payer: Aetna Commercial |
$1,625.47
|
| Rate for Payer: Anthem Medicaid |
$725.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,478.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,646.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,070.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,996.31
|
| Rate for Payer: Cash Price |
$1,055.50
|
| Rate for Payer: Cash Price |
$1,055.50
|
| Rate for Payer: Cigna Commercial |
$1,752.13
|
| Rate for Payer: First Health Commercial |
$2,005.45
|
| Rate for Payer: Humana Commercial |
$1,794.35
|
| Rate for Payer: Humana KY Medicaid |
$725.97
|
| Rate for Payer: Humana Medicare Advantage |
$1,478.75
|
| Rate for Payer: Kentucky WC Medicaid |
$733.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,731.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,557.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,774.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$740.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,857.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,583.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,688.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,836.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,456.59
|
| Rate for Payer: PHCS Commercial |
$2,026.56
|
| Rate for Payer: United Healthcare All Payer |
$1,857.68
|
|
|
CLSD TX ANKL DISLOCCATW ANES
|
Facility
|
IP
|
$2,111.00
|
|
|
Service Code
|
HCPCS 27842
|
| Hospital Charge Code |
76100953
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$633.30 |
| Max. Negotiated Rate |
$2,026.56 |
| Rate for Payer: Aetna Commercial |
$1,625.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,646.58
|
| Rate for Payer: Cash Price |
$1,055.50
|
| Rate for Payer: Cigna Commercial |
$1,752.13
|
| Rate for Payer: First Health Commercial |
$2,005.45
|
| Rate for Payer: Humana Commercial |
$1,794.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,731.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,557.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$633.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,857.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,583.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,688.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,836.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,456.59
|
| Rate for Payer: PHCS Commercial |
$2,026.56
|
| Rate for Payer: United Healthcare All Payer |
$1,857.68
|
|
|
CLSD TX DISLOCAT HIP W/O ANES
|
Facility
|
OP
|
$544.00
|
|
| Hospital Charge Code |
45000334
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$163.20 |
| Max. Negotiated Rate |
$522.24 |
| Rate for Payer: Aetna Commercial |
$418.88
|
| Rate for Payer: Anthem Medicaid |
$187.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$424.32
|
| Rate for Payer: Cash Price |
$272.00
|
| Rate for Payer: Cigna Commercial |
$451.52
|
| Rate for Payer: First Health Commercial |
$516.80
|
| Rate for Payer: Humana Commercial |
$462.40
|
| Rate for Payer: Humana KY Medicaid |
$187.08
|
| Rate for Payer: Kentucky WC Medicaid |
$188.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$446.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$401.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$190.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$478.72
|
| Rate for Payer: Ohio Health Group HMO |
$408.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$435.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$473.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$375.36
|
| Rate for Payer: PHCS Commercial |
$522.24
|
| Rate for Payer: United Healthcare All Payer |
$478.72
|
|
|
CLSD TX DISLOCAT HIP W/O ANES
|
Facility
|
IP
|
$544.00
|
|
| Hospital Charge Code |
45000334
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$163.20 |
| Max. Negotiated Rate |
$522.24 |
| Rate for Payer: Aetna Commercial |
$418.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$424.32
|
| Rate for Payer: Cash Price |
$272.00
|
| Rate for Payer: Cigna Commercial |
$451.52
|
| Rate for Payer: First Health Commercial |
$516.80
|
| Rate for Payer: Humana Commercial |
$462.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$446.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$401.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$478.72
|
| Rate for Payer: Ohio Health Group HMO |
$408.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$435.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$473.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$375.36
|
| Rate for Payer: PHCS Commercial |
$522.24
|
| Rate for Payer: United Healthcare All Payer |
$478.72
|
|
