|
CLSD TX DISLOCAT HIP W/O ANES
|
Facility
|
OP
|
$522.00
|
|
| Hospital Charge Code |
76102562
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$156.60 |
| Max. Negotiated Rate |
$501.12 |
| Rate for Payer: Aetna Commercial |
$401.94
|
| Rate for Payer: Anthem Medicaid |
$179.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$407.16
|
| Rate for Payer: Cash Price |
$261.00
|
| Rate for Payer: Cigna Commercial |
$433.26
|
| Rate for Payer: First Health Commercial |
$495.90
|
| Rate for Payer: Humana Commercial |
$443.70
|
| Rate for Payer: Humana KY Medicaid |
$179.52
|
| Rate for Payer: Kentucky WC Medicaid |
$181.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$428.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$385.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$156.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$183.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$459.36
|
| Rate for Payer: Ohio Health Group HMO |
$391.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$417.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$454.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$360.18
|
| Rate for Payer: PHCS Commercial |
$501.12
|
| Rate for Payer: United Healthcare All Payer |
$459.36
|
|
|
CLSD TX DISLOCAT HIP W/O ANES
|
Facility
|
IP
|
$522.00
|
|
| Hospital Charge Code |
76102562
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$156.60 |
| Max. Negotiated Rate |
$501.12 |
| Rate for Payer: Aetna Commercial |
$401.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$407.16
|
| Rate for Payer: Cash Price |
$261.00
|
| Rate for Payer: Cigna Commercial |
$433.26
|
| Rate for Payer: First Health Commercial |
$495.90
|
| Rate for Payer: Humana Commercial |
$443.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$428.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$385.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$156.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$459.36
|
| Rate for Payer: Ohio Health Group HMO |
$391.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$417.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$454.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$360.18
|
| Rate for Payer: PHCS Commercial |
$501.12
|
| Rate for Payer: United Healthcare All Payer |
$459.36
|
|
|
CLSD TX DISLOCATION HIP W/ANES
|
Facility
|
IP
|
$594.00
|
|
| Hospital Charge Code |
76102563
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$178.20 |
| Max. Negotiated Rate |
$570.24 |
| Rate for Payer: Aetna Commercial |
$457.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$463.32
|
| Rate for Payer: Cash Price |
$297.00
|
| Rate for Payer: Cigna Commercial |
$493.02
|
| Rate for Payer: First Health Commercial |
$564.30
|
| Rate for Payer: Humana Commercial |
$504.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$487.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$438.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$178.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$522.72
|
| Rate for Payer: Ohio Health Group HMO |
$445.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$475.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$516.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$409.86
|
| Rate for Payer: PHCS Commercial |
$570.24
|
| Rate for Payer: United Healthcare All Payer |
$522.72
|
|
|
CLSD TX DISLOCATION HIP W/ANES
|
Facility
|
OP
|
$619.00
|
|
| Hospital Charge Code |
45000335
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$185.70 |
| Max. Negotiated Rate |
$594.24 |
| Rate for Payer: Aetna Commercial |
$476.63
|
| Rate for Payer: Anthem Medicaid |
$212.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$482.82
|
| Rate for Payer: Cash Price |
$309.50
|
| Rate for Payer: Cigna Commercial |
$513.77
|
| Rate for Payer: First Health Commercial |
$588.05
|
| Rate for Payer: Humana Commercial |
$526.15
|
| Rate for Payer: Humana KY Medicaid |
$212.87
|
| Rate for Payer: Kentucky WC Medicaid |
$215.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$507.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$456.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$185.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$217.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$544.72
|
| Rate for Payer: Ohio Health Group HMO |
$464.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$495.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$538.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$427.11
|
| Rate for Payer: PHCS Commercial |
$594.24
|
| Rate for Payer: United Healthcare All Payer |
$544.72
|
|
|
CLSD TX DISLOCATION HIP W/ANES
|
Facility
|
IP
|
$619.00
|
|
| Hospital Charge Code |
45000335
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$185.70 |
| Max. Negotiated Rate |
$594.24 |
| Rate for Payer: Aetna Commercial |
$476.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$482.82
|
| Rate for Payer: Cash Price |
$309.50
|
| Rate for Payer: Cigna Commercial |
$513.77
|
| Rate for Payer: First Health Commercial |
$588.05
|
| Rate for Payer: Humana Commercial |
$526.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$507.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$456.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$185.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$544.72
|
| Rate for Payer: Ohio Health Group HMO |
$464.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$495.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$538.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$427.11
|
| Rate for Payer: PHCS Commercial |
$594.24
|
| Rate for Payer: United Healthcare All Payer |
$544.72
|
|
|
CLSD TX DISLOCATION HIP W/ANES
|
Facility
|
OP
|
$594.00
|
|
| Hospital Charge Code |
76102563
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$178.20 |
| Max. Negotiated Rate |
$570.24 |
| Rate for Payer: Aetna Commercial |
$457.38
|
| Rate for Payer: Anthem Medicaid |
$204.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$463.32
|
| Rate for Payer: Cash Price |
$297.00
|
| Rate for Payer: Cigna Commercial |
$493.02
|
| Rate for Payer: First Health Commercial |
$564.30
|
| Rate for Payer: Humana Commercial |
$504.90
|
| Rate for Payer: Humana KY Medicaid |
$204.28
|
| Rate for Payer: Kentucky WC Medicaid |
$206.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$487.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$438.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$178.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$208.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$522.72
|
| Rate for Payer: Ohio Health Group HMO |
$445.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$475.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$516.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$409.86
|
| Rate for Payer: PHCS Commercial |
$570.24
|
| Rate for Payer: United Healthcare All Payer |
$522.72
|
|
|
CLSD TXFNGTOEJNTDSLOWMANANES
|
Professional
|
Both
|
$590.00
|
|
|
Service Code
|
HCPCS 26775
|
| Hospital Charge Code |
76100749
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$137.44 |
| Max. Negotiated Rate |
$499.63 |
| Rate for Payer: Aetna Commercial |
$464.32
|
| Rate for Payer: Ambetter Exchange |
$343.56
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$183.42
|
| Rate for Payer: Anthem Medicaid |
$137.44
|
| Rate for Payer: Buckeye Individual/Medicaid |
$343.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$343.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$412.27
|
| Rate for Payer: Cash Price |
$295.00
|
| Rate for Payer: Cash Price |
$295.00
|
| Rate for Payer: Cigna Commercial |
$499.63
|
| Rate for Payer: Healthspan PPO |
$464.20
|
| Rate for Payer: Humana Medicaid |
$137.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$409.95
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$343.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$343.56
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$140.19
|
| Rate for Payer: Molina Healthcare Passport |
$137.44
|
| Rate for Payer: Multiplan PHCS |
$354.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$446.63
|
| Rate for Payer: UHCCP Medicaid |
$192.59
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$138.81
|
| Rate for Payer: Wellcare Medicare Advantage |
$343.56
|
|
|
CLSD TXFNGTOEJNTDSLOWMANANES
|
Facility
|
IP
|
$390.00
|
|
|
Service Code
|
HCPCS 26775
|
| Hospital Charge Code |
76100749
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$117.00 |
| Max. Negotiated Rate |
$374.40 |
| Rate for Payer: Aetna Commercial |
$300.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$304.20
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cigna Commercial |
$323.70
|
| Rate for Payer: First Health Commercial |
$370.50
|
| Rate for Payer: Humana Commercial |
$331.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$319.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$287.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$343.20
|
| Rate for Payer: Ohio Health Group HMO |
$292.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$312.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$339.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$269.10
|
| Rate for Payer: PHCS Commercial |
$374.40
|
| Rate for Payer: United Healthcare All Payer |
$343.20
|
|
|
CLSD TXFNGTOEJNTDSLOWMANANES
|
Facility
|
OP
|
$390.00
|
|
|
Service Code
|
HCPCS 26775
|
| Hospital Charge Code |
76100749
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$134.12 |
| Max. Negotiated Rate |
$374.40 |
| Rate for Payer: Aetna Commercial |
$300.30
|
| Rate for Payer: Anthem Medicaid |
$134.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$245.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$304.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$343.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$331.28
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cigna Commercial |
$323.70
|
| Rate for Payer: First Health Commercial |
$370.50
|
| Rate for Payer: Humana Commercial |
$331.50
|
| Rate for Payer: Humana KY Medicaid |
$134.12
|
| Rate for Payer: Humana Medicare Advantage |
$245.39
|
| Rate for Payer: Kentucky WC Medicaid |
$135.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$319.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$287.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$294.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$136.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$343.20
|
| Rate for Payer: Ohio Health Group HMO |
$292.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$312.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$339.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$269.10
|
| Rate for Payer: PHCS Commercial |
$374.40
|
| Rate for Payer: United Healthcare All Payer |
$343.20
|
|
|
CLSD TXFNGTOEJNTDSLOWMANANES
|
Facility
|
IP
|
$390.00
|
|
|
Service Code
|
HCPCS 26775
|
| Hospital Charge Code |
45000148
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$117.00 |
| Max. Negotiated Rate |
$374.40 |
| Rate for Payer: Aetna Commercial |
$300.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$304.20
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cigna Commercial |
$323.70
|
| Rate for Payer: First Health Commercial |
$370.50
|
| Rate for Payer: Humana Commercial |
$331.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$319.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$287.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$343.20
|
| Rate for Payer: Ohio Health Group HMO |
$292.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$312.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$339.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$269.10
|
| Rate for Payer: PHCS Commercial |
$374.40
|
| Rate for Payer: United Healthcare All Payer |
$343.20
|
|
|
CLSD TXFNGTOEJNTDSLOWMANANES
|
Facility
|
OP
|
$390.00
|
|
|
Service Code
|
HCPCS 26775
|
| Hospital Charge Code |
45000148
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$134.12 |
| Max. Negotiated Rate |
$374.40 |
| Rate for Payer: Aetna Commercial |
$300.30
|
| Rate for Payer: Anthem Medicaid |
$134.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$245.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$304.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$343.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$331.28
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cigna Commercial |
$323.70
|
| Rate for Payer: First Health Commercial |
$370.50
|
| Rate for Payer: Humana Commercial |
$331.50
|
| Rate for Payer: Humana KY Medicaid |
$134.12
|
| Rate for Payer: Humana Medicare Advantage |
$245.39
|
| Rate for Payer: Kentucky WC Medicaid |
$135.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$319.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$287.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$294.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$136.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$343.20
|
| Rate for Payer: Ohio Health Group HMO |
$292.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$312.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$339.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$269.10
|
| Rate for Payer: PHCS Commercial |
$374.40
|
| Rate for Payer: United Healthcare All Payer |
$343.20
|
|
|
CLSD TXHUMCNDYLFXMEDLATWMAN
|
Facility
|
IP
|
$2,111.00
|
|
|
Service Code
|
HCPCS 24577
|
| Hospital Charge Code |
76100548
|
|
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 TXHUMCNDYLFXMEDLATWMAN
|
Facility
|
OP
|
$2,111.00
|
|
|
Service Code
|
HCPCS 24577
|
| Hospital Charge Code |
45000121
|
|
Hospital Revenue Code
|
450
|
| 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 TXHUMCNDYLFXMEDLATWMAN
|
Facility
|
IP
|
$2,111.00
|
|
|
Service Code
|
HCPCS 24577
|
| Hospital Charge Code |
45000121
|
|
Hospital Revenue Code
|
450
|
| 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 TXHUMCNDYLFXMEDLATWMAN
|
Facility
|
OP
|
$2,111.00
|
|
|
Service Code
|
HCPCS 24577
|
| Hospital Charge Code |
76100548
|
|
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 META JNT DIS W/O ANES
|
Facility
|
IP
|
$309.00
|
|
|
Service Code
|
HCPCS 28630
|
| Hospital Charge Code |
76101033
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$92.70 |
| Max. Negotiated Rate |
$296.64 |
| Rate for Payer: Aetna Commercial |
$237.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$241.02
|
| Rate for Payer: Cash Price |
$154.50
|
| Rate for Payer: Cigna Commercial |
$256.47
|
| Rate for Payer: First Health Commercial |
$293.55
|
| Rate for Payer: Humana Commercial |
$262.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$253.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$228.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$92.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$271.92
|
| Rate for Payer: Ohio Health Group HMO |
$231.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$247.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$268.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$213.21
|
| Rate for Payer: PHCS Commercial |
$296.64
|
| Rate for Payer: United Healthcare All Payer |
$271.92
|
|
|
CLSD TX META JNT DIS W/O ANES
|
Facility
|
OP
|
$309.00
|
|
|
Service Code
|
HCPCS 28630
|
| Hospital Charge Code |
76101033
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$106.27 |
| Max. Negotiated Rate |
$310.30 |
| Rate for Payer: Aetna Commercial |
$237.93
|
| Rate for Payer: Anthem Medicaid |
$106.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$221.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$241.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$310.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$299.21
|
| Rate for Payer: Cash Price |
$154.50
|
| Rate for Payer: Cash Price |
$154.50
|
| Rate for Payer: Cigna Commercial |
$256.47
|
| Rate for Payer: First Health Commercial |
$293.55
|
| Rate for Payer: Humana Commercial |
$262.65
|
| Rate for Payer: Humana KY Medicaid |
$106.27
|
| Rate for Payer: Humana Medicare Advantage |
$221.64
|
| Rate for Payer: Kentucky WC Medicaid |
$107.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$253.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$228.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$108.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$271.92
|
| Rate for Payer: Ohio Health Group HMO |
$231.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$247.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$268.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$213.21
|
| Rate for Payer: PHCS Commercial |
$296.64
|
| Rate for Payer: United Healthcare All Payer |
$271.92
|
|
|
CLSD TX META JNT DIS W/O ANES
|
Facility
|
IP
|
$322.00
|
|
|
Service Code
|
HCPCS 28630
|
| Hospital Charge Code |
45000181
|
|
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 TX META JNT DIS W/O ANES
|
Facility
|
OP
|
$322.00
|
|
|
Service Code
|
HCPCS 28630
|
| Hospital Charge Code |
45000181
|
|
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 TX NSL FX MNPJ WO STBLJ
|
Facility
|
OP
|
$2,015.00
|
|
|
Service Code
|
HCPCS 21315
|
| Hospital Charge Code |
45000100
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$692.96 |
| Max. Negotiated Rate |
$1,934.40 |
| Rate for Payer: Aetna Commercial |
$1,551.55
|
| Rate for Payer: Anthem Medicaid |
$692.96
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,368.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,571.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,916.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,847.70
|
| Rate for Payer: Cash Price |
$1,007.50
|
| Rate for Payer: Cash Price |
$1,007.50
|
| Rate for Payer: Cigna Commercial |
$1,672.45
|
| Rate for Payer: First Health Commercial |
$1,914.25
|
| Rate for Payer: Humana Commercial |
$1,712.75
|
| Rate for Payer: Humana KY Medicaid |
$692.96
|
| Rate for Payer: Humana Medicare Advantage |
$1,368.67
|
| Rate for Payer: Kentucky WC Medicaid |
$700.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,652.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,642.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$706.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,773.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,511.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,753.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,390.35
|
| Rate for Payer: PHCS Commercial |
$1,934.40
|
| Rate for Payer: United Healthcare All Payer |
$1,773.20
|
|
|
CLSD TX NSL FX MNPJ WO STBLJ
|
Facility
|
IP
|
$2,015.00
|
|
|
Service Code
|
HCPCS 21315
|
| Hospital Charge Code |
45000100
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$604.50 |
| Max. Negotiated Rate |
$1,934.40 |
| Rate for Payer: Aetna Commercial |
$1,551.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,571.70
|
| Rate for Payer: Cash Price |
$1,007.50
|
| Rate for Payer: Cigna Commercial |
$1,672.45
|
| Rate for Payer: First Health Commercial |
$1,914.25
|
| Rate for Payer: Humana Commercial |
$1,712.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,652.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$604.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,773.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,511.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,753.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,390.35
|
| Rate for Payer: PHCS Commercial |
$1,934.40
|
| Rate for Payer: United Healthcare All Payer |
$1,773.20
|
|
|
CLSD TX NSL FX MNPJ WO STBLJ
|
Professional
|
Both
|
$2,365.00
|
|
|
Service Code
|
HCPCS 21315
|
| Hospital Charge Code |
76100379
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$56.73 |
| Max. Negotiated Rate |
$1,419.00 |
| Rate for Payer: Aetna Commercial |
$208.54
|
| Rate for Payer: Ambetter Exchange |
$56.73
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$60.21
|
| Rate for Payer: Anthem Medicaid |
$95.02
|
| Rate for Payer: Buckeye Individual/Medicaid |
$56.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$56.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$68.08
|
| Rate for Payer: Cash Price |
$1,182.50
|
| Rate for Payer: Cash Price |
$1,182.50
|
| Rate for Payer: Cigna Commercial |
$229.84
|
| Rate for Payer: Healthspan PPO |
$320.75
|
| Rate for Payer: Humana Medicaid |
$95.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$187.24
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$56.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.73
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$96.92
|
| Rate for Payer: Molina Healthcare Passport |
$95.02
|
| Rate for Payer: Multiplan PHCS |
$1,419.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$73.75
|
| Rate for Payer: UHCCP Medicaid |
$63.22
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$95.97
|
| Rate for Payer: Wellcare Medicare Advantage |
$56.73
|
|
|
CLSD TX NSL FX MNPJ WO STBLJ
|
Facility
|
OP
|
$2,365.00
|
|
|
Service Code
|
HCPCS 21315
|
| Hospital Charge Code |
76100379
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$813.32 |
| Max. Negotiated Rate |
$2,270.40 |
| Rate for Payer: Aetna Commercial |
$1,821.05
|
| Rate for Payer: Anthem Medicaid |
$813.32
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,368.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,844.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,916.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,847.70
|
| Rate for Payer: Cash Price |
$1,182.50
|
| Rate for Payer: Cash Price |
$1,182.50
|
| Rate for Payer: Cigna Commercial |
$1,962.95
|
| Rate for Payer: First Health Commercial |
$2,246.75
|
| Rate for Payer: Humana Commercial |
$2,010.25
|
| Rate for Payer: Humana KY Medicaid |
$813.32
|
| Rate for Payer: Humana Medicare Advantage |
$1,368.67
|
| Rate for Payer: Kentucky WC Medicaid |
$821.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,939.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,745.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,642.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$829.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,081.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,773.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,892.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,057.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,631.85
|
| Rate for Payer: PHCS Commercial |
$2,270.40
|
| Rate for Payer: United Healthcare All Payer |
$2,081.20
|
|
|
CLSD TX NSL FX MNPJ WO STBLJ
|
Facility
|
IP
|
$2,365.00
|
|
|
Service Code
|
HCPCS 21315
|
| Hospital Charge Code |
76100379
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$709.50 |
| Max. Negotiated Rate |
$2,270.40 |
| Rate for Payer: Aetna Commercial |
$1,821.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,844.70
|
| Rate for Payer: Cash Price |
$1,182.50
|
| Rate for Payer: Cigna Commercial |
$1,962.95
|
| Rate for Payer: First Health Commercial |
$2,246.75
|
| Rate for Payer: Humana Commercial |
$2,010.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,939.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,745.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$709.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,081.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,773.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,892.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,057.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,631.85
|
| Rate for Payer: PHCS Commercial |
$2,270.40
|
| Rate for Payer: United Healthcare All Payer |
$2,081.20
|
|
|
CLSD TX NSL FX MNPJ WO STBLJ(P
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
HCPCS 21315
|
| Hospital Charge Code |
761P0379
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$56.73 |
| Max. Negotiated Rate |
$320.75 |
| Rate for Payer: Aetna Commercial |
$208.54
|
| Rate for Payer: Ambetter Exchange |
$56.73
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$60.21
|
| Rate for Payer: Anthem Medicaid |
$95.02
|
| Rate for Payer: Buckeye Individual/Medicaid |
$56.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$56.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$68.08
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna Commercial |
$229.84
|
| Rate for Payer: Healthspan PPO |
$320.75
|
| Rate for Payer: Humana Medicaid |
$95.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$187.24
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$56.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.73
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$96.92
|
| Rate for Payer: Molina Healthcare Passport |
$95.02
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$73.75
|
| Rate for Payer: UHCCP Medicaid |
$63.22
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$95.97
|
| Rate for Payer: Wellcare Medicare Advantage |
$56.73
|
|
