|
CLTX FX GRT TOE PHLX/PHLG(T
|
Facility
|
OP
|
$387.00
|
|
|
Service Code
|
HCPCS 28490
|
| Hospital Charge Code |
761T1023
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$133.09 |
| Max. Negotiated Rate |
$371.52 |
| Rate for Payer: Aetna Commercial |
$297.99
|
| Rate for Payer: Anthem Medicaid |
$133.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$221.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$301.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$310.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$299.21
|
| Rate for Payer: Cash Price |
$193.50
|
| Rate for Payer: Cash Price |
$193.50
|
| Rate for Payer: Cigna Commercial |
$321.21
|
| Rate for Payer: First Health Commercial |
$367.65
|
| Rate for Payer: Humana Commercial |
$328.95
|
| Rate for Payer: Humana KY Medicaid |
$133.09
|
| Rate for Payer: Humana Medicare Advantage |
$221.64
|
| Rate for Payer: Kentucky WC Medicaid |
$134.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$317.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$285.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$135.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$340.56
|
| Rate for Payer: Ohio Health Group HMO |
$290.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$309.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$336.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$267.03
|
| Rate for Payer: PHCS Commercial |
$371.52
|
| Rate for Payer: United Healthcare All Payer |
$340.56
|
|
|
CLTX FX GRT TOE PHLX/PHLG(T
|
Facility
|
IP
|
$387.00
|
|
|
Service Code
|
HCPCS 28490
|
| Hospital Charge Code |
761T1023
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$116.10 |
| Max. Negotiated Rate |
$371.52 |
| Rate for Payer: Aetna Commercial |
$297.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$301.86
|
| Rate for Payer: Cash Price |
$193.50
|
| Rate for Payer: Cigna Commercial |
$321.21
|
| Rate for Payer: First Health Commercial |
$367.65
|
| Rate for Payer: Humana Commercial |
$328.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$317.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$285.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$116.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$340.56
|
| Rate for Payer: Ohio Health Group HMO |
$290.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$309.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$336.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$267.03
|
| Rate for Payer: PHCS Commercial |
$371.52
|
| Rate for Payer: United Healthcare All Payer |
$340.56
|
|
|
CLTX FX PHLX/PHLG NOT GRT TOE
|
Professional
|
Both
|
$786.00
|
|
|
Service Code
|
HCPCS 28510
|
| Hospital Charge Code |
76101026
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$55.70 |
| Max. Negotiated Rate |
$471.60 |
| Rate for Payer: Aetna Commercial |
$158.11
|
| Rate for Payer: Ambetter Exchange |
$115.94
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$60.91
|
| Rate for Payer: Anthem Medicaid |
$55.70
|
| Rate for Payer: Buckeye Individual/Medicaid |
$115.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$115.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$139.13
|
| Rate for Payer: Cash Price |
$393.00
|
| Rate for Payer: Cash Price |
$393.00
|
| Rate for Payer: Cigna Commercial |
$174.24
|
| Rate for Payer: Healthspan PPO |
$145.64
|
| Rate for Payer: Humana Medicaid |
$55.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$139.62
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$115.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$115.94
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$56.81
|
| Rate for Payer: Molina Healthcare Passport |
$55.70
|
| Rate for Payer: Multiplan PHCS |
$471.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$150.72
|
| Rate for Payer: UHCCP Medicaid |
$63.96
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$56.26
|
| Rate for Payer: Wellcare Medicare Advantage |
$115.94
|
|
|
CLTX FX PHLX/PHLG NOT GRT TOE
|
Facility
|
OP
|
$786.00
|
|
|
Service Code
|
HCPCS 28510
|
| Hospital Charge Code |
76101026
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$221.64 |
| Max. Negotiated Rate |
$754.56 |
| Rate for Payer: Aetna Commercial |
$605.22
|
| Rate for Payer: Anthem Medicaid |
$270.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$221.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$613.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$310.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$299.21
|
| Rate for Payer: Cash Price |
$393.00
|
| Rate for Payer: Cash Price |
$393.00
|
| Rate for Payer: Cigna Commercial |
$652.38
|
| Rate for Payer: First Health Commercial |
$746.70
|
| Rate for Payer: Humana Commercial |
$668.10
|
| Rate for Payer: Humana KY Medicaid |
$270.31
|
| Rate for Payer: Humana Medicare Advantage |
$221.64
|
| Rate for Payer: Kentucky WC Medicaid |
$273.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$644.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$580.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$275.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$691.68
|
| Rate for Payer: Ohio Health Group HMO |
$589.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$628.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$683.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$542.34
|
| Rate for Payer: PHCS Commercial |
$754.56
|
| Rate for Payer: United Healthcare All Payer |
$691.68
|
|
|
CLTX FX PHLX/PHLG NOT GRT TOE
|
Facility
|
IP
|
$786.00
|
|
|
Service Code
|
HCPCS 28510
|
| Hospital Charge Code |
76101026
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$235.80 |
| Max. Negotiated Rate |
$754.56 |
| Rate for Payer: Aetna Commercial |
$605.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$613.08
|
| Rate for Payer: Cash Price |
$393.00
|
| Rate for Payer: Cigna Commercial |
$652.38
|
| Rate for Payer: First Health Commercial |
$746.70
|
| Rate for Payer: Humana Commercial |
$668.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$644.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$580.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$235.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$691.68
|
| Rate for Payer: Ohio Health Group HMO |
$589.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$628.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$683.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$542.34
|
| Rate for Payer: PHCS Commercial |
$754.56
|
| Rate for Payer: United Healthcare All Payer |
$691.68
|
|
|
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 |
$55.70 |
| Max. Negotiated Rate |
$210.00 |
| Rate for Payer: Aetna Commercial |
$158.11
|
| Rate for Payer: Ambetter Exchange |
$115.94
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$60.91
|
| Rate for Payer: Anthem Medicaid |
$55.70
|
| Rate for Payer: Buckeye Individual/Medicaid |
$115.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$115.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$139.13
|
| 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 |
$55.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$139.62
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$115.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$115.94
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$56.81
|
| Rate for Payer: Molina Healthcare Passport |
$55.70
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$150.72
|
| Rate for Payer: UHCCP Medicaid |
$63.96
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$56.26
|
| Rate for Payer: Wellcare Medicare Advantage |
$115.94
|
|
|
CLTX FX PHLX/PHLG NOT GRT TO(T
|
Facility
|
OP
|
$436.00
|
|
|
Service Code
|
HCPCS 28510
|
| Hospital Charge Code |
761T1026
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$149.94 |
| Max. Negotiated Rate |
$418.56 |
| Rate for Payer: Aetna Commercial |
$335.72
|
| Rate for Payer: Anthem Medicaid |
$149.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$221.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$340.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$310.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$299.21
|
| Rate for Payer: Cash Price |
$218.00
|
| Rate for Payer: Cash Price |
$218.00
|
| Rate for Payer: Cigna Commercial |
$361.88
|
| Rate for Payer: First Health Commercial |
$414.20
|
| Rate for Payer: Humana Commercial |
$370.60
|
| Rate for Payer: Humana KY Medicaid |
$149.94
|
| Rate for Payer: Humana Medicare Advantage |
$221.64
|
| Rate for Payer: Kentucky WC Medicaid |
$151.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$357.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$321.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$152.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$383.68
|
| Rate for Payer: Ohio Health Group HMO |
$327.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$348.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$379.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$300.84
|
| Rate for Payer: PHCS Commercial |
$418.56
|
| Rate for Payer: United Healthcare All Payer |
$383.68
|
|
|
CLTX FX PHLX/PHLG NOT GRT TO(T
|
Facility
|
IP
|
$436.00
|
|
|
Service Code
|
HCPCS 28510
|
| Hospital Charge Code |
761T1026
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$130.80 |
| Max. Negotiated Rate |
$418.56 |
| Rate for Payer: Aetna Commercial |
$335.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$340.08
|
| Rate for Payer: Cash Price |
$218.00
|
| Rate for Payer: Cigna Commercial |
$361.88
|
| Rate for Payer: First Health Commercial |
$414.20
|
| Rate for Payer: Humana Commercial |
$370.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$357.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$321.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$130.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$383.68
|
| Rate for Payer: Ohio Health Group HMO |
$327.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$348.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$379.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$300.84
|
| Rate for Payer: PHCS Commercial |
$418.56
|
| Rate for Payer: United Healthcare All Payer |
$383.68
|
|
|
CLTX FX W8 BRG ARTCLR DSTTIB
|
Professional
|
Both
|
$1,324.00
|
|
|
Service Code
|
HCPCS 27824
|
| Hospital Charge Code |
76100946
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$185.96 |
| Max. Negotiated Rate |
$794.40 |
| Rate for Payer: Aetna Commercial |
$406.77
|
| Rate for Payer: Ambetter Exchange |
$296.08
|
| 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 Individual/Medicaid |
$296.08
|
| Rate for Payer: Buckeye Medicare Advantage |
$296.08
|
| Rate for Payer: CareSource Just4Me Medicare |
$355.30
|
| Rate for Payer: Cash Price |
$662.00
|
| Rate for Payer: Cash Price |
$662.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$296.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$296.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$189.68
|
| Rate for Payer: Molina Healthcare Passport |
$185.96
|
| Rate for Payer: Multiplan PHCS |
$794.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$384.90
|
| Rate for Payer: UHCCP Medicaid |
$206.89
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$187.82
|
| Rate for Payer: Wellcare Medicare Advantage |
$296.08
|
|
|
CLTX FX W8 BRG ARTCLR DSTTIB
|
Facility
|
OP
|
$1,324.00
|
|
|
Service Code
|
HCPCS 27824
|
| Hospital Charge Code |
76100946
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$221.64 |
| Max. Negotiated Rate |
$1,271.04 |
| Rate for Payer: Aetna Commercial |
$1,019.48
|
| Rate for Payer: Anthem Medicaid |
$455.32
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$221.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,032.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$310.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$299.21
|
| Rate for Payer: Cash Price |
$662.00
|
| Rate for Payer: Cash Price |
$662.00
|
| Rate for Payer: Cigna Commercial |
$1,098.92
|
| Rate for Payer: First Health Commercial |
$1,257.80
|
| Rate for Payer: Humana Commercial |
$1,125.40
|
| Rate for Payer: Humana KY Medicaid |
$455.32
|
| Rate for Payer: Humana Medicare Advantage |
$221.64
|
| Rate for Payer: Kentucky WC Medicaid |
$459.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,085.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$977.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$464.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,165.12
|
| Rate for Payer: Ohio Health Group HMO |
$993.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,059.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,151.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$913.56
|
| Rate for Payer: PHCS Commercial |
$1,271.04
|
| Rate for Payer: United Healthcare All Payer |
$1,165.12
|
|
|
CLTX FX W8 BRG ARTCLR DSTTIB
|
Facility
|
IP
|
$1,324.00
|
|
|
Service Code
|
HCPCS 27824
|
| Hospital Charge Code |
76100946
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$397.20 |
| Max. Negotiated Rate |
$1,271.04 |
| Rate for Payer: Aetna Commercial |
$1,019.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,032.72
|
| Rate for Payer: Cash Price |
$662.00
|
| Rate for Payer: Cigna Commercial |
$1,098.92
|
| Rate for Payer: First Health Commercial |
$1,257.80
|
| Rate for Payer: Humana Commercial |
$1,125.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,085.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$977.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$397.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,165.12
|
| Rate for Payer: Ohio Health Group HMO |
$993.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,059.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,151.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$913.56
|
| Rate for Payer: PHCS Commercial |
$1,271.04
|
| Rate for Payer: United Healthcare All Payer |
$1,165.12
|
|
|
CLTX FX W8 BRG ARTCLR DSTTIB(P
|
Professional
|
Both
|
$720.00
|
|
|
Service Code
|
HCPCS 27824
|
| Hospital Charge Code |
761P0946
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$185.96 |
| Max. Negotiated Rate |
$469.14 |
| Rate for Payer: Aetna Commercial |
$406.77
|
| Rate for Payer: Ambetter Exchange |
$296.08
|
| 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 Individual/Medicaid |
$296.08
|
| Rate for Payer: Buckeye Medicare Advantage |
$296.08
|
| Rate for Payer: CareSource Just4Me Medicare |
$355.30
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$296.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$296.08
|
| 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 |
$384.90
|
| Rate for Payer: UHCCP Medicaid |
$206.89
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$187.82
|
| Rate for Payer: Wellcare Medicare Advantage |
$296.08
|
|
|
CLTX FX W8 BRG ARTCLR DSTTIB(T
|
Facility
|
IP
|
$604.00
|
|
|
Service Code
|
HCPCS 27824
|
| Hospital Charge Code |
761T0946
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$181.20 |
| Max. Negotiated Rate |
$579.84 |
| Rate for Payer: Aetna Commercial |
$465.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$471.12
|
| Rate for Payer: Cash Price |
$302.00
|
| Rate for Payer: Cigna Commercial |
$501.32
|
| Rate for Payer: First Health Commercial |
$573.80
|
| Rate for Payer: Humana Commercial |
$513.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$495.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$445.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$181.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$531.52
|
| Rate for Payer: Ohio Health Group HMO |
$453.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$483.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$525.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$416.76
|
| Rate for Payer: PHCS Commercial |
$579.84
|
| Rate for Payer: United Healthcare All Payer |
$531.52
|
|
|
CLTX FX W8 BRG ARTCLR DSTTIB(T
|
Facility
|
OP
|
$604.00
|
|
|
Service Code
|
HCPCS 27824
|
| Hospital Charge Code |
761T0946
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$207.72 |
| Max. Negotiated Rate |
$579.84 |
| Rate for Payer: Aetna Commercial |
$465.08
|
| Rate for Payer: Anthem Medicaid |
$207.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$221.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$471.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$310.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$299.21
|
| Rate for Payer: Cash Price |
$302.00
|
| Rate for Payer: Cash Price |
$302.00
|
| Rate for Payer: Cigna Commercial |
$501.32
|
| Rate for Payer: First Health Commercial |
$573.80
|
| Rate for Payer: Humana Commercial |
$513.40
|
| Rate for Payer: Humana KY Medicaid |
$207.72
|
| Rate for Payer: Humana Medicare Advantage |
$221.64
|
| Rate for Payer: Kentucky WC Medicaid |
$209.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$495.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$445.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$211.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$531.52
|
| Rate for Payer: Ohio Health Group HMO |
$453.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$483.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$525.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$416.76
|
| Rate for Payer: PHCS Commercial |
$579.84
|
| Rate for Payer: United Healthcare All Payer |
$531.52
|
|
|
CLTX GREATER HUM TUB FX W/OMAN
|
Professional
|
Both
|
$585.00
|
|
|
Service Code
|
HCPCS 23620
|
| Hospital Charge Code |
761P0482
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$154.45 |
| Max. Negotiated Rate |
$395.04 |
| Rate for Payer: Aetna Commercial |
$336.94
|
| Rate for Payer: Ambetter Exchange |
$252.42
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$161.07
|
| Rate for Payer: Anthem Medicaid |
$154.45
|
| Rate for Payer: Buckeye Individual/Medicaid |
$252.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$252.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$302.90
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Cigna Commercial |
$395.04
|
| Rate for Payer: Healthspan PPO |
$322.16
|
| Rate for Payer: Humana Medicaid |
$154.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$300.73
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$252.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$252.42
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$157.54
|
| Rate for Payer: Molina Healthcare Passport |
$154.45
|
| Rate for Payer: Multiplan PHCS |
$351.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$328.15
|
| Rate for Payer: UHCCP Medicaid |
$169.12
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$155.99
|
| Rate for Payer: Wellcare Medicare Advantage |
$252.42
|
|
|
CLTX GREATER HUM TUB FX W/OMAN
|
Facility
|
IP
|
$1,544.00
|
|
|
Service Code
|
HCPCS 23620
|
| Hospital Charge Code |
76100482
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$463.20 |
| Max. Negotiated Rate |
$1,482.24 |
| Rate for Payer: Aetna Commercial |
$1,188.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,204.32
|
| Rate for Payer: Cash Price |
$772.00
|
| Rate for Payer: Cigna Commercial |
$1,281.52
|
| Rate for Payer: First Health Commercial |
$1,466.80
|
| Rate for Payer: Humana Commercial |
$1,312.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,266.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,139.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$463.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,358.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,158.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,235.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,343.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,065.36
|
| Rate for Payer: PHCS Commercial |
$1,482.24
|
| Rate for Payer: United Healthcare All Payer |
$1,358.72
|
|
|
CLTX GREATER HUM TUB FX W/OMAN
|
Facility
|
OP
|
$1,544.00
|
|
|
Service Code
|
HCPCS 23620
|
| Hospital Charge Code |
76100482
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$221.64 |
| Max. Negotiated Rate |
$1,482.24 |
| Rate for Payer: Aetna Commercial |
$1,188.88
|
| Rate for Payer: Anthem Medicaid |
$530.98
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$221.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,204.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$310.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$299.21
|
| Rate for Payer: Cash Price |
$772.00
|
| Rate for Payer: Cash Price |
$772.00
|
| Rate for Payer: Cigna Commercial |
$1,281.52
|
| Rate for Payer: First Health Commercial |
$1,466.80
|
| Rate for Payer: Humana Commercial |
$1,312.40
|
| Rate for Payer: Humana KY Medicaid |
$530.98
|
| Rate for Payer: Humana Medicare Advantage |
$221.64
|
| Rate for Payer: Kentucky WC Medicaid |
$536.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,266.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,139.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$541.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,358.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,158.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,235.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,343.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,065.36
|
| Rate for Payer: PHCS Commercial |
$1,482.24
|
| Rate for Payer: United Healthcare All Payer |
$1,358.72
|
|
|
CLTX GREATER HUM TUB FX W/OMAN
|
Professional
|
Both
|
$1,544.00
|
|
|
Service Code
|
HCPCS 23620
|
| Hospital Charge Code |
76100482
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$154.45 |
| Max. Negotiated Rate |
$926.40 |
| Rate for Payer: Aetna Commercial |
$336.94
|
| Rate for Payer: Ambetter Exchange |
$252.42
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$161.07
|
| Rate for Payer: Anthem Medicaid |
$154.45
|
| Rate for Payer: Buckeye Individual/Medicaid |
$252.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$252.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$302.90
|
| Rate for Payer: Cash Price |
$772.00
|
| Rate for Payer: Cash Price |
$772.00
|
| Rate for Payer: Cigna Commercial |
$395.04
|
| Rate for Payer: Healthspan PPO |
$322.16
|
| Rate for Payer: Humana Medicaid |
$154.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$300.73
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$252.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$252.42
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$157.54
|
| Rate for Payer: Molina Healthcare Passport |
$154.45
|
| Rate for Payer: Multiplan PHCS |
$926.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$328.15
|
| Rate for Payer: UHCCP Medicaid |
$169.12
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$155.99
|
| Rate for Payer: Wellcare Medicare Advantage |
$252.42
|
|
|
CLTX GREATER HUM TUB FX W/OMAN
|
Facility
|
OP
|
$959.00
|
|
|
Service Code
|
HCPCS 23620
|
| Hospital Charge Code |
761T0482
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$221.64 |
| Max. Negotiated Rate |
$920.64 |
| Rate for Payer: Aetna Commercial |
$738.43
|
| Rate for Payer: Anthem Medicaid |
$329.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$221.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$748.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$310.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$299.21
|
| Rate for Payer: Cash Price |
$479.50
|
| Rate for Payer: Cash Price |
$479.50
|
| Rate for Payer: Cigna Commercial |
$795.97
|
| Rate for Payer: First Health Commercial |
$911.05
|
| Rate for Payer: Humana Commercial |
$815.15
|
| Rate for Payer: Humana KY Medicaid |
$329.80
|
| Rate for Payer: Humana Medicare Advantage |
$221.64
|
| Rate for Payer: Kentucky WC Medicaid |
$333.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$786.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$707.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$336.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$843.92
|
| Rate for Payer: Ohio Health Group HMO |
$719.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$767.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$834.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$661.71
|
| Rate for Payer: PHCS Commercial |
$920.64
|
| Rate for Payer: United Healthcare All Payer |
$843.92
|
|
|
CLTX GREATER HUM TUB FX W/OMAN
|
Facility
|
IP
|
$959.00
|
|
|
Service Code
|
HCPCS 23620
|
| Hospital Charge Code |
761T0482
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$287.70 |
| Max. Negotiated Rate |
$920.64 |
| Rate for Payer: Aetna Commercial |
$738.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$748.02
|
| Rate for Payer: Cash Price |
$479.50
|
| Rate for Payer: Cigna Commercial |
$795.97
|
| Rate for Payer: First Health Commercial |
$911.05
|
| Rate for Payer: Humana Commercial |
$815.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$786.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$707.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$287.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$843.92
|
| Rate for Payer: Ohio Health Group HMO |
$719.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$767.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$834.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$661.71
|
| Rate for Payer: PHCS Commercial |
$920.64
|
| Rate for Payer: United Healthcare All Payer |
$843.92
|
|
|
CLTX GRTER HUM TBRSTY FX W/MAN
|
Facility
|
IP
|
$3,378.00
|
|
|
Service Code
|
HCPCS 23625
|
| Hospital Charge Code |
76100483
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,013.40 |
| Max. Negotiated Rate |
$3,242.88 |
| Rate for Payer: Aetna Commercial |
$2,601.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,634.84
|
| Rate for Payer: Cash Price |
$1,689.00
|
| Rate for Payer: Cigna Commercial |
$2,803.74
|
| Rate for Payer: First Health Commercial |
$3,209.10
|
| Rate for Payer: Humana Commercial |
$2,871.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,769.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,492.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,013.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,972.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,533.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,702.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,938.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,330.82
|
| Rate for Payer: PHCS Commercial |
$3,242.88
|
| Rate for Payer: United Healthcare All Payer |
$2,972.64
|
|
|
CLTX GRTER HUM TBRSTY FX W/MAN
|
Facility
|
OP
|
$2,578.00
|
|
|
Service Code
|
HCPCS 23625
|
| Hospital Charge Code |
761T0483
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$886.57 |
| Max. Negotiated Rate |
$2,474.88 |
| Rate for Payer: Aetna Commercial |
$1,985.06
|
| Rate for Payer: Anthem Medicaid |
$886.57
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,478.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,010.84
|
| 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 |
$1,289.00
|
| Rate for Payer: Cash Price |
$1,289.00
|
| Rate for Payer: Cigna Commercial |
$2,139.74
|
| Rate for Payer: First Health Commercial |
$2,449.10
|
| Rate for Payer: Humana Commercial |
$2,191.30
|
| Rate for Payer: Humana KY Medicaid |
$886.57
|
| Rate for Payer: Humana Medicare Advantage |
$1,478.75
|
| Rate for Payer: Kentucky WC Medicaid |
$895.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,113.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,902.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,774.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$904.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,268.64
|
| Rate for Payer: Ohio Health Group HMO |
$1,933.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,062.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,242.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,778.82
|
| Rate for Payer: PHCS Commercial |
$2,474.88
|
| Rate for Payer: United Healthcare All Payer |
$2,268.64
|
|
|
CLTX GRTER HUM TBRSTY FX W/MAN
|
Facility
|
IP
|
$2,578.00
|
|
|
Service Code
|
HCPCS 23625
|
| Hospital Charge Code |
761T0483
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$773.40 |
| Max. Negotiated Rate |
$2,474.88 |
| Rate for Payer: Aetna Commercial |
$1,985.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,010.84
|
| Rate for Payer: Cash Price |
$1,289.00
|
| Rate for Payer: Cigna Commercial |
$2,139.74
|
| Rate for Payer: First Health Commercial |
$2,449.10
|
| Rate for Payer: Humana Commercial |
$2,191.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,113.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,902.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$773.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,268.64
|
| Rate for Payer: Ohio Health Group HMO |
$1,933.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,062.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,242.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,778.82
|
| Rate for Payer: PHCS Commercial |
$2,474.88
|
| Rate for Payer: United Healthcare All Payer |
$2,268.64
|
|
|
CLTX GRTER HUM TBRSTY FX W/MAN
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 23625
|
| Hospital Charge Code |
761P0483
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$203.75 |
| Max. Negotiated Rate |
$582.97 |
| Rate for Payer: Aetna Commercial |
$493.18
|
| Rate for Payer: Ambetter Exchange |
$338.55
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$203.75
|
| Rate for Payer: Anthem Medicaid |
$223.85
|
| Rate for Payer: Buckeye Individual/Medicaid |
$338.55
|
| Rate for Payer: Buckeye Medicare Advantage |
$338.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$406.26
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$582.97
|
| Rate for Payer: Healthspan PPO |
$472.89
|
| Rate for Payer: Humana Medicaid |
$223.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$426.39
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$338.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$338.55
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$228.33
|
| Rate for Payer: Molina Healthcare Passport |
$223.85
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$440.12
|
| Rate for Payer: UHCCP Medicaid |
$213.94
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$226.09
|
| Rate for Payer: Wellcare Medicare Advantage |
$338.55
|
|
|
CLTX GRTER HUM TBRSTY FX W/MAN
|
Facility
|
OP
|
$3,378.00
|
|
|
Service Code
|
HCPCS 23625
|
| Hospital Charge Code |
76100483
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,161.69 |
| Max. Negotiated Rate |
$3,242.88 |
| Rate for Payer: Aetna Commercial |
$2,601.06
|
| Rate for Payer: Anthem Medicaid |
$1,161.69
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,478.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,634.84
|
| 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 |
$1,689.00
|
| Rate for Payer: Cash Price |
$1,689.00
|
| Rate for Payer: Cigna Commercial |
$2,803.74
|
| Rate for Payer: First Health Commercial |
$3,209.10
|
| Rate for Payer: Humana Commercial |
$2,871.30
|
| Rate for Payer: Humana KY Medicaid |
$1,161.69
|
| Rate for Payer: Humana Medicare Advantage |
$1,478.75
|
| Rate for Payer: Kentucky WC Medicaid |
$1,173.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,769.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,492.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,774.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,185.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,972.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,533.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,702.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,938.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,330.82
|
| Rate for Payer: PHCS Commercial |
$3,242.88
|
| Rate for Payer: United Healthcare All Payer |
$2,972.64
|
|
