|
DES MAL LES 2.1-3CM FEENL
|
Professional
|
Both
|
$958.00
|
|
|
Service Code
|
HCPCS 17283
|
| Hospital Charge Code |
76100269
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$114.94 |
| Max. Negotiated Rate |
$958.00 |
| Rate for Payer: Aetna Commercial |
$255.06
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$114.94
|
| Rate for Payer: Anthem Medicaid |
$123.17
|
| Rate for Payer: Buckeye Medicare Advantage |
$958.00
|
| Rate for Payer: Cash Price |
$479.00
|
| Rate for Payer: Cash Price |
$479.00
|
| Rate for Payer: Cigna Commercial |
$302.29
|
| Rate for Payer: Healthspan PPO |
$270.71
|
| Rate for Payer: Humana Medicaid |
$123.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$227.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$125.63
|
| Rate for Payer: Molina Healthcare Passport |
$123.17
|
| Rate for Payer: Multiplan PHCS |
$574.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$670.60
|
| Rate for Payer: UHCCP Medicaid |
$120.69
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$124.40
|
|
|
DES MAL LES 2.1-3CM FEENL
|
Facility
|
IP
|
$958.00
|
|
|
Service Code
|
HCPCS 17283
|
| Hospital Charge Code |
76100269
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$124.54 |
| Max. Negotiated Rate |
$919.68 |
| Rate for Payer: Aetna Commercial |
$737.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$747.24
|
| Rate for Payer: Cash Price |
$479.00
|
| Rate for Payer: Cigna Commercial |
$795.14
|
| Rate for Payer: First Health Commercial |
$910.10
|
| Rate for Payer: Humana Commercial |
$814.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$785.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$707.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$287.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$843.04
|
| Rate for Payer: Ohio Health Group HMO |
$718.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$191.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$124.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$296.98
|
| Rate for Payer: PHCS Commercial |
$919.68
|
| Rate for Payer: United Healthcare All Payer |
$843.04
|
|
|
DES MAL LES 2.1-3CM FEENL(P
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 17283
|
| Hospital Charge Code |
761P0269
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$114.94 |
| Max. Negotiated Rate |
$500.00 |
| Rate for Payer: Aetna Commercial |
$255.06
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$114.94
|
| Rate for Payer: Anthem Medicaid |
$123.17
|
| Rate for Payer: Buckeye Medicare Advantage |
$500.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$302.29
|
| Rate for Payer: Healthspan PPO |
$270.71
|
| Rate for Payer: Humana Medicaid |
$123.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$227.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$125.63
|
| Rate for Payer: Molina Healthcare Passport |
$123.17
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$350.00
|
| Rate for Payer: UHCCP Medicaid |
$120.69
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$124.40
|
|
|
DES MAL LES 2.1-3CM FEENL(T
|
Facility
|
OP
|
$458.00
|
|
|
Service Code
|
HCPCS 17283
|
| Hospital Charge Code |
761T0269
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$59.54 |
| Max. Negotiated Rate |
$482.75 |
| Rate for Payer: Aetna Commercial |
$352.66
|
| Rate for Payer: Anthem Medicaid |
$157.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$357.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$229.00
|
| Rate for Payer: Cash Price |
$229.00
|
| Rate for Payer: Cigna Commercial |
$380.14
|
| Rate for Payer: First Health Commercial |
$435.10
|
| Rate for Payer: Humana Commercial |
$389.30
|
| Rate for Payer: Humana KY Medicaid |
$157.51
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$159.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$375.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$338.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$160.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$403.04
|
| Rate for Payer: Ohio Health Group HMO |
$343.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$141.98
|
| Rate for Payer: PHCS Commercial |
$439.68
|
| Rate for Payer: United Healthcare All Payer |
$403.04
|
|
|
DES MAL LES 2.1-3CM FEENL(T
|
Facility
|
IP
|
$458.00
|
|
|
Service Code
|
HCPCS 17283
|
| Hospital Charge Code |
761T0269
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$59.54 |
| Max. Negotiated Rate |
$439.68 |
| Rate for Payer: Aetna Commercial |
$352.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$357.24
|
| Rate for Payer: Cash Price |
$229.00
|
| Rate for Payer: Cigna Commercial |
$380.14
|
| Rate for Payer: First Health Commercial |
$435.10
|
| Rate for Payer: Humana Commercial |
$389.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$375.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$338.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$403.04
|
| Rate for Payer: Ohio Health Group HMO |
$343.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$141.98
|
| Rate for Payer: PHCS Commercial |
$439.68
|
| Rate for Payer: United Healthcare All Payer |
$403.04
|
|
|
DES MAL LES 3.1-4CM
|
Facility
|
OP
|
$1,312.00
|
|
|
Service Code
|
HCPCS 17284
|
| Hospital Charge Code |
76100270
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$170.56 |
| Max. Negotiated Rate |
$1,259.52 |
| Rate for Payer: Aetna Commercial |
$1,010.24
|
| Rate for Payer: Anthem Medicaid |
$451.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,023.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$656.00
|
| Rate for Payer: Cash Price |
$656.00
|
| Rate for Payer: Cigna Commercial |
$1,088.96
|
| Rate for Payer: First Health Commercial |
$1,246.40
|
| Rate for Payer: Humana Commercial |
$1,115.20
|
| Rate for Payer: Humana KY Medicaid |
$451.20
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$455.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,075.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$968.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$460.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,154.56
|
| Rate for Payer: Ohio Health Group HMO |
$984.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$262.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$170.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$406.72
|
| Rate for Payer: PHCS Commercial |
$1,259.52
|
| Rate for Payer: United Healthcare All Payer |
$1,154.56
|
|
|
DES MAL LES 3.1-4CM
|
Facility
|
IP
|
$1,312.00
|
|
|
Service Code
|
HCPCS 17284
|
| Hospital Charge Code |
76100270
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$170.56 |
| Max. Negotiated Rate |
$1,259.52 |
| Rate for Payer: Aetna Commercial |
$1,010.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,023.36
|
| Rate for Payer: Cash Price |
$656.00
|
| Rate for Payer: Cigna Commercial |
$1,088.96
|
| Rate for Payer: First Health Commercial |
$1,246.40
|
| Rate for Payer: Humana Commercial |
$1,115.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,075.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$968.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$393.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,154.56
|
| Rate for Payer: Ohio Health Group HMO |
$984.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$262.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$170.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$406.72
|
| Rate for Payer: PHCS Commercial |
$1,259.52
|
| Rate for Payer: United Healthcare All Payer |
$1,154.56
|
|
|
DES MAL LES 3.1-4CM
|
Professional
|
Both
|
$1,312.00
|
|
|
Service Code
|
HCPCS 17284
|
| Hospital Charge Code |
76100270
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$137.92 |
| Max. Negotiated Rate |
$1,312.00 |
| Rate for Payer: Aetna Commercial |
$304.38
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$137.92
|
| Rate for Payer: Anthem Medicaid |
$147.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,312.00
|
| Rate for Payer: Cash Price |
$656.00
|
| Rate for Payer: Cash Price |
$656.00
|
| Rate for Payer: Cigna Commercial |
$355.62
|
| Rate for Payer: Healthspan PPO |
$315.28
|
| Rate for Payer: Humana Medicaid |
$147.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$269.25
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$150.78
|
| Rate for Payer: Molina Healthcare Passport |
$147.82
|
| Rate for Payer: Multiplan PHCS |
$787.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$918.40
|
| Rate for Payer: UHCCP Medicaid |
$144.82
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$149.30
|
|
|
DES MAL LES 3.1-4CM(P
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 17284
|
| Hospital Charge Code |
761P0270
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$137.92 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial |
$304.38
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$137.92
|
| Rate for Payer: Anthem Medicaid |
$147.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$600.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$355.62
|
| Rate for Payer: Healthspan PPO |
$315.28
|
| Rate for Payer: Humana Medicaid |
$147.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$269.25
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$150.78
|
| Rate for Payer: Molina Healthcare Passport |
$147.82
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$144.82
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$149.30
|
|
|
DES MAL LES 3.1-4CM(T
|
Facility
|
OP
|
$712.00
|
|
|
Service Code
|
HCPCS 17284
|
| Hospital Charge Code |
761T0270
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$92.56 |
| Max. Negotiated Rate |
$760.35 |
| Rate for Payer: Aetna Commercial |
$548.24
|
| Rate for Payer: Anthem Medicaid |
$244.86
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$555.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$356.00
|
| Rate for Payer: Cash Price |
$356.00
|
| Rate for Payer: Cigna Commercial |
$590.96
|
| Rate for Payer: First Health Commercial |
$676.40
|
| Rate for Payer: Humana Commercial |
$605.20
|
| Rate for Payer: Humana KY Medicaid |
$244.86
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$247.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$583.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$525.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$249.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$626.56
|
| Rate for Payer: Ohio Health Group HMO |
$534.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$142.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$92.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$220.72
|
| Rate for Payer: PHCS Commercial |
$683.52
|
| Rate for Payer: United Healthcare All Payer |
$626.56
|
|
|
DES MAL LES 3.1-4CM(T
|
Facility
|
IP
|
$712.00
|
|
|
Service Code
|
HCPCS 17284
|
| Hospital Charge Code |
761T0270
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$92.56 |
| Max. Negotiated Rate |
$683.52 |
| Rate for Payer: Aetna Commercial |
$548.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$555.36
|
| Rate for Payer: Cash Price |
$356.00
|
| Rate for Payer: Cigna Commercial |
$590.96
|
| Rate for Payer: First Health Commercial |
$676.40
|
| Rate for Payer: Humana Commercial |
$605.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$583.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$525.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$213.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$626.56
|
| Rate for Payer: Ohio Health Group HMO |
$534.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$142.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$92.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$220.72
|
| Rate for Payer: PHCS Commercial |
$683.52
|
| Rate for Payer: United Healthcare All Payer |
$626.56
|
|
|
DES MAL LES > 4CM
|
Facility
|
OP
|
$1,562.00
|
|
|
Service Code
|
HCPCS 17286
|
| Hospital Charge Code |
76100271
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$203.06 |
| Max. Negotiated Rate |
$1,499.52 |
| Rate for Payer: Aetna Commercial |
$1,202.74
|
| Rate for Payer: Anthem Medicaid |
$537.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,218.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$781.00
|
| Rate for Payer: Cash Price |
$781.00
|
| Rate for Payer: Cigna Commercial |
$1,296.46
|
| Rate for Payer: First Health Commercial |
$1,483.90
|
| Rate for Payer: Humana Commercial |
$1,327.70
|
| Rate for Payer: Humana KY Medicaid |
$537.17
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$542.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,280.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,152.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$547.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,374.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,171.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$312.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$203.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$484.22
|
| Rate for Payer: PHCS Commercial |
$1,499.52
|
| Rate for Payer: United Healthcare All Payer |
$1,374.56
|
|
|
DES MAL LES > 4CM
|
Facility
|
IP
|
$1,562.00
|
|
|
Service Code
|
HCPCS 17286
|
| Hospital Charge Code |
76100271
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$203.06 |
| Max. Negotiated Rate |
$1,499.52 |
| Rate for Payer: Aetna Commercial |
$1,202.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,218.36
|
| Rate for Payer: Cash Price |
$781.00
|
| Rate for Payer: Cigna Commercial |
$1,296.46
|
| Rate for Payer: First Health Commercial |
$1,483.90
|
| Rate for Payer: Humana Commercial |
$1,327.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,280.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,152.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$468.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,374.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,171.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$312.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$203.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$484.22
|
| Rate for Payer: PHCS Commercial |
$1,499.52
|
| Rate for Payer: United Healthcare All Payer |
$1,374.56
|
|
|
DES MAL LES > 4CM
|
Professional
|
Both
|
$1,562.00
|
|
|
Service Code
|
HCPCS 17286
|
| Hospital Charge Code |
76100271
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$183.00 |
| Max. Negotiated Rate |
$1,562.00 |
| Rate for Payer: Aetna Commercial |
$411.38
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$183.00
|
| Rate for Payer: Anthem Medicaid |
$201.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,562.00
|
| Rate for Payer: Cash Price |
$781.00
|
| Rate for Payer: Cash Price |
$781.00
|
| Rate for Payer: Cigna Commercial |
$462.60
|
| Rate for Payer: Healthspan PPO |
$401.68
|
| Rate for Payer: Humana Medicaid |
$201.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$361.78
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$205.36
|
| Rate for Payer: Molina Healthcare Passport |
$201.33
|
| Rate for Payer: Multiplan PHCS |
$937.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,093.40
|
| Rate for Payer: UHCCP Medicaid |
$192.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$203.34
|
|
|
DES MAL LES > 4CM(P
|
Professional
|
Both
|
$850.00
|
|
|
Service Code
|
HCPCS 17286
|
| Hospital Charge Code |
761P0271
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$183.00 |
| Max. Negotiated Rate |
$850.00 |
| Rate for Payer: Aetna Commercial |
$411.38
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$183.00
|
| Rate for Payer: Anthem Medicaid |
$201.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$850.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$462.60
|
| Rate for Payer: Healthspan PPO |
$401.68
|
| Rate for Payer: Humana Medicaid |
$201.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$361.78
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$205.36
|
| Rate for Payer: Molina Healthcare Passport |
$201.33
|
| Rate for Payer: Multiplan PHCS |
$510.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$595.00
|
| Rate for Payer: UHCCP Medicaid |
$192.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$203.34
|
|
|
DES MAL LES > 4CM(T
|
Facility
|
IP
|
$712.00
|
|
|
Service Code
|
HCPCS 17286
|
| Hospital Charge Code |
761T0271
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$92.56 |
| Max. Negotiated Rate |
$683.52 |
| Rate for Payer: Aetna Commercial |
$548.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$555.36
|
| Rate for Payer: Cash Price |
$356.00
|
| Rate for Payer: Cigna Commercial |
$590.96
|
| Rate for Payer: First Health Commercial |
$676.40
|
| Rate for Payer: Humana Commercial |
$605.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$583.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$525.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$213.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$626.56
|
| Rate for Payer: Ohio Health Group HMO |
$534.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$142.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$92.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$220.72
|
| Rate for Payer: PHCS Commercial |
$683.52
|
| Rate for Payer: United Healthcare All Payer |
$626.56
|
|
|
DES MAL LES > 4CM(T
|
Facility
|
OP
|
$712.00
|
|
|
Service Code
|
HCPCS 17286
|
| Hospital Charge Code |
761T0271
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$92.56 |
| Max. Negotiated Rate |
$760.35 |
| Rate for Payer: Aetna Commercial |
$548.24
|
| Rate for Payer: Anthem Medicaid |
$244.86
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$555.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$356.00
|
| Rate for Payer: Cash Price |
$356.00
|
| Rate for Payer: Cigna Commercial |
$590.96
|
| Rate for Payer: First Health Commercial |
$676.40
|
| Rate for Payer: Humana Commercial |
$605.20
|
| Rate for Payer: Humana KY Medicaid |
$244.86
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$247.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$583.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$525.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$249.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$626.56
|
| Rate for Payer: Ohio Health Group HMO |
$534.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$142.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$92.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$220.72
|
| Rate for Payer: PHCS Commercial |
$683.52
|
| Rate for Payer: United Healthcare All Payer |
$626.56
|
|
|
DES MAL LES .6-1.0CM SNHF
|
Facility
|
OP
|
$587.50
|
|
|
Service Code
|
HCPCS 17271
|
| Hospital Charge Code |
76100261
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$76.38 |
| Max. Negotiated Rate |
$564.00 |
| Rate for Payer: Aetna Commercial |
$452.38
|
| Rate for Payer: Anthem Medicaid |
$202.04
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$458.25
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$293.75
|
| Rate for Payer: Cash Price |
$293.75
|
| Rate for Payer: Cigna Commercial |
$487.62
|
| Rate for Payer: First Health Commercial |
$558.12
|
| Rate for Payer: Humana Commercial |
$499.38
|
| Rate for Payer: Humana KY Medicaid |
$202.04
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$204.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$481.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$433.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$206.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$517.00
|
| Rate for Payer: Ohio Health Group HMO |
$440.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$117.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$76.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$182.12
|
| Rate for Payer: PHCS Commercial |
$564.00
|
| Rate for Payer: United Healthcare All Payer |
$517.00
|
|
|
DES MAL LES .6-1.0CM SNHF
|
Facility
|
IP
|
$587.50
|
|
|
Service Code
|
HCPCS 17271
|
| Hospital Charge Code |
76100261
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$76.38 |
| Max. Negotiated Rate |
$564.00 |
| Rate for Payer: Aetna Commercial |
$452.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$458.25
|
| Rate for Payer: Cash Price |
$293.75
|
| Rate for Payer: Cigna Commercial |
$487.62
|
| Rate for Payer: First Health Commercial |
$558.12
|
| Rate for Payer: Humana Commercial |
$499.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$481.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$433.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$176.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$517.00
|
| Rate for Payer: Ohio Health Group HMO |
$440.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$117.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$76.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$182.12
|
| Rate for Payer: PHCS Commercial |
$564.00
|
| Rate for Payer: United Healthcare All Payer |
$517.00
|
|
|
DES MAL LES .6-1.0CM SNHF
|
Professional
|
Both
|
$587.50
|
|
|
Service Code
|
HCPCS 17271
|
| Hospital Charge Code |
76100261
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$65.26 |
| Max. Negotiated Rate |
$587.50 |
| Rate for Payer: Aetna Commercial |
$155.14
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$65.26
|
| Rate for Payer: Anthem Medicaid |
$69.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$587.50
|
| Rate for Payer: Cash Price |
$293.75
|
| Rate for Payer: Cash Price |
$293.75
|
| Rate for Payer: Cigna Commercial |
$193.97
|
| Rate for Payer: Healthspan PPO |
$177.11
|
| Rate for Payer: Humana Medicaid |
$69.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$140.04
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$71.00
|
| Rate for Payer: Molina Healthcare Passport |
$69.61
|
| Rate for Payer: Multiplan PHCS |
$352.50
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$411.25
|
| Rate for Payer: UHCCP Medicaid |
$68.52
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$70.31
|
|
|
DES MAL LES .6-1.0CM SNHF(P
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 17271
|
| Hospital Charge Code |
761P0261
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$65.26 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Aetna Commercial |
$155.14
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$65.26
|
| Rate for Payer: Anthem Medicaid |
$69.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$300.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$193.97
|
| Rate for Payer: Healthspan PPO |
$177.11
|
| Rate for Payer: Humana Medicaid |
$69.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$140.04
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$71.00
|
| Rate for Payer: Molina Healthcare Passport |
$69.61
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$210.00
|
| Rate for Payer: UHCCP Medicaid |
$68.52
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$70.31
|
|
|
DES MAL LES .6-1.0CM SNHF(T
|
Facility
|
IP
|
$287.50
|
|
|
Service Code
|
HCPCS 17271
|
| Hospital Charge Code |
761T0261
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$37.38 |
| Max. Negotiated Rate |
$276.00 |
| Rate for Payer: Aetna Commercial |
$221.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$224.25
|
| Rate for Payer: Cash Price |
$143.75
|
| Rate for Payer: Cigna Commercial |
$238.62
|
| Rate for Payer: First Health Commercial |
$273.12
|
| Rate for Payer: Humana Commercial |
$244.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$235.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$212.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$86.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$253.00
|
| Rate for Payer: Ohio Health Group HMO |
$215.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$89.12
|
| Rate for Payer: PHCS Commercial |
$276.00
|
| Rate for Payer: United Healthcare All Payer |
$253.00
|
|
|
DES MAL LES .6-1.0CM SNHF(T
|
Facility
|
OP
|
$287.50
|
|
|
Service Code
|
HCPCS 17271
|
| Hospital Charge Code |
761T0261
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$37.38 |
| Max. Negotiated Rate |
$276.00 |
| Rate for Payer: Aetna Commercial |
$221.38
|
| Rate for Payer: Anthem Medicaid |
$98.87
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$224.25
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$143.75
|
| Rate for Payer: Cash Price |
$143.75
|
| Rate for Payer: Cigna Commercial |
$238.62
|
| Rate for Payer: First Health Commercial |
$273.12
|
| Rate for Payer: Humana Commercial |
$244.38
|
| Rate for Payer: Humana KY Medicaid |
$98.87
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$99.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$235.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$212.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$100.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$253.00
|
| Rate for Payer: Ohio Health Group HMO |
$215.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$89.12
|
| Rate for Payer: PHCS Commercial |
$276.00
|
| Rate for Payer: United Healthcare All Payer |
$253.00
|
|
|
DESMOPRESSIN 0.1MG TABLET
|
Facility
|
OP
|
$9.05
|
|
|
Service Code
|
NDC 69918010101
|
| Hospital Charge Code |
25003743
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$8.69 |
| Rate for Payer: Aetna Commercial |
$6.97
|
| Rate for Payer: Anthem Medicaid |
$3.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.06
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Cigna Commercial |
$7.51
|
| Rate for Payer: First Health Commercial |
$8.60
|
| Rate for Payer: Humana Commercial |
$7.69
|
| Rate for Payer: Humana KY Medicaid |
$3.11
|
| Rate for Payer: Kentucky WC Medicaid |
$3.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.96
|
| Rate for Payer: Ohio Health Group HMO |
$6.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.81
|
| Rate for Payer: PHCS Commercial |
$8.69
|
| Rate for Payer: United Healthcare All Payer |
$7.96
|
|
|
DESMOPRESSIN 0.1MG TABLET
|
Facility
|
IP
|
$9.05
|
|
|
Service Code
|
NDC 69918010101
|
| Hospital Charge Code |
25003743
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$8.69 |
| Rate for Payer: Aetna Commercial |
$6.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.06
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Cigna Commercial |
$7.51
|
| Rate for Payer: First Health Commercial |
$8.60
|
| Rate for Payer: Humana Commercial |
$7.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.96
|
| Rate for Payer: Ohio Health Group HMO |
$6.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.81
|
| Rate for Payer: PHCS Commercial |
$8.69
|
| Rate for Payer: United Healthcare All Payer |
$7.96
|
|
