|
DEST MAL LES 2.1-3CM SNHF
|
Facility
|
IP
|
$878.00
|
|
|
Service Code
|
HCPCS 17273
|
| Hospital Charge Code |
76100263
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$114.14 |
| Max. Negotiated Rate |
$842.88 |
| Rate for Payer: Aetna Commercial |
$676.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$684.84
|
| Rate for Payer: Cash Price |
$439.00
|
| Rate for Payer: Cigna Commercial |
$728.74
|
| Rate for Payer: First Health Commercial |
$834.10
|
| Rate for Payer: Humana Commercial |
$746.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$719.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$647.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$263.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$772.64
|
| Rate for Payer: Ohio Health Group HMO |
$658.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$175.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$114.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$272.18
|
| Rate for Payer: PHCS Commercial |
$842.88
|
| Rate for Payer: United Healthcare All Payer |
$772.64
|
|
|
DEST MAL LES 2.1-3CM SNHF
|
Facility
|
OP
|
$878.00
|
|
|
Service Code
|
HCPCS 17273
|
| Hospital Charge Code |
76100263
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$114.14 |
| Max. Negotiated Rate |
$842.88 |
| Rate for Payer: Aetna Commercial |
$676.06
|
| Rate for Payer: Anthem Medicaid |
$301.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$684.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$439.00
|
| Rate for Payer: Cash Price |
$439.00
|
| Rate for Payer: Cigna Commercial |
$728.74
|
| Rate for Payer: First Health Commercial |
$834.10
|
| Rate for Payer: Humana Commercial |
$746.30
|
| Rate for Payer: Humana KY Medicaid |
$301.94
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$305.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$719.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$647.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$308.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$772.64
|
| Rate for Payer: Ohio Health Group HMO |
$658.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$175.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$114.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$272.18
|
| Rate for Payer: PHCS Commercial |
$842.88
|
| Rate for Payer: United Healthcare All Payer |
$772.64
|
|
|
DEST MAL LES 2.1-3CM SNHF
|
Professional
|
Both
|
$878.00
|
|
|
Service Code
|
HCPCS 17273
|
| Hospital Charge Code |
76100263
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$95.48 |
| Max. Negotiated Rate |
$878.00 |
| Rate for Payer: Aetna Commercial |
$203.35
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$95.48
|
| Rate for Payer: Anthem Medicaid |
$99.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$878.00
|
| Rate for Payer: Cash Price |
$439.00
|
| Rate for Payer: Cash Price |
$439.00
|
| Rate for Payer: Cigna Commercial |
$249.99
|
| Rate for Payer: Healthspan PPO |
$226.79
|
| Rate for Payer: Humana Medicaid |
$99.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$182.10
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$101.35
|
| Rate for Payer: Molina Healthcare Passport |
$99.36
|
| Rate for Payer: Multiplan PHCS |
$526.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$614.60
|
| Rate for Payer: UHCCP Medicaid |
$100.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$100.35
|
|
|
DEST MAL LES 2.1-3CM SNHF(P
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 17273
|
| Hospital Charge Code |
761P0263
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$95.48 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna Commercial |
$203.35
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$95.48
|
| Rate for Payer: Anthem Medicaid |
$99.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$400.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$249.99
|
| Rate for Payer: Healthspan PPO |
$226.79
|
| Rate for Payer: Humana Medicaid |
$99.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$182.10
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$101.35
|
| Rate for Payer: Molina Healthcare Passport |
$99.36
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$100.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$100.35
|
|
|
DEST MAL LES 2.1-3CM SNHF(T
|
Facility
|
OP
|
$478.00
|
|
|
Service Code
|
HCPCS 17273
|
| Hospital Charge Code |
761T0263
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$62.14 |
| Max. Negotiated Rate |
$482.75 |
| Rate for Payer: Aetna Commercial |
$368.06
|
| Rate for Payer: Anthem Medicaid |
$164.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$372.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$239.00
|
| Rate for Payer: Cash Price |
$239.00
|
| Rate for Payer: Cigna Commercial |
$396.74
|
| Rate for Payer: First Health Commercial |
$454.10
|
| Rate for Payer: Humana Commercial |
$406.30
|
| Rate for Payer: Humana KY Medicaid |
$164.38
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$166.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$391.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$352.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$167.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$420.64
|
| Rate for Payer: Ohio Health Group HMO |
$358.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$95.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$148.18
|
| Rate for Payer: PHCS Commercial |
$458.88
|
| Rate for Payer: United Healthcare All Payer |
$420.64
|
|
|
DEST MAL LES 2.1-3CM SNHF(T
|
Facility
|
IP
|
$478.00
|
|
|
Service Code
|
HCPCS 17273
|
| Hospital Charge Code |
761T0263
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$62.14 |
| Max. Negotiated Rate |
$458.88 |
| Rate for Payer: Aetna Commercial |
$368.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$372.84
|
| Rate for Payer: Cash Price |
$239.00
|
| Rate for Payer: Cigna Commercial |
$396.74
|
| Rate for Payer: First Health Commercial |
$454.10
|
| Rate for Payer: Humana Commercial |
$406.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$391.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$352.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$143.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$420.64
|
| Rate for Payer: Ohio Health Group HMO |
$358.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$95.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$148.18
|
| Rate for Payer: PHCS Commercial |
$458.88
|
| Rate for Payer: United Healthcare All Payer |
$420.64
|
|
|
DEST MAL LES 2.1-3CM TAL
|
Professional
|
Both
|
$729.29
|
|
|
Service Code
|
HCPCS 17263
|
| Hospital Charge Code |
76100257
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$82.27 |
| Max. Negotiated Rate |
$729.29 |
| Rate for Payer: Aetna Commercial |
$180.67
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$82.27
|
| Rate for Payer: Anthem Medicaid |
$86.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$729.29
|
| Rate for Payer: Cash Price |
$364.64
|
| Rate for Payer: Cash Price |
$364.64
|
| Rate for Payer: Cigna Commercial |
$227.58
|
| Rate for Payer: Healthspan PPO |
$207.80
|
| Rate for Payer: Humana Medicaid |
$86.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$162.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$88.07
|
| Rate for Payer: Molina Healthcare Passport |
$86.34
|
| Rate for Payer: Multiplan PHCS |
$437.57
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$510.50
|
| Rate for Payer: UHCCP Medicaid |
$86.38
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$87.20
|
|
|
DEST MAL LES 2.1-3CM TAL
|
Facility
|
OP
|
$729.29
|
|
|
Service Code
|
HCPCS 17263
|
| Hospital Charge Code |
76100257
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$94.81 |
| Max. Negotiated Rate |
$700.12 |
| Rate for Payer: Aetna Commercial |
$561.55
|
| Rate for Payer: Anthem Medicaid |
$250.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$568.85
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$364.64
|
| Rate for Payer: Cash Price |
$364.64
|
| Rate for Payer: Cigna Commercial |
$605.31
|
| Rate for Payer: First Health Commercial |
$692.83
|
| Rate for Payer: Humana Commercial |
$619.90
|
| Rate for Payer: Humana KY Medicaid |
$250.80
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$253.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$598.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$538.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$255.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$641.78
|
| Rate for Payer: Ohio Health Group HMO |
$546.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$145.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$94.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$226.08
|
| Rate for Payer: PHCS Commercial |
$700.12
|
| Rate for Payer: United Healthcare All Payer |
$641.78
|
|
|
DEST MAL LES 2.1-3CM TAL
|
Facility
|
IP
|
$729.29
|
|
|
Service Code
|
HCPCS 17263
|
| Hospital Charge Code |
76100257
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$94.81 |
| Max. Negotiated Rate |
$700.12 |
| Rate for Payer: Aetna Commercial |
$561.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$568.85
|
| Rate for Payer: Cash Price |
$364.64
|
| Rate for Payer: Cigna Commercial |
$605.31
|
| Rate for Payer: First Health Commercial |
$692.83
|
| Rate for Payer: Humana Commercial |
$619.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$598.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$538.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$218.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$641.78
|
| Rate for Payer: Ohio Health Group HMO |
$546.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$145.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$94.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$226.08
|
| Rate for Payer: PHCS Commercial |
$700.12
|
| Rate for Payer: United Healthcare All Payer |
$641.78
|
|
|
DEST MAL LES 2.1-3CM TAL(P
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 17263
|
| Hospital Charge Code |
761P0257
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$82.27 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna Commercial |
$180.67
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$82.27
|
| Rate for Payer: Anthem Medicaid |
$86.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$400.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$227.58
|
| Rate for Payer: Healthspan PPO |
$207.80
|
| Rate for Payer: Humana Medicaid |
$86.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$162.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$88.07
|
| Rate for Payer: Molina Healthcare Passport |
$86.34
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$86.38
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$87.20
|
|
|
DEST MAL LES 2.1-3CM TAL(T
|
Facility
|
IP
|
$329.29
|
|
|
Service Code
|
HCPCS 17263
|
| Hospital Charge Code |
761T0257
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$42.81 |
| Max. Negotiated Rate |
$316.12 |
| Rate for Payer: Aetna Commercial |
$253.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$256.85
|
| Rate for Payer: Cash Price |
$164.65
|
| Rate for Payer: Cigna Commercial |
$273.31
|
| Rate for Payer: First Health Commercial |
$312.83
|
| Rate for Payer: Humana Commercial |
$279.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$270.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$243.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$289.78
|
| Rate for Payer: Ohio Health Group HMO |
$246.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$65.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$102.08
|
| Rate for Payer: PHCS Commercial |
$316.12
|
| Rate for Payer: United Healthcare All Payer |
$289.78
|
|
|
DEST MAL LES 2.1-3CM TAL(T
|
Facility
|
OP
|
$329.29
|
|
|
Service Code
|
HCPCS 17263
|
| Hospital Charge Code |
761T0257
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$42.81 |
| Max. Negotiated Rate |
$316.12 |
| Rate for Payer: Aetna Commercial |
$253.55
|
| Rate for Payer: Anthem Medicaid |
$113.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$256.85
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$164.65
|
| Rate for Payer: Cash Price |
$164.65
|
| Rate for Payer: Cigna Commercial |
$273.31
|
| Rate for Payer: First Health Commercial |
$312.83
|
| Rate for Payer: Humana Commercial |
$279.90
|
| Rate for Payer: Humana KY Medicaid |
$113.24
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$114.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$270.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$243.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$115.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$289.78
|
| Rate for Payer: Ohio Health Group HMO |
$246.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$65.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$102.08
|
| Rate for Payer: PHCS Commercial |
$316.12
|
| Rate for Payer: United Healthcare All Payer |
$289.78
|
|
|
DEST MAL LES 3.1-4CM SNHF
|
Professional
|
Both
|
$1,016.00
|
|
|
Service Code
|
HCPCS 17274
|
| Hospital Charge Code |
76100264
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$116.48 |
| Max. Negotiated Rate |
$1,016.00 |
| Rate for Payer: Aetna Commercial |
$249.86
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$116.48
|
| Rate for Payer: Anthem Medicaid |
$125.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,016.00
|
| Rate for Payer: Cash Price |
$508.00
|
| Rate for Payer: Cash Price |
$508.00
|
| Rate for Payer: Cigna Commercial |
$301.02
|
| Rate for Payer: Healthspan PPO |
$269.12
|
| Rate for Payer: Humana Medicaid |
$125.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$222.50
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$127.87
|
| Rate for Payer: Molina Healthcare Passport |
$125.36
|
| Rate for Payer: Multiplan PHCS |
$609.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$711.20
|
| Rate for Payer: UHCCP Medicaid |
$122.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$126.61
|
|
|
DEST MAL LES 3.1-4CM SNHF
|
Facility
|
IP
|
$1,016.00
|
|
|
Service Code
|
HCPCS 17274
|
| Hospital Charge Code |
76100264
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$132.08 |
| Max. Negotiated Rate |
$975.36 |
| Rate for Payer: Aetna Commercial |
$782.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$792.48
|
| Rate for Payer: Cash Price |
$508.00
|
| Rate for Payer: Cigna Commercial |
$843.28
|
| Rate for Payer: First Health Commercial |
$965.20
|
| Rate for Payer: Humana Commercial |
$863.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$833.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$749.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$304.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$894.08
|
| Rate for Payer: Ohio Health Group HMO |
$762.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$203.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$132.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$314.96
|
| Rate for Payer: PHCS Commercial |
$975.36
|
| Rate for Payer: United Healthcare All Payer |
$894.08
|
|
|
DEST MAL LES 3.1-4CM SNHF
|
Facility
|
OP
|
$1,016.00
|
|
|
Service Code
|
HCPCS 17274
|
| Hospital Charge Code |
76100264
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$132.08 |
| Max. Negotiated Rate |
$975.36 |
| Rate for Payer: Aetna Commercial |
$782.32
|
| Rate for Payer: Anthem Medicaid |
$349.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$792.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$508.00
|
| Rate for Payer: Cash Price |
$508.00
|
| Rate for Payer: Cigna Commercial |
$843.28
|
| Rate for Payer: First Health Commercial |
$965.20
|
| Rate for Payer: Humana Commercial |
$863.60
|
| Rate for Payer: Humana KY Medicaid |
$349.40
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$352.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$833.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$749.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$356.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$894.08
|
| Rate for Payer: Ohio Health Group HMO |
$762.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$203.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$132.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$314.96
|
| Rate for Payer: PHCS Commercial |
$975.36
|
| Rate for Payer: United Healthcare All Payer |
$894.08
|
|
|
DEST MAL LES 3.1-4CM SNHF(P
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 17274
|
| Hospital Charge Code |
761P0264
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$116.48 |
| Max. Negotiated Rate |
$500.00 |
| Rate for Payer: Aetna Commercial |
$249.86
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$116.48
|
| Rate for Payer: Anthem Medicaid |
$125.36
|
| 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 |
$301.02
|
| Rate for Payer: Healthspan PPO |
$269.12
|
| Rate for Payer: Humana Medicaid |
$125.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$222.50
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$127.87
|
| Rate for Payer: Molina Healthcare Passport |
$125.36
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$350.00
|
| Rate for Payer: UHCCP Medicaid |
$122.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$126.61
|
|
|
DEST MAL LES 3.1-4CM SNHF(T
|
Facility
|
IP
|
$516.00
|
|
|
Service Code
|
HCPCS 17274
|
| Hospital Charge Code |
761T0264
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$67.08 |
| Max. Negotiated Rate |
$495.36 |
| Rate for Payer: Aetna Commercial |
$397.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$402.48
|
| Rate for Payer: Cash Price |
$258.00
|
| Rate for Payer: Cigna Commercial |
$428.28
|
| Rate for Payer: First Health Commercial |
$490.20
|
| Rate for Payer: Humana Commercial |
$438.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$423.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$380.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$154.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$454.08
|
| Rate for Payer: Ohio Health Group HMO |
$387.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$159.96
|
| Rate for Payer: PHCS Commercial |
$495.36
|
| Rate for Payer: United Healthcare All Payer |
$454.08
|
|
|
DEST MAL LES 3.1-4CM SNHF(T
|
Facility
|
OP
|
$516.00
|
|
|
Service Code
|
HCPCS 17274
|
| Hospital Charge Code |
761T0264
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$67.08 |
| Max. Negotiated Rate |
$495.36 |
| Rate for Payer: Aetna Commercial |
$397.32
|
| Rate for Payer: Anthem Medicaid |
$177.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$402.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$258.00
|
| Rate for Payer: Cash Price |
$258.00
|
| Rate for Payer: Cigna Commercial |
$428.28
|
| Rate for Payer: First Health Commercial |
$490.20
|
| Rate for Payer: Humana Commercial |
$438.60
|
| Rate for Payer: Humana KY Medicaid |
$177.45
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$179.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$423.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$380.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$181.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$454.08
|
| Rate for Payer: Ohio Health Group HMO |
$387.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$159.96
|
| Rate for Payer: PHCS Commercial |
$495.36
|
| Rate for Payer: United Healthcare All Payer |
$454.08
|
|
|
DEST MAL LES 3.1-4CM - TAL
|
Facility
|
OP
|
$858.00
|
|
|
Service Code
|
HCPCS 17264
|
| Hospital Charge Code |
76100258
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$111.54 |
| Max. Negotiated Rate |
$823.68 |
| Rate for Payer: Aetna Commercial |
$660.66
|
| Rate for Payer: Anthem Medicaid |
$295.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$669.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$429.00
|
| Rate for Payer: Cash Price |
$429.00
|
| Rate for Payer: Cigna Commercial |
$712.14
|
| Rate for Payer: First Health Commercial |
$815.10
|
| Rate for Payer: Humana Commercial |
$729.30
|
| Rate for Payer: Humana KY Medicaid |
$295.07
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$298.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$703.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$633.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$300.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$755.04
|
| Rate for Payer: Ohio Health Group HMO |
$643.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$171.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$111.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$265.98
|
| Rate for Payer: PHCS Commercial |
$823.68
|
| Rate for Payer: United Healthcare All Payer |
$755.04
|
|
|
DEST MAL LES 3.1-4CM - TAL
|
Professional
|
Both
|
$858.00
|
|
|
Service Code
|
HCPCS 17264
|
| Hospital Charge Code |
76100258
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$93.95 |
| Max. Negotiated Rate |
$858.00 |
| Rate for Payer: Aetna Commercial |
$193.25
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$93.95
|
| Rate for Payer: Anthem Medicaid |
$96.51
|
| Rate for Payer: Buckeye Medicare Advantage |
$858.00
|
| Rate for Payer: Cash Price |
$429.00
|
| Rate for Payer: Cash Price |
$429.00
|
| Rate for Payer: Cigna Commercial |
$245.74
|
| Rate for Payer: Healthspan PPO |
$222.57
|
| Rate for Payer: Humana Medicaid |
$96.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$173.25
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$98.44
|
| Rate for Payer: Molina Healthcare Passport |
$96.51
|
| Rate for Payer: Multiplan PHCS |
$514.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$600.60
|
| Rate for Payer: UHCCP Medicaid |
$98.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$97.48
|
|
|
DEST MAL LES 3.1-4CM - TAL
|
Facility
|
IP
|
$858.00
|
|
|
Service Code
|
HCPCS 17264
|
| Hospital Charge Code |
76100258
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$111.54 |
| Max. Negotiated Rate |
$823.68 |
| Rate for Payer: Aetna Commercial |
$660.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$669.24
|
| Rate for Payer: Cash Price |
$429.00
|
| Rate for Payer: Cigna Commercial |
$712.14
|
| Rate for Payer: First Health Commercial |
$815.10
|
| Rate for Payer: Humana Commercial |
$729.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$703.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$633.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$257.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$755.04
|
| Rate for Payer: Ohio Health Group HMO |
$643.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$171.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$111.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$265.98
|
| Rate for Payer: PHCS Commercial |
$823.68
|
| Rate for Payer: United Healthcare All Payer |
$755.04
|
|
|
DEST MAL LES 3.1-4CM - TAL(P
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 17264
|
| Hospital Charge Code |
761P0258
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$93.95 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna Commercial |
$193.25
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$93.95
|
| Rate for Payer: Anthem Medicaid |
$96.51
|
| Rate for Payer: Buckeye Medicare Advantage |
$400.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$245.74
|
| Rate for Payer: Healthspan PPO |
$222.57
|
| Rate for Payer: Humana Medicaid |
$96.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$173.25
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$98.44
|
| Rate for Payer: Molina Healthcare Passport |
$96.51
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$98.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$97.48
|
|
|
DEST MAL LES 3.1-4CM - TAL(T
|
Facility
|
OP
|
$458.00
|
|
|
Service Code
|
HCPCS 17264
|
| Hospital Charge Code |
761T0258
|
|
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
|
|
|
DEST MAL LES 3.1-4CM - TAL(T
|
Facility
|
IP
|
$458.00
|
|
|
Service Code
|
HCPCS 17264
|
| Hospital Charge Code |
761T0258
|
|
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
|
|
|
DEST MAL LES > 4.0CM SNHFG
|
Facility
|
OP
|
$1,075.00
|
|
|
Service Code
|
HCPCS 17276
|
| Hospital Charge Code |
76100265
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$139.75 |
| Max. Negotiated Rate |
$1,032.00 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Aetna Commercial |
$827.75
|
| Rate for Payer: Anthem Medicaid |
$369.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$838.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$537.50
|
| Rate for Payer: Cash Price |
$537.50
|
| Rate for Payer: Cigna Commercial |
$892.25
|
| Rate for Payer: First Health Commercial |
$1,021.25
|
| Rate for Payer: Humana Commercial |
$913.75
|
| Rate for Payer: Humana KY Medicaid |
$369.69
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$373.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$881.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$793.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$377.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$946.00
|
| Rate for Payer: Ohio Health Group HMO |
$806.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$215.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$139.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$333.25
|
| Rate for Payer: PHCS Commercial |
$1,032.00
|
| Rate for Payer: United Healthcare All Payer |
$946.00
|
|
