|
DEST MAL LES > 4.0CM SNHFG
|
Professional
|
Both
|
$1,075.00
|
|
|
Service Code
|
HCPCS 17276
|
| Hospital Charge Code |
76100265
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$138.35 |
| Max. Negotiated Rate |
$1,075.00 |
| Rate for Payer: Aetna Commercial |
$302.19
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$138.35
|
| Rate for Payer: Anthem Medicaid |
$150.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,075.00
|
| Rate for Payer: Cash Price |
$537.50
|
| Rate for Payer: Cash Price |
$537.50
|
| Rate for Payer: Cigna Commercial |
$356.17
|
| Rate for Payer: Healthspan PPO |
$313.52
|
| Rate for Payer: Humana Medicaid |
$150.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$267.14
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$153.57
|
| Rate for Payer: Molina Healthcare Passport |
$150.56
|
| Rate for Payer: Multiplan PHCS |
$645.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$752.50
|
| Rate for Payer: UHCCP Medicaid |
$145.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$152.07
|
|
|
DEST MAL LES > 4.0CM SNHFG
|
Facility
|
IP
|
$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: Aetna Commercial |
$827.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$838.50
|
| 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: 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 |
$322.50
|
| 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
|
|
|
DEST MAL LES > 4.0CM SNHFG(P
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 17276
|
| Hospital Charge Code |
761P0265
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$138.35 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial |
$302.19
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$138.35
|
| Rate for Payer: Anthem Medicaid |
$150.56
|
| 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 |
$356.17
|
| Rate for Payer: Healthspan PPO |
$313.52
|
| Rate for Payer: Humana Medicaid |
$150.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$267.14
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$153.57
|
| Rate for Payer: Molina Healthcare Passport |
$150.56
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$145.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$152.07
|
|
|
DEST MAL LES > 4.0CM SNHFG(T
|
Facility
|
OP
|
$475.00
|
|
|
Service Code
|
HCPCS 17276
|
| Hospital Charge Code |
761T0265
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$61.75 |
| Max. Negotiated Rate |
$482.75 |
| Rate for Payer: Aetna Commercial |
$365.75
|
| Rate for Payer: Anthem Medicaid |
$163.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$370.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Cigna Commercial |
$394.25
|
| Rate for Payer: First Health Commercial |
$451.25
|
| Rate for Payer: Humana Commercial |
$403.75
|
| Rate for Payer: Humana KY Medicaid |
$163.35
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$165.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$389.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$350.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$166.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$418.00
|
| Rate for Payer: Ohio Health Group HMO |
$356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$95.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$61.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$147.25
|
| Rate for Payer: PHCS Commercial |
$456.00
|
| Rate for Payer: United Healthcare All Payer |
$418.00
|
|
|
DEST MAL LES > 4.0CM SNHFG(T
|
Facility
|
IP
|
$475.00
|
|
|
Service Code
|
HCPCS 17276
|
| Hospital Charge Code |
761T0265
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$61.75 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Aetna Commercial |
$365.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$370.50
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Cigna Commercial |
$394.25
|
| Rate for Payer: First Health Commercial |
$451.25
|
| Rate for Payer: Humana Commercial |
$403.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$389.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$350.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$418.00
|
| Rate for Payer: Ohio Health Group HMO |
$356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$95.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$61.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$147.25
|
| Rate for Payer: PHCS Commercial |
$456.00
|
| Rate for Payer: United Healthcare All Payer |
$418.00
|
|
|
DEST MAL LES > 4.0CM - TAL
|
Professional
|
Both
|
$916.20
|
|
|
Service Code
|
HCPCS 17266
|
| Hospital Charge Code |
76100259
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$99.51 |
| Max. Negotiated Rate |
$916.20 |
| Rate for Payer: Aetna Commercial |
$225.08
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$99.51
|
| Rate for Payer: Anthem Medicaid |
$120.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$916.20
|
| Rate for Payer: Cash Price |
$458.10
|
| Rate for Payer: Cash Price |
$458.10
|
| Rate for Payer: Cigna Commercial |
$282.99
|
| Rate for Payer: Healthspan PPO |
$253.16
|
| Rate for Payer: Humana Medicaid |
$120.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$201.77
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$123.23
|
| Rate for Payer: Molina Healthcare Passport |
$120.81
|
| Rate for Payer: Multiplan PHCS |
$549.72
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$641.34
|
| Rate for Payer: UHCCP Medicaid |
$104.49
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$122.02
|
|
|
DEST MAL LES > 4.0CM - TAL
|
Facility
|
IP
|
$916.20
|
|
|
Service Code
|
HCPCS 17266
|
| Hospital Charge Code |
76100259
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$119.11 |
| Max. Negotiated Rate |
$879.55 |
| Rate for Payer: Aetna Commercial |
$705.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$714.64
|
| Rate for Payer: Cash Price |
$458.10
|
| Rate for Payer: Cigna Commercial |
$760.45
|
| Rate for Payer: First Health Commercial |
$870.39
|
| Rate for Payer: Humana Commercial |
$778.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$751.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$676.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$274.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$806.26
|
| Rate for Payer: Ohio Health Group HMO |
$687.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$183.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$119.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$284.02
|
| Rate for Payer: PHCS Commercial |
$879.55
|
| Rate for Payer: United Healthcare All Payer |
$806.26
|
|
|
DEST MAL LES > 4.0CM - TAL
|
Facility
|
OP
|
$916.20
|
|
|
Service Code
|
HCPCS 17266
|
| Hospital Charge Code |
76100259
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$119.11 |
| Max. Negotiated Rate |
$879.55 |
| Rate for Payer: Aetna Commercial |
$705.47
|
| Rate for Payer: Anthem Medicaid |
$315.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$714.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$458.10
|
| Rate for Payer: Cash Price |
$458.10
|
| Rate for Payer: Cigna Commercial |
$760.45
|
| Rate for Payer: First Health Commercial |
$870.39
|
| Rate for Payer: Humana Commercial |
$778.77
|
| Rate for Payer: Humana KY Medicaid |
$315.08
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$318.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$751.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$676.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$321.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$806.26
|
| Rate for Payer: Ohio Health Group HMO |
$687.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$183.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$119.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$284.02
|
| Rate for Payer: PHCS Commercial |
$879.55
|
| Rate for Payer: United Healthcare All Payer |
$806.26
|
|
|
DEST MAL LES > 4.0CM - TAL(P
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 17266
|
| Hospital Charge Code |
761P0259
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$99.51 |
| Max. Negotiated Rate |
$450.00 |
| Rate for Payer: Aetna Commercial |
$225.08
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$99.51
|
| Rate for Payer: Anthem Medicaid |
$120.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$450.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$282.99
|
| Rate for Payer: Healthspan PPO |
$253.16
|
| Rate for Payer: Humana Medicaid |
$120.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$201.77
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$123.23
|
| Rate for Payer: Molina Healthcare Passport |
$120.81
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$315.00
|
| Rate for Payer: UHCCP Medicaid |
$104.49
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$122.02
|
|
|
DEST MAL LES > 4.0CM - TAL(T
|
Facility
|
OP
|
$466.20
|
|
|
Service Code
|
HCPCS 17266
|
| Hospital Charge Code |
761T0259
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$60.61 |
| Max. Negotiated Rate |
$482.75 |
| Rate for Payer: Aetna Commercial |
$358.97
|
| Rate for Payer: Anthem Medicaid |
$160.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$363.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$233.10
|
| Rate for Payer: Cash Price |
$233.10
|
| Rate for Payer: Cigna Commercial |
$386.95
|
| Rate for Payer: First Health Commercial |
$442.89
|
| Rate for Payer: Humana Commercial |
$396.27
|
| Rate for Payer: Humana KY Medicaid |
$160.33
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$161.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$382.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$344.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$163.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$410.26
|
| Rate for Payer: Ohio Health Group HMO |
$349.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$144.52
|
| Rate for Payer: PHCS Commercial |
$447.55
|
| Rate for Payer: United Healthcare All Payer |
$410.26
|
|
|
DEST MAL LES > 4.0CM - TAL(T
|
Facility
|
IP
|
$466.20
|
|
|
Service Code
|
HCPCS 17266
|
| Hospital Charge Code |
761T0259
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$60.61 |
| Max. Negotiated Rate |
$447.55 |
| Rate for Payer: Aetna Commercial |
$358.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$363.64
|
| Rate for Payer: Cash Price |
$233.10
|
| Rate for Payer: Cigna Commercial |
$386.95
|
| Rate for Payer: First Health Commercial |
$442.89
|
| Rate for Payer: Humana Commercial |
$396.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$382.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$344.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$139.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$410.26
|
| Rate for Payer: Ohio Health Group HMO |
$349.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$144.52
|
| Rate for Payer: PHCS Commercial |
$447.55
|
| Rate for Payer: United Healthcare All Payer |
$410.26
|
|
|
DEST MAL LES .6-1.0CM - TAL
|
Professional
|
Both
|
$521.61
|
|
|
Service Code
|
HCPCS 17261
|
| Hospital Charge Code |
76100255
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$43.43 |
| Max. Negotiated Rate |
$521.61 |
| Rate for Payer: Aetna Commercial |
$127.39
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$43.43
|
| Rate for Payer: Anthem Medicaid |
$54.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$521.61
|
| Rate for Payer: Cash Price |
$260.80
|
| Rate for Payer: Cash Price |
$260.80
|
| Rate for Payer: Cigna Commercial |
$178.19
|
| Rate for Payer: Healthspan PPO |
$154.07
|
| Rate for Payer: Humana Medicaid |
$54.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$114.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$55.51
|
| Rate for Payer: Molina Healthcare Passport |
$54.42
|
| Rate for Payer: Multiplan PHCS |
$312.97
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$365.13
|
| Rate for Payer: UHCCP Medicaid |
$45.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$54.96
|
|
|
DEST MAL LES .6-1.0CM - TAL
|
Facility
|
IP
|
$521.61
|
|
|
Service Code
|
HCPCS 17261
|
| Hospital Charge Code |
76100255
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$67.81 |
| Max. Negotiated Rate |
$500.75 |
| Rate for Payer: Aetna Commercial |
$401.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$406.86
|
| Rate for Payer: Cash Price |
$260.80
|
| Rate for Payer: Cigna Commercial |
$432.94
|
| Rate for Payer: First Health Commercial |
$495.53
|
| Rate for Payer: Humana Commercial |
$443.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$427.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$384.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$156.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$459.02
|
| Rate for Payer: Ohio Health Group HMO |
$391.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$104.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$161.70
|
| Rate for Payer: PHCS Commercial |
$500.75
|
| Rate for Payer: United Healthcare All Payer |
$459.02
|
|
|
DEST MAL LES .6-1.0CM - TAL
|
Facility
|
OP
|
$521.61
|
|
|
Service Code
|
HCPCS 17261
|
| Hospital Charge Code |
76100255
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$67.81 |
| Max. Negotiated Rate |
$500.75 |
| Rate for Payer: Aetna Commercial |
$401.64
|
| Rate for Payer: Anthem Medicaid |
$179.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$406.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$260.80
|
| Rate for Payer: Cash Price |
$260.80
|
| Rate for Payer: Cigna Commercial |
$432.94
|
| Rate for Payer: First Health Commercial |
$495.53
|
| Rate for Payer: Humana Commercial |
$443.37
|
| Rate for Payer: Humana KY Medicaid |
$179.38
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$181.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$427.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$384.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$182.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$459.02
|
| Rate for Payer: Ohio Health Group HMO |
$391.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$104.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$161.70
|
| Rate for Payer: PHCS Commercial |
$500.75
|
| Rate for Payer: United Healthcare All Payer |
$459.02
|
|
|
DEST MAL LES .6-1.0CM - TAL(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 17261
|
| Hospital Charge Code |
761P0255
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$43.43 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Aetna Commercial |
$127.39
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$43.43
|
| Rate for Payer: Anthem Medicaid |
$54.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$178.19
|
| Rate for Payer: Healthspan PPO |
$154.07
|
| Rate for Payer: Humana Medicaid |
$54.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$114.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$55.51
|
| Rate for Payer: Molina Healthcare Passport |
$54.42
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$45.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$54.96
|
|
|
DEST MAL LES .6-1.0CM - TAL(T
|
Facility
|
IP
|
$271.61
|
|
|
Service Code
|
HCPCS 17261
|
| Hospital Charge Code |
761T0255
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$35.31 |
| Max. Negotiated Rate |
$260.75 |
| Rate for Payer: Aetna Commercial |
$209.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$211.86
|
| Rate for Payer: Cash Price |
$135.80
|
| Rate for Payer: Cigna Commercial |
$225.44
|
| Rate for Payer: First Health Commercial |
$258.03
|
| Rate for Payer: Humana Commercial |
$230.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$222.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$200.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$81.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$239.02
|
| Rate for Payer: Ohio Health Group HMO |
$203.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$54.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.20
|
| Rate for Payer: PHCS Commercial |
$260.75
|
| Rate for Payer: United Healthcare All Payer |
$239.02
|
|
|
DEST MAL LES .6-1.0CM - TAL(T
|
Facility
|
OP
|
$271.61
|
|
|
Service Code
|
HCPCS 17261
|
| Hospital Charge Code |
761T0255
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$35.31 |
| Max. Negotiated Rate |
$260.75 |
| Rate for Payer: Aetna Commercial |
$209.14
|
| Rate for Payer: Anthem Medicaid |
$93.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$211.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$135.80
|
| Rate for Payer: Cash Price |
$135.80
|
| Rate for Payer: Cigna Commercial |
$225.44
|
| Rate for Payer: First Health Commercial |
$258.03
|
| Rate for Payer: Humana Commercial |
$230.87
|
| Rate for Payer: Humana KY Medicaid |
$93.41
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$94.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$222.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$200.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$95.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$239.02
|
| Rate for Payer: Ohio Health Group HMO |
$203.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$54.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.20
|
| Rate for Payer: PHCS Commercial |
$260.75
|
| Rate for Payer: United Healthcare All Payer |
$239.02
|
|
|
DEST MAL LESION < 0.5CM TAL
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 17260
|
| Hospital Charge Code |
76100254
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$42.82 |
| Max. Negotiated Rate |
$450.00 |
| Rate for Payer: Aetna Commercial |
$94.54
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$50.18
|
| Rate for Payer: Anthem Medicaid |
$42.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$450.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$124.64
|
| Rate for Payer: Healthspan PPO |
$103.83
|
| Rate for Payer: Humana Medicaid |
$42.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$84.43
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$43.68
|
| Rate for Payer: Molina Healthcare Passport |
$42.82
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$315.00
|
| Rate for Payer: UHCCP Medicaid |
$52.69
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$43.25
|
|
|
DEST MAL LESION < 0.5CM TAL
|
Facility
|
OP
|
$450.00
|
|
|
Service Code
|
HCPCS 17260
|
| Hospital Charge Code |
76100254
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$58.50 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna Commercial |
$346.50
|
| Rate for Payer: Anthem Medicaid |
$154.76
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$351.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$373.50
|
| Rate for Payer: First Health Commercial |
$427.50
|
| Rate for Payer: Humana Commercial |
$382.50
|
| Rate for Payer: Humana KY Medicaid |
$154.76
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$156.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$369.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$332.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$157.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$396.00
|
| Rate for Payer: Ohio Health Group HMO |
$337.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$90.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$58.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$139.50
|
| Rate for Payer: PHCS Commercial |
$432.00
|
| Rate for Payer: United Healthcare All Payer |
$396.00
|
|
|
DEST MAL LESION < 0.5CM TAL
|
Facility
|
IP
|
$450.00
|
|
|
Service Code
|
HCPCS 17260
|
| Hospital Charge Code |
76100254
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$58.50 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna Commercial |
$346.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$351.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$373.50
|
| Rate for Payer: First Health Commercial |
$427.50
|
| Rate for Payer: Humana Commercial |
$382.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$369.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$332.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$135.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$396.00
|
| Rate for Payer: Ohio Health Group HMO |
$337.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$90.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$58.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$139.50
|
| Rate for Payer: PHCS Commercial |
$432.00
|
| Rate for Payer: United Healthcare All Payer |
$396.00
|
|
|
DEST MAL LESION < 0.5CM TAL(P
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 17260
|
| Hospital Charge Code |
761P0254
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$42.82 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna Commercial |
$94.54
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$50.18
|
| Rate for Payer: Anthem Medicaid |
$42.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$200.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$124.64
|
| Rate for Payer: Healthspan PPO |
$103.83
|
| Rate for Payer: Humana Medicaid |
$42.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$84.43
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$43.68
|
| Rate for Payer: Molina Healthcare Passport |
$42.82
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.00
|
| Rate for Payer: UHCCP Medicaid |
$52.69
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$43.25
|
|
|
DEST MAL LESION < 0.5CM TAL(T
|
Facility
|
OP
|
$250.00
|
|
|
Service Code
|
HCPCS 17260
|
| Hospital Charge Code |
761T0254
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$32.50 |
| Max. Negotiated Rate |
$242.37 |
| Rate for Payer: Aetna Commercial |
$192.50
|
| Rate for Payer: Anthem Medicaid |
$85.98
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$195.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$207.50
|
| Rate for Payer: First Health Commercial |
$237.50
|
| Rate for Payer: Humana Commercial |
$212.50
|
| Rate for Payer: Humana KY Medicaid |
$85.98
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$86.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$205.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$184.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$87.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$220.00
|
| Rate for Payer: Ohio Health Group HMO |
$187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$50.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.50
|
| Rate for Payer: PHCS Commercial |
$240.00
|
| Rate for Payer: United Healthcare All Payer |
$220.00
|
|
|
DEST MAL LESION < 0.5CM TAL(T
|
Facility
|
IP
|
$250.00
|
|
|
Service Code
|
HCPCS 17260
|
| Hospital Charge Code |
761T0254
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$32.50 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: Aetna Commercial |
$192.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$195.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$207.50
|
| Rate for Payer: First Health Commercial |
$237.50
|
| Rate for Payer: Humana Commercial |
$212.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$205.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$184.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$220.00
|
| Rate for Payer: Ohio Health Group HMO |
$187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$50.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.50
|
| Rate for Payer: PHCS Commercial |
$240.00
|
| Rate for Payer: United Healthcare All Payer |
$220.00
|
|
|
DEST MOLL CONT TO 15
|
Facility
|
OP
|
$436.00
|
|
|
Service Code
|
HCPCS 17110
|
| Hospital Charge Code |
76100251
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$56.68 |
| 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 |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$340.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| 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 |
$173.12
|
| 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 |
$207.74
|
| 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 |
$87.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$56.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$135.16
|
| Rate for Payer: PHCS Commercial |
$418.56
|
| Rate for Payer: United Healthcare All Payer |
$383.68
|
|
|
DEST MOLL CONT TO 15
|
Professional
|
Both
|
$436.00
|
|
|
Service Code
|
HCPCS 17110
|
| Hospital Charge Code |
76100251
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$22.23 |
| Max. Negotiated Rate |
$436.00 |
| Rate for Payer: Aetna Commercial |
$94.16
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$36.13
|
| Rate for Payer: Anthem Medicaid |
$22.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$436.00
|
| Rate for Payer: Cash Price |
$218.00
|
| Rate for Payer: Cash Price |
$218.00
|
| Rate for Payer: Cigna Commercial |
$135.24
|
| Rate for Payer: Healthspan PPO |
$118.52
|
| Rate for Payer: Humana Medicaid |
$22.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$83.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$22.67
|
| Rate for Payer: Molina Healthcare Passport |
$22.23
|
| Rate for Payer: Multiplan PHCS |
$261.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$305.20
|
| Rate for Payer: UHCCP Medicaid |
$37.94
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$22.45
|
|
