|
DEST MAL LES > 0.5CM FEENL(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 17280
|
| Hospital Charge Code |
761P0266
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$58.12 |
| Max. Negotiated Rate |
$165.26 |
| Rate for Payer: Aetna Commercial |
$125.25
|
| Rate for Payer: Ambetter Exchange |
$82.11
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$58.12
|
| Rate for Payer: Anthem Medicaid |
$80.77
|
| Rate for Payer: Buckeye Individual/Medicaid |
$82.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$82.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$98.53
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$165.26
|
| Rate for Payer: Healthspan PPO |
$150.22
|
| Rate for Payer: Humana Medicaid |
$80.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$113.66
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$82.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$82.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$82.39
|
| Rate for Payer: Molina Healthcare Passport |
$80.77
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$106.74
|
| Rate for Payer: UHCCP Medicaid |
$61.03
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$81.58
|
| Rate for Payer: Wellcare Medicare Advantage |
$82.11
|
|
|
DEST MAL LES > 0.5CM FEENL(T
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
HCPCS 17280
|
| Hospital Charge Code |
761T0266
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$81.00 |
| Max. Negotiated Rate |
$259.20 |
| Rate for Payer: Aetna Commercial |
$207.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$210.60
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cigna Commercial |
$224.10
|
| Rate for Payer: First Health Commercial |
$256.50
|
| Rate for Payer: Humana Commercial |
$229.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$221.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$199.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$81.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$237.60
|
| Rate for Payer: Ohio Health Group HMO |
$202.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$216.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$186.30
|
| Rate for Payer: PHCS Commercial |
$259.20
|
| Rate for Payer: United Healthcare All Payer |
$237.60
|
|
|
DEST MAL LES > 0.5CM FEENL(T
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
HCPCS 17280
|
| Hospital Charge Code |
761T0266
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$92.85 |
| Max. Negotiated Rate |
$259.20 |
| Rate for Payer: Aetna Commercial |
$207.90
|
| Rate for Payer: Anthem Medicaid |
$92.85
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$210.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cigna Commercial |
$224.10
|
| Rate for Payer: First Health Commercial |
$256.50
|
| Rate for Payer: Humana Commercial |
$229.50
|
| Rate for Payer: Humana KY Medicaid |
$92.85
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$93.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$221.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$199.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$94.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$237.60
|
| Rate for Payer: Ohio Health Group HMO |
$202.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$216.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$186.30
|
| Rate for Payer: PHCS Commercial |
$259.20
|
| Rate for Payer: United Healthcare All Payer |
$237.60
|
|
|
DEST MAL LES < 0.5CM SNHFG
|
Professional
|
Both
|
$495.00
|
|
|
Service Code
|
HCPCS 17270
|
| Hospital Charge Code |
76100260
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$53.47 |
| Max. Negotiated Rate |
$297.00 |
| Rate for Payer: Aetna Commercial |
$137.65
|
| Rate for Payer: Ambetter Exchange |
$90.62
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$53.47
|
| Rate for Payer: Anthem Medicaid |
$76.12
|
| Rate for Payer: Buckeye Individual/Medicaid |
$90.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$90.62
|
| Rate for Payer: CareSource Just4Me Medicare |
$108.74
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Cigna Commercial |
$178.48
|
| Rate for Payer: Healthspan PPO |
$160.14
|
| Rate for Payer: Humana Medicaid |
$76.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$124.73
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$90.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$90.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$77.64
|
| Rate for Payer: Molina Healthcare Passport |
$76.12
|
| Rate for Payer: Multiplan PHCS |
$297.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$117.81
|
| Rate for Payer: UHCCP Medicaid |
$56.14
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$76.88
|
| Rate for Payer: Wellcare Medicare Advantage |
$90.62
|
|
|
DEST MAL LES < 0.5CM SNHFG
|
Facility
|
IP
|
$495.00
|
|
|
Service Code
|
HCPCS 17270
|
| Hospital Charge Code |
76100260
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$148.50 |
| Max. Negotiated Rate |
$475.20 |
| Rate for Payer: Aetna Commercial |
$381.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$386.10
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Cigna Commercial |
$410.85
|
| Rate for Payer: First Health Commercial |
$470.25
|
| Rate for Payer: Humana Commercial |
$420.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$405.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$365.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$148.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$435.60
|
| Rate for Payer: Ohio Health Group HMO |
$371.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$396.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$430.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$341.55
|
| Rate for Payer: PHCS Commercial |
$475.20
|
| Rate for Payer: United Healthcare All Payer |
$435.60
|
|
|
DEST MAL LES < 0.5CM SNHFG
|
Facility
|
OP
|
$495.00
|
|
|
Service Code
|
HCPCS 17270
|
| Hospital Charge Code |
76100260
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$170.23 |
| Max. Negotiated Rate |
$475.20 |
| Rate for Payer: Aetna Commercial |
$381.15
|
| Rate for Payer: Anthem Medicaid |
$170.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$386.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Cash Price |
$247.50
|
| Rate for Payer: Cigna Commercial |
$410.85
|
| Rate for Payer: First Health Commercial |
$470.25
|
| Rate for Payer: Humana Commercial |
$420.75
|
| Rate for Payer: Humana KY Medicaid |
$170.23
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$171.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$405.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$365.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$173.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$435.60
|
| Rate for Payer: Ohio Health Group HMO |
$371.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$396.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$430.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$341.55
|
| Rate for Payer: PHCS Commercial |
$475.20
|
| Rate for Payer: United Healthcare All Payer |
$435.60
|
|
|
DEST MAL LES < 0.5CM SNHFG(P
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 17270
|
| Hospital Charge Code |
761P0260
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$53.47 |
| Max. Negotiated Rate |
$178.48 |
| Rate for Payer: Aetna Commercial |
$137.65
|
| Rate for Payer: Ambetter Exchange |
$90.62
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$53.47
|
| Rate for Payer: Anthem Medicaid |
$76.12
|
| Rate for Payer: Buckeye Individual/Medicaid |
$90.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$90.62
|
| Rate for Payer: CareSource Just4Me Medicare |
$108.74
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$178.48
|
| Rate for Payer: Healthspan PPO |
$160.14
|
| Rate for Payer: Humana Medicaid |
$76.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$124.73
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$90.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$90.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$77.64
|
| Rate for Payer: Molina Healthcare Passport |
$76.12
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$117.81
|
| Rate for Payer: UHCCP Medicaid |
$56.14
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$76.88
|
| Rate for Payer: Wellcare Medicare Advantage |
$90.62
|
|
|
DEST MAL LES < 0.5CM SNHFG(T
|
Facility
|
OP
|
$295.00
|
|
|
Service Code
|
HCPCS 17270
|
| Hospital Charge Code |
761T0260
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$101.45 |
| Max. Negotiated Rate |
$283.20 |
| Rate for Payer: Aetna Commercial |
$227.15
|
| Rate for Payer: Anthem Medicaid |
$101.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$230.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$147.50
|
| Rate for Payer: Cash Price |
$147.50
|
| Rate for Payer: Cigna Commercial |
$244.85
|
| Rate for Payer: First Health Commercial |
$280.25
|
| Rate for Payer: Humana Commercial |
$250.75
|
| Rate for Payer: Humana KY Medicaid |
$101.45
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$102.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$241.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$217.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$103.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$259.60
|
| Rate for Payer: Ohio Health Group HMO |
$221.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$236.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$256.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$203.55
|
| Rate for Payer: PHCS Commercial |
$283.20
|
| Rate for Payer: United Healthcare All Payer |
$259.60
|
|
|
DEST MAL LES < 0.5CM SNHFG(T
|
Facility
|
IP
|
$295.00
|
|
|
Service Code
|
HCPCS 17270
|
| Hospital Charge Code |
761T0260
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$88.50 |
| Max. Negotiated Rate |
$283.20 |
| Rate for Payer: Aetna Commercial |
$227.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$230.10
|
| Rate for Payer: Cash Price |
$147.50
|
| Rate for Payer: Cigna Commercial |
$244.85
|
| Rate for Payer: First Health Commercial |
$280.25
|
| Rate for Payer: Humana Commercial |
$250.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$241.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$217.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$88.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$259.60
|
| Rate for Payer: Ohio Health Group HMO |
$221.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$236.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$256.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$203.55
|
| Rate for Payer: PHCS Commercial |
$283.20
|
| Rate for Payer: United Healthcare All Payer |
$259.60
|
|
|
DEST MAL LES 1.1-2CM TAL
|
Facility
|
IP
|
$673.00
|
|
|
Service Code
|
HCPCS 17262
|
| Hospital Charge Code |
76100256
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$201.90 |
| Max. Negotiated Rate |
$646.08 |
| Rate for Payer: Aetna Commercial |
$518.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$524.94
|
| Rate for Payer: Cash Price |
$336.50
|
| Rate for Payer: Cigna Commercial |
$558.59
|
| Rate for Payer: First Health Commercial |
$639.35
|
| Rate for Payer: Humana Commercial |
$572.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$551.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$496.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$201.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$592.24
|
| Rate for Payer: Ohio Health Group HMO |
$504.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$538.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$585.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$464.37
|
| Rate for Payer: PHCS Commercial |
$646.08
|
| Rate for Payer: United Healthcare All Payer |
$592.24
|
|
|
DEST MAL LES 1.1-2CM TAL
|
Facility
|
OP
|
$673.00
|
|
|
Service Code
|
HCPCS 17262
|
| Hospital Charge Code |
76100256
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$183.59 |
| Max. Negotiated Rate |
$646.08 |
| Rate for Payer: Aetna Commercial |
$518.21
|
| Rate for Payer: Anthem Medicaid |
$231.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$524.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$336.50
|
| Rate for Payer: Cash Price |
$336.50
|
| Rate for Payer: Cigna Commercial |
$558.59
|
| Rate for Payer: First Health Commercial |
$639.35
|
| Rate for Payer: Humana Commercial |
$572.05
|
| Rate for Payer: Humana KY Medicaid |
$231.44
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$233.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$551.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$496.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$236.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$592.24
|
| Rate for Payer: Ohio Health Group HMO |
$504.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$538.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$585.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$464.37
|
| Rate for Payer: PHCS Commercial |
$646.08
|
| Rate for Payer: United Healthcare All Payer |
$592.24
|
|
|
DEST MAL LES 1.1-2CM TAL
|
Professional
|
Both
|
$673.00
|
|
|
Service Code
|
HCPCS 17262
|
| Hospital Charge Code |
76100256
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$69.39 |
| Max. Negotiated Rate |
$403.80 |
| Rate for Payer: Aetna Commercial |
$163.01
|
| Rate for Payer: Ambetter Exchange |
$103.75
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$69.39
|
| Rate for Payer: Anthem Medicaid |
$97.60
|
| Rate for Payer: Buckeye Individual/Medicaid |
$103.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$103.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$124.50
|
| Rate for Payer: Cash Price |
$336.50
|
| Rate for Payer: Cash Price |
$336.50
|
| Rate for Payer: Cigna Commercial |
$216.61
|
| Rate for Payer: Healthspan PPO |
$188.12
|
| Rate for Payer: Humana Medicaid |
$97.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$146.30
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$103.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$103.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$99.55
|
| Rate for Payer: Molina Healthcare Passport |
$97.60
|
| Rate for Payer: Multiplan PHCS |
$403.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$134.88
|
| Rate for Payer: UHCCP Medicaid |
$72.86
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$98.58
|
| Rate for Payer: Wellcare Medicare Advantage |
$103.75
|
|
|
DEST MAL LES 1.1-2CM TAL(P
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
HCPCS 17262
|
| Hospital Charge Code |
761P0256
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$69.39 |
| Max. Negotiated Rate |
$216.61 |
| Rate for Payer: Aetna Commercial |
$163.01
|
| Rate for Payer: Ambetter Exchange |
$103.75
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$69.39
|
| Rate for Payer: Anthem Medicaid |
$97.60
|
| Rate for Payer: Buckeye Individual/Medicaid |
$103.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$103.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$124.50
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna Commercial |
$216.61
|
| Rate for Payer: Healthspan PPO |
$188.12
|
| Rate for Payer: Humana Medicaid |
$97.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$146.30
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$103.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$103.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$99.55
|
| Rate for Payer: Molina Healthcare Passport |
$97.60
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$134.88
|
| Rate for Payer: UHCCP Medicaid |
$72.86
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$98.58
|
| Rate for Payer: Wellcare Medicare Advantage |
$103.75
|
|
|
DEST MAL LES 1.1-2CM TAL(T
|
Facility
|
OP
|
$323.00
|
|
|
Service Code
|
HCPCS 17262
|
| Hospital Charge Code |
761T0256
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$111.08 |
| Max. Negotiated Rate |
$310.08 |
| Rate for Payer: Aetna Commercial |
$248.71
|
| Rate for Payer: Anthem Medicaid |
$111.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$251.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$161.50
|
| Rate for Payer: Cash Price |
$161.50
|
| Rate for Payer: Cigna Commercial |
$268.09
|
| Rate for Payer: First Health Commercial |
$306.85
|
| Rate for Payer: Humana Commercial |
$274.55
|
| Rate for Payer: Humana KY Medicaid |
$111.08
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$112.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$264.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$238.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$113.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$284.24
|
| Rate for Payer: Ohio Health Group HMO |
$242.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$258.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$281.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$222.87
|
| Rate for Payer: PHCS Commercial |
$310.08
|
| Rate for Payer: United Healthcare All Payer |
$284.24
|
|
|
DEST MAL LES 1.1-2CM TAL(T
|
Facility
|
IP
|
$323.00
|
|
|
Service Code
|
HCPCS 17262
|
| Hospital Charge Code |
761T0256
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$96.90 |
| Max. Negotiated Rate |
$310.08 |
| Rate for Payer: Aetna Commercial |
$248.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$251.94
|
| Rate for Payer: Cash Price |
$161.50
|
| Rate for Payer: Cigna Commercial |
$268.09
|
| Rate for Payer: First Health Commercial |
$306.85
|
| Rate for Payer: Humana Commercial |
$274.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$264.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$238.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$284.24
|
| Rate for Payer: Ohio Health Group HMO |
$242.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$258.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$281.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$222.87
|
| Rate for Payer: PHCS Commercial |
$310.08
|
| Rate for Payer: United Healthcare All Payer |
$284.24
|
|
|
DEST MAL LES 2.1-3CM SNHF
|
Facility
|
IP
|
$892.00
|
|
|
Service Code
|
HCPCS 17273
|
| Hospital Charge Code |
76100263
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$267.60 |
| Max. Negotiated Rate |
$856.32 |
| Rate for Payer: Aetna Commercial |
$686.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$695.76
|
| Rate for Payer: Cash Price |
$446.00
|
| Rate for Payer: Cigna Commercial |
$740.36
|
| Rate for Payer: First Health Commercial |
$847.40
|
| Rate for Payer: Humana Commercial |
$758.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$731.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$658.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$267.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$784.96
|
| Rate for Payer: Ohio Health Group HMO |
$669.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$713.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$776.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$615.48
|
| Rate for Payer: PHCS Commercial |
$856.32
|
| Rate for Payer: United Healthcare All Payer |
$784.96
|
|
|
DEST MAL LES 2.1-3CM SNHF
|
Professional
|
Both
|
$892.00
|
|
|
Service Code
|
HCPCS 17273
|
| Hospital Charge Code |
76100263
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$95.48 |
| Max. Negotiated Rate |
$535.20 |
| Rate for Payer: Aetna Commercial |
$203.35
|
| Rate for Payer: Ambetter Exchange |
$128.87
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$95.48
|
| Rate for Payer: Anthem Medicaid |
$133.96
|
| Rate for Payer: Buckeye Individual/Medicaid |
$128.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$128.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$154.64
|
| Rate for Payer: Cash Price |
$446.00
|
| Rate for Payer: Cash Price |
$446.00
|
| Rate for Payer: Cigna Commercial |
$249.99
|
| Rate for Payer: Healthspan PPO |
$226.79
|
| Rate for Payer: Humana Medicaid |
$133.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$182.10
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$128.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$128.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$136.64
|
| Rate for Payer: Molina Healthcare Passport |
$133.96
|
| Rate for Payer: Multiplan PHCS |
$535.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$167.53
|
| Rate for Payer: UHCCP Medicaid |
$100.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$135.30
|
| Rate for Payer: Wellcare Medicare Advantage |
$128.87
|
|
|
DEST MAL LES 2.1-3CM SNHF
|
Facility
|
OP
|
$892.00
|
|
|
Service Code
|
HCPCS 17273
|
| Hospital Charge Code |
76100263
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$306.76 |
| Max. Negotiated Rate |
$856.32 |
| Rate for Payer: Aetna Commercial |
$686.84
|
| Rate for Payer: Anthem Medicaid |
$306.76
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$695.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$446.00
|
| Rate for Payer: Cash Price |
$446.00
|
| Rate for Payer: Cigna Commercial |
$740.36
|
| Rate for Payer: First Health Commercial |
$847.40
|
| Rate for Payer: Humana Commercial |
$758.20
|
| Rate for Payer: Humana KY Medicaid |
$306.76
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$309.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$731.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$658.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$312.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$784.96
|
| Rate for Payer: Ohio Health Group HMO |
$669.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$713.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$776.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$615.48
|
| Rate for Payer: PHCS Commercial |
$856.32
|
| Rate for Payer: United Healthcare All Payer |
$784.96
|
|
|
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 |
$249.99 |
| Rate for Payer: Aetna Commercial |
$203.35
|
| Rate for Payer: Ambetter Exchange |
$128.87
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$95.48
|
| Rate for Payer: Anthem Medicaid |
$133.96
|
| Rate for Payer: Buckeye Individual/Medicaid |
$128.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$128.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$154.64
|
| 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 |
$133.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$182.10
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$128.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$128.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$136.64
|
| Rate for Payer: Molina Healthcare Passport |
$133.96
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$167.53
|
| Rate for Payer: UHCCP Medicaid |
$100.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$135.30
|
| Rate for Payer: Wellcare Medicare Advantage |
$128.87
|
|
|
DEST MAL LES 2.1-3CM SNHF(T
|
Facility
|
OP
|
$492.00
|
|
|
Service Code
|
HCPCS 17273
|
| Hospital Charge Code |
761T0263
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$169.20 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Aetna Commercial |
$378.84
|
| Rate for Payer: Anthem Medicaid |
$169.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$383.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Cigna Commercial |
$408.36
|
| Rate for Payer: First Health Commercial |
$467.40
|
| Rate for Payer: Humana Commercial |
$418.20
|
| Rate for Payer: Humana KY Medicaid |
$169.20
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$170.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$403.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$363.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$172.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$432.96
|
| Rate for Payer: Ohio Health Group HMO |
$369.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$393.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$428.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$339.48
|
| Rate for Payer: PHCS Commercial |
$472.32
|
| Rate for Payer: United Healthcare All Payer |
$432.96
|
|
|
DEST MAL LES 2.1-3CM SNHF(T
|
Facility
|
IP
|
$492.00
|
|
|
Service Code
|
HCPCS 17273
|
| Hospital Charge Code |
761T0263
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$147.60 |
| Max. Negotiated Rate |
$472.32 |
| Rate for Payer: Aetna Commercial |
$378.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$383.76
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Cigna Commercial |
$408.36
|
| Rate for Payer: First Health Commercial |
$467.40
|
| Rate for Payer: Humana Commercial |
$418.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$403.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$363.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$432.96
|
| Rate for Payer: Ohio Health Group HMO |
$369.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$393.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$428.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$339.48
|
| Rate for Payer: PHCS Commercial |
$472.32
|
| Rate for Payer: United Healthcare All Payer |
$432.96
|
|
|
DEST MAL LES 2.1-3CM TAL
|
Professional
|
Both
|
$739.00
|
|
|
Service Code
|
HCPCS 17263
|
| Hospital Charge Code |
76100257
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$82.27 |
| Max. Negotiated Rate |
$443.40 |
| Rate for Payer: Aetna Commercial |
$180.67
|
| Rate for Payer: Ambetter Exchange |
$114.74
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$82.27
|
| Rate for Payer: Anthem Medicaid |
$116.51
|
| Rate for Payer: Buckeye Individual/Medicaid |
$114.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$114.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$137.69
|
| Rate for Payer: Cash Price |
$369.50
|
| Rate for Payer: Cash Price |
$369.50
|
| Rate for Payer: Cigna Commercial |
$227.58
|
| Rate for Payer: Healthspan PPO |
$207.80
|
| Rate for Payer: Humana Medicaid |
$116.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$162.06
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$114.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.74
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$118.84
|
| Rate for Payer: Molina Healthcare Passport |
$116.51
|
| Rate for Payer: Multiplan PHCS |
$443.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$149.16
|
| Rate for Payer: UHCCP Medicaid |
$86.38
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$117.68
|
| Rate for Payer: Wellcare Medicare Advantage |
$114.74
|
|
|
DEST MAL LES 2.1-3CM TAL
|
Facility
|
IP
|
$739.00
|
|
|
Service Code
|
HCPCS 17263
|
| Hospital Charge Code |
76100257
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$221.70 |
| Max. Negotiated Rate |
$709.44 |
| Rate for Payer: Aetna Commercial |
$569.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$576.42
|
| Rate for Payer: Cash Price |
$369.50
|
| Rate for Payer: Cigna Commercial |
$613.37
|
| Rate for Payer: First Health Commercial |
$702.05
|
| Rate for Payer: Humana Commercial |
$628.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$605.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$545.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$221.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$650.32
|
| Rate for Payer: Ohio Health Group HMO |
$554.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$591.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$642.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$509.91
|
| Rate for Payer: PHCS Commercial |
$709.44
|
| Rate for Payer: United Healthcare All Payer |
$650.32
|
|
|
DEST MAL LES 2.1-3CM TAL
|
Facility
|
OP
|
$739.00
|
|
|
Service Code
|
HCPCS 17263
|
| Hospital Charge Code |
76100257
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$183.59 |
| Max. Negotiated Rate |
$709.44 |
| Rate for Payer: Aetna Commercial |
$569.03
|
| Rate for Payer: Anthem Medicaid |
$254.14
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$576.42
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$369.50
|
| Rate for Payer: Cash Price |
$369.50
|
| Rate for Payer: Cigna Commercial |
$613.37
|
| Rate for Payer: First Health Commercial |
$702.05
|
| Rate for Payer: Humana Commercial |
$628.15
|
| Rate for Payer: Humana KY Medicaid |
$254.14
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$256.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$605.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$545.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$259.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$650.32
|
| Rate for Payer: Ohio Health Group HMO |
$554.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$591.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$642.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$509.91
|
| Rate for Payer: PHCS Commercial |
$709.44
|
| Rate for Payer: United Healthcare All Payer |
$650.32
|
|
|
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 |
$240.00 |
| Rate for Payer: Aetna Commercial |
$180.67
|
| Rate for Payer: Ambetter Exchange |
$114.74
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$82.27
|
| Rate for Payer: Anthem Medicaid |
$116.51
|
| Rate for Payer: Buckeye Individual/Medicaid |
$114.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$114.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$137.69
|
| 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 |
$116.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$162.06
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$114.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.74
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$118.84
|
| Rate for Payer: Molina Healthcare Passport |
$116.51
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$149.16
|
| Rate for Payer: UHCCP Medicaid |
$86.38
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$117.68
|
| Rate for Payer: Wellcare Medicare Advantage |
$114.74
|
|
