|
DEST MAL LES 2.1-3CM TAL(T
|
Facility
|
IP
|
$339.00
|
|
|
Service Code
|
HCPCS 17263
|
| Hospital Charge Code |
761T0257
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$101.70 |
| Max. Negotiated Rate |
$325.44 |
| Rate for Payer: Aetna Commercial |
$261.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$264.42
|
| Rate for Payer: Cash Price |
$169.50
|
| Rate for Payer: Cigna Commercial |
$281.37
|
| Rate for Payer: First Health Commercial |
$322.05
|
| Rate for Payer: Humana Commercial |
$288.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$277.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$250.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$101.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$298.32
|
| Rate for Payer: Ohio Health Group HMO |
$254.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$271.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$294.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$233.91
|
| Rate for Payer: PHCS Commercial |
$325.44
|
| Rate for Payer: United Healthcare All Payer |
$298.32
|
|
|
DEST MAL LES 2.1-3CM TAL(T
|
Facility
|
OP
|
$339.00
|
|
|
Service Code
|
HCPCS 17263
|
| Hospital Charge Code |
761T0257
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$116.58 |
| Max. Negotiated Rate |
$325.44 |
| Rate for Payer: Aetna Commercial |
$261.03
|
| Rate for Payer: Anthem Medicaid |
$116.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$264.42
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$169.50
|
| Rate for Payer: Cash Price |
$169.50
|
| Rate for Payer: Cigna Commercial |
$281.37
|
| Rate for Payer: First Health Commercial |
$322.05
|
| Rate for Payer: Humana Commercial |
$288.15
|
| Rate for Payer: Humana KY Medicaid |
$116.58
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$117.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$277.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$250.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$118.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$298.32
|
| Rate for Payer: Ohio Health Group HMO |
$254.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$271.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$294.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$233.91
|
| Rate for Payer: PHCS Commercial |
$325.44
|
| Rate for Payer: United Healthcare All Payer |
$298.32
|
|
|
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 |
$349.40 |
| 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 |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$792.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| 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 |
$369.16
|
| 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 |
$442.99
|
| 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 |
$812.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$883.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$701.04
|
| Rate for Payer: PHCS Commercial |
$975.36
|
| Rate for Payer: United Healthcare All Payer |
$894.08
|
|
|
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 |
$609.60 |
| Rate for Payer: Aetna Commercial |
$249.86
|
| Rate for Payer: Ambetter Exchange |
$158.11
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$116.48
|
| Rate for Payer: Anthem Medicaid |
$168.41
|
| Rate for Payer: Buckeye Individual/Medicaid |
$158.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$158.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$189.73
|
| 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 |
$168.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$222.50
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$158.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$158.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$171.78
|
| Rate for Payer: Molina Healthcare Passport |
$168.41
|
| Rate for Payer: Multiplan PHCS |
$609.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$205.54
|
| Rate for Payer: UHCCP Medicaid |
$122.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$170.09
|
| Rate for Payer: Wellcare Medicare Advantage |
$158.11
|
|
|
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 |
$304.80 |
| 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 |
$812.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$883.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$701.04
|
| 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 |
$301.02 |
| Rate for Payer: Aetna Commercial |
$249.86
|
| Rate for Payer: Ambetter Exchange |
$158.11
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$116.48
|
| Rate for Payer: Anthem Medicaid |
$168.41
|
| Rate for Payer: Buckeye Individual/Medicaid |
$158.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$158.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$189.73
|
| 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 |
$168.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$222.50
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$158.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$158.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$171.78
|
| Rate for Payer: Molina Healthcare Passport |
$168.41
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$205.54
|
| Rate for Payer: UHCCP Medicaid |
$122.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$170.09
|
| Rate for Payer: Wellcare Medicare Advantage |
$158.11
|
|
|
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 |
$177.45 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Aetna Commercial |
$397.32
|
| Rate for Payer: Anthem Medicaid |
$177.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$402.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| 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 |
$369.16
|
| 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 |
$442.99
|
| 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 |
$412.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$448.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$356.04
|
| 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
|
IP
|
$516.00
|
|
|
Service Code
|
HCPCS 17274
|
| Hospital Charge Code |
761T0264
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$154.80 |
| 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 |
$412.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$448.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$356.04
|
| Rate for Payer: PHCS Commercial |
$495.36
|
| Rate for Payer: United Healthcare All Payer |
$454.08
|
|
|
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 |
$257.40 |
| 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 |
$686.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$746.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$592.02
|
| 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 |
$514.80 |
| Rate for Payer: Aetna Commercial |
$193.25
|
| Rate for Payer: Ambetter Exchange |
$123.25
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$93.95
|
| Rate for Payer: Anthem Medicaid |
$131.25
|
| Rate for Payer: Buckeye Individual/Medicaid |
$123.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$123.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$147.90
|
| 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 |
$131.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$173.25
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$123.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$123.25
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$133.88
|
| Rate for Payer: Molina Healthcare Passport |
$131.25
|
| Rate for Payer: Multiplan PHCS |
$514.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$160.22
|
| Rate for Payer: UHCCP Medicaid |
$98.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$132.56
|
| Rate for Payer: Wellcare Medicare Advantage |
$123.25
|
|
|
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 |
$295.07 |
| 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 |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$669.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| 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 |
$369.16
|
| 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 |
$442.99
|
| 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 |
$686.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$746.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$592.02
|
| 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 |
$245.74 |
| Rate for Payer: Aetna Commercial |
$193.25
|
| Rate for Payer: Ambetter Exchange |
$123.25
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$93.95
|
| Rate for Payer: Anthem Medicaid |
$131.25
|
| Rate for Payer: Buckeye Individual/Medicaid |
$123.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$123.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$147.90
|
| 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 |
$131.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$173.25
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$123.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$123.25
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$133.88
|
| Rate for Payer: Molina Healthcare Passport |
$131.25
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$160.22
|
| Rate for Payer: UHCCP Medicaid |
$98.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$132.56
|
| Rate for Payer: Wellcare Medicare Advantage |
$123.25
|
|
|
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 |
$137.40 |
| 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 |
$366.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$398.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$316.02
|
| 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
|
OP
|
$458.00
|
|
|
Service Code
|
HCPCS 17264
|
| Hospital Charge Code |
761T0258
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$157.51 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Aetna Commercial |
$352.66
|
| Rate for Payer: Anthem Medicaid |
$157.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$357.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| 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 |
$369.16
|
| 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 |
$442.99
|
| 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 |
$366.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$398.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$316.02
|
| Rate for Payer: PHCS Commercial |
$439.68
|
| Rate for Payer: United Healthcare All Payer |
$403.04
|
|
|
DEST MAL LES > 4.0CM SNHFG
|
Professional
|
Both
|
$1,089.00
|
|
|
Service Code
|
HCPCS 17276
|
| Hospital Charge Code |
76100265
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$138.35 |
| Max. Negotiated Rate |
$653.40 |
| Rate for Payer: Aetna Commercial |
$302.19
|
| Rate for Payer: Ambetter Exchange |
$190.23
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$138.35
|
| Rate for Payer: Anthem Medicaid |
$196.29
|
| Rate for Payer: Buckeye Individual/Medicaid |
$190.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$190.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$228.28
|
| Rate for Payer: Cash Price |
$544.50
|
| Rate for Payer: Cash Price |
$544.50
|
| Rate for Payer: Cigna Commercial |
$356.17
|
| Rate for Payer: Healthspan PPO |
$313.52
|
| Rate for Payer: Humana Medicaid |
$196.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$267.14
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$190.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.23
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$200.22
|
| Rate for Payer: Molina Healthcare Passport |
$196.29
|
| Rate for Payer: Multiplan PHCS |
$653.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$247.30
|
| Rate for Payer: UHCCP Medicaid |
$145.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$198.25
|
| Rate for Payer: Wellcare Medicare Advantage |
$190.23
|
|
|
DEST MAL LES > 4.0CM SNHFG
|
Facility
|
OP
|
$1,089.00
|
|
|
Service Code
|
HCPCS 17276
|
| Hospital Charge Code |
76100265
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$369.16 |
| Max. Negotiated Rate |
$1,045.44 |
| Rate for Payer: Aetna Commercial |
$838.53
|
| Rate for Payer: Anthem Medicaid |
$374.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$849.42
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$544.50
|
| Rate for Payer: Cash Price |
$544.50
|
| Rate for Payer: Cigna Commercial |
$903.87
|
| Rate for Payer: First Health Commercial |
$1,034.55
|
| Rate for Payer: Humana Commercial |
$925.65
|
| Rate for Payer: Humana KY Medicaid |
$374.51
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$378.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$892.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$803.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$382.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$958.32
|
| Rate for Payer: Ohio Health Group HMO |
$816.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$871.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$947.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$751.41
|
| Rate for Payer: PHCS Commercial |
$1,045.44
|
| Rate for Payer: United Healthcare All Payer |
$958.32
|
|
|
DEST MAL LES > 4.0CM SNHFG
|
Facility
|
IP
|
$1,089.00
|
|
|
Service Code
|
HCPCS 17276
|
| Hospital Charge Code |
76100265
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$326.70 |
| Max. Negotiated Rate |
$1,045.44 |
| Rate for Payer: Aetna Commercial |
$838.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$849.42
|
| Rate for Payer: Cash Price |
$544.50
|
| Rate for Payer: Cigna Commercial |
$903.87
|
| Rate for Payer: First Health Commercial |
$1,034.55
|
| Rate for Payer: Humana Commercial |
$925.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$892.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$803.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$326.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$958.32
|
| Rate for Payer: Ohio Health Group HMO |
$816.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$871.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$947.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$751.41
|
| Rate for Payer: PHCS Commercial |
$1,045.44
|
| Rate for Payer: United Healthcare All Payer |
$958.32
|
|
|
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 |
$360.00 |
| Rate for Payer: Aetna Commercial |
$302.19
|
| Rate for Payer: Ambetter Exchange |
$190.23
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$138.35
|
| Rate for Payer: Anthem Medicaid |
$196.29
|
| Rate for Payer: Buckeye Individual/Medicaid |
$190.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$190.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$228.28
|
| 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 |
$196.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$267.14
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$190.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.23
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$200.22
|
| Rate for Payer: Molina Healthcare Passport |
$196.29
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$247.30
|
| Rate for Payer: UHCCP Medicaid |
$145.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$198.25
|
| Rate for Payer: Wellcare Medicare Advantage |
$190.23
|
|
|
DEST MAL LES > 4.0CM SNHFG(T
|
Facility
|
OP
|
$489.00
|
|
|
Service Code
|
HCPCS 17276
|
| Hospital Charge Code |
761T0265
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$168.17 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Aetna Commercial |
$376.53
|
| Rate for Payer: Anthem Medicaid |
$168.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$381.42
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$244.50
|
| Rate for Payer: Cash Price |
$244.50
|
| Rate for Payer: Cigna Commercial |
$405.87
|
| Rate for Payer: First Health Commercial |
$464.55
|
| Rate for Payer: Humana Commercial |
$415.65
|
| Rate for Payer: Humana KY Medicaid |
$168.17
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$169.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$400.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$360.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$171.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$430.32
|
| Rate for Payer: Ohio Health Group HMO |
$366.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$391.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$425.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$337.41
|
| Rate for Payer: PHCS Commercial |
$469.44
|
| Rate for Payer: United Healthcare All Payer |
$430.32
|
|
|
DEST MAL LES > 4.0CM SNHFG(T
|
Facility
|
IP
|
$489.00
|
|
|
Service Code
|
HCPCS 17276
|
| Hospital Charge Code |
761T0265
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$146.70 |
| Max. Negotiated Rate |
$469.44 |
| Rate for Payer: Aetna Commercial |
$376.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$381.42
|
| Rate for Payer: Cash Price |
$244.50
|
| Rate for Payer: Cigna Commercial |
$405.87
|
| Rate for Payer: First Health Commercial |
$464.55
|
| Rate for Payer: Humana Commercial |
$415.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$400.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$360.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$146.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$430.32
|
| Rate for Payer: Ohio Health Group HMO |
$366.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$391.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$425.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$337.41
|
| Rate for Payer: PHCS Commercial |
$469.44
|
| Rate for Payer: United Healthcare All Payer |
$430.32
|
|
|
DEST MAL LES > 4.0CM - TAL
|
Professional
|
Both
|
$917.00
|
|
|
Service Code
|
HCPCS 17266
|
| Hospital Charge Code |
76100259
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$99.51 |
| Max. Negotiated Rate |
$550.20 |
| Rate for Payer: Aetna Commercial |
$225.08
|
| Rate for Payer: Ambetter Exchange |
$144.30
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$99.51
|
| Rate for Payer: Anthem Medicaid |
$162.52
|
| Rate for Payer: Buckeye Individual/Medicaid |
$144.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$144.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$173.16
|
| Rate for Payer: Cash Price |
$458.50
|
| Rate for Payer: Cash Price |
$458.50
|
| Rate for Payer: Cigna Commercial |
$282.99
|
| Rate for Payer: Healthspan PPO |
$253.16
|
| Rate for Payer: Humana Medicaid |
$162.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$201.77
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$144.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$144.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$165.77
|
| Rate for Payer: Molina Healthcare Passport |
$162.52
|
| Rate for Payer: Multiplan PHCS |
$550.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$187.59
|
| Rate for Payer: UHCCP Medicaid |
$104.49
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$164.15
|
| Rate for Payer: Wellcare Medicare Advantage |
$144.30
|
|
|
DEST MAL LES > 4.0CM - TAL
|
Facility
|
IP
|
$917.00
|
|
|
Service Code
|
HCPCS 17266
|
| Hospital Charge Code |
76100259
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$275.10 |
| Max. Negotiated Rate |
$880.32 |
| Rate for Payer: Aetna Commercial |
$706.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$715.26
|
| Rate for Payer: Cash Price |
$458.50
|
| Rate for Payer: Cigna Commercial |
$761.11
|
| Rate for Payer: First Health Commercial |
$871.15
|
| Rate for Payer: Humana Commercial |
$779.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$751.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$676.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$275.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$806.96
|
| Rate for Payer: Ohio Health Group HMO |
$687.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$733.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$797.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$632.73
|
| Rate for Payer: PHCS Commercial |
$880.32
|
| Rate for Payer: United Healthcare All Payer |
$806.96
|
|
|
DEST MAL LES > 4.0CM - TAL
|
Facility
|
OP
|
$917.00
|
|
|
Service Code
|
HCPCS 17266
|
| Hospital Charge Code |
76100259
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$315.36 |
| Max. Negotiated Rate |
$880.32 |
| Rate for Payer: Aetna Commercial |
$706.09
|
| Rate for Payer: Anthem Medicaid |
$315.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$715.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$458.50
|
| Rate for Payer: Cash Price |
$458.50
|
| Rate for Payer: Cigna Commercial |
$761.11
|
| Rate for Payer: First Health Commercial |
$871.15
|
| Rate for Payer: Humana Commercial |
$779.45
|
| Rate for Payer: Humana KY Medicaid |
$315.36
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$318.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$751.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$676.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$321.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$806.96
|
| Rate for Payer: Ohio Health Group HMO |
$687.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$733.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$797.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$632.73
|
| Rate for Payer: PHCS Commercial |
$880.32
|
| Rate for Payer: United Healthcare All Payer |
$806.96
|
|
|
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 |
$282.99 |
| Rate for Payer: Aetna Commercial |
$225.08
|
| Rate for Payer: Ambetter Exchange |
$144.30
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$99.51
|
| Rate for Payer: Anthem Medicaid |
$162.52
|
| Rate for Payer: Buckeye Individual/Medicaid |
$144.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$144.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$173.16
|
| 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 |
$162.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$201.77
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$144.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$144.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$165.77
|
| Rate for Payer: Molina Healthcare Passport |
$162.52
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$187.59
|
| Rate for Payer: UHCCP Medicaid |
$104.49
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$164.15
|
| Rate for Payer: Wellcare Medicare Advantage |
$144.30
|
|
|
DEST MAL LES > 4.0CM - TAL(T
|
Facility
|
IP
|
$467.00
|
|
|
Service Code
|
HCPCS 17266
|
| Hospital Charge Code |
761T0259
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$140.10 |
| Max. Negotiated Rate |
$448.32 |
| Rate for Payer: Aetna Commercial |
$359.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$364.26
|
| Rate for Payer: Cash Price |
$233.50
|
| Rate for Payer: Cigna Commercial |
$387.61
|
| Rate for Payer: First Health Commercial |
$443.65
|
| Rate for Payer: Humana Commercial |
$396.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$382.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$344.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$140.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$410.96
|
| Rate for Payer: Ohio Health Group HMO |
$350.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$373.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$406.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$322.23
|
| Rate for Payer: PHCS Commercial |
$448.32
|
| Rate for Payer: United Healthcare All Payer |
$410.96
|
|
