|
EXC ABD LES SC 3 CM/>
|
Facility
|
IP
|
$6,065.00
|
|
|
Service Code
|
HCPCS 22903
|
| Hospital Charge Code |
76100430
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,819.50 |
| Max. Negotiated Rate |
$5,822.40 |
| Rate for Payer: Aetna Commercial |
$4,670.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,730.70
|
| Rate for Payer: Cash Price |
$3,032.50
|
| Rate for Payer: Cigna Commercial |
$5,033.95
|
| Rate for Payer: First Health Commercial |
$5,761.75
|
| Rate for Payer: Humana Commercial |
$5,155.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,973.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,475.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,819.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,337.20
|
| Rate for Payer: Ohio Health Group HMO |
$4,548.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,852.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,276.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,184.85
|
| Rate for Payer: PHCS Commercial |
$5,822.40
|
| Rate for Payer: United Healthcare All Payer |
$5,337.20
|
|
|
EXC ABD LES SC 3 CM/>(P
|
Professional
|
Both
|
$575.00
|
|
|
Service Code
|
HCPCS 22903
|
| Hospital Charge Code |
761P0430
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$201.25 |
| Max. Negotiated Rate |
$770.20 |
| Rate for Payer: Aetna Commercial |
$675.66
|
| Rate for Payer: Ambetter Exchange |
$421.15
|
| Rate for Payer: Anthem Medicaid |
$318.49
|
| Rate for Payer: Buckeye Individual/Medicaid |
$421.15
|
| Rate for Payer: Buckeye Medicare Advantage |
$421.15
|
| Rate for Payer: CareSource Just4Me Medicare |
$505.38
|
| Rate for Payer: Cash Price |
$287.50
|
| Rate for Payer: Cash Price |
$287.50
|
| Rate for Payer: Cigna Commercial |
$770.20
|
| Rate for Payer: Healthspan PPO |
$481.50
|
| Rate for Payer: Humana Medicaid |
$318.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$559.76
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$421.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$421.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$324.86
|
| Rate for Payer: Molina Healthcare Passport |
$318.49
|
| Rate for Payer: Multiplan PHCS |
$345.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$547.50
|
| Rate for Payer: UHCCP Medicaid |
$201.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$321.67
|
| Rate for Payer: Wellcare Medicare Advantage |
$421.15
|
|
|
EXC ABD LES SC 3 CM/>(T
|
Facility
|
OP
|
$5,490.00
|
|
|
Service Code
|
HCPCS 22903
|
| Hospital Charge Code |
761T0430
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,888.01 |
| Max. Negotiated Rate |
$5,270.40 |
| Rate for Payer: Aetna Commercial |
$4,227.30
|
| Rate for Payer: Anthem Medicaid |
$1,888.01
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,644.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,282.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,702.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,570.05
|
| Rate for Payer: Cash Price |
$2,745.00
|
| Rate for Payer: Cash Price |
$2,745.00
|
| Rate for Payer: Cigna Commercial |
$4,556.70
|
| Rate for Payer: First Health Commercial |
$5,215.50
|
| Rate for Payer: Humana Commercial |
$4,666.50
|
| Rate for Payer: Humana KY Medicaid |
$1,888.01
|
| Rate for Payer: Humana Medicare Advantage |
$2,644.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1,907.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,501.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,051.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,173.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,925.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,831.20
|
| Rate for Payer: Ohio Health Group HMO |
$4,117.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,392.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,776.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,788.10
|
| Rate for Payer: PHCS Commercial |
$5,270.40
|
| Rate for Payer: United Healthcare All Payer |
$4,831.20
|
|
|
EXC ABD LES SC 3 CM/>(T
|
Facility
|
IP
|
$5,490.00
|
|
|
Service Code
|
HCPCS 22903
|
| Hospital Charge Code |
761T0430
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,647.00 |
| Max. Negotiated Rate |
$5,270.40 |
| Rate for Payer: Aetna Commercial |
$4,227.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,282.20
|
| Rate for Payer: Cash Price |
$2,745.00
|
| Rate for Payer: Cigna Commercial |
$4,556.70
|
| Rate for Payer: First Health Commercial |
$5,215.50
|
| Rate for Payer: Humana Commercial |
$4,666.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,501.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,051.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,647.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,831.20
|
| Rate for Payer: Ohio Health Group HMO |
$4,117.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,392.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,776.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,788.10
|
| Rate for Payer: PHCS Commercial |
$5,270.40
|
| Rate for Payer: United Healthcare All Payer |
$4,831.20
|
|
|
EXC ABDL TUM DEEP 5 CM/>
|
Facility
|
IP
|
$1,100.00
|
|
|
Service Code
|
HCPCS 22901
|
| Hospital Charge Code |
76100428
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$330.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$759.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
EXC ABDL TUM DEEP 5 CM/>
|
Professional
|
Both
|
$1,100.00
|
|
|
Service Code
|
HCPCS 22901
|
| Hospital Charge Code |
76100428
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$385.00 |
| Max. Negotiated Rate |
$1,166.64 |
| Rate for Payer: Aetna Commercial |
$1,026.53
|
| Rate for Payer: Ambetter Exchange |
$637.06
|
| Rate for Payer: Anthem Medicaid |
$481.77
|
| Rate for Payer: Buckeye Individual/Medicaid |
$637.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$637.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$764.47
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$1,166.64
|
| Rate for Payer: Healthspan PPO |
$732.54
|
| Rate for Payer: Humana Medicaid |
$481.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$838.08
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$637.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$637.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$491.41
|
| Rate for Payer: Molina Healthcare Passport |
$481.77
|
| Rate for Payer: Multiplan PHCS |
$660.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$828.18
|
| Rate for Payer: UHCCP Medicaid |
$385.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$486.59
|
| Rate for Payer: Wellcare Medicare Advantage |
$637.06
|
|
|
EXC ABDL TUM DEEP 5 CM/>
|
Facility
|
OP
|
$1,100.00
|
|
|
Service Code
|
HCPCS 22901
|
| Hospital Charge Code |
76100428
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$378.29 |
| Max. Negotiated Rate |
$3,702.27 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem Medicaid |
$378.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,644.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,702.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,570.05
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Humana KY Medicaid |
$378.29
|
| Rate for Payer: Humana Medicare Advantage |
$2,644.48
|
| Rate for Payer: Kentucky WC Medicaid |
$382.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,173.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$385.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$759.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
EXC ABDL TUM DEEP 5 CM/>(P
|
Professional
|
Both
|
$1,100.00
|
|
|
Service Code
|
HCPCS 22901
|
| Hospital Charge Code |
761P0428
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$385.00 |
| Max. Negotiated Rate |
$1,166.64 |
| Rate for Payer: Aetna Commercial |
$1,026.53
|
| Rate for Payer: Ambetter Exchange |
$637.06
|
| Rate for Payer: Anthem Medicaid |
$481.77
|
| Rate for Payer: Buckeye Individual/Medicaid |
$637.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$637.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$764.47
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$1,166.64
|
| Rate for Payer: Healthspan PPO |
$732.54
|
| Rate for Payer: Humana Medicaid |
$481.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$838.08
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$637.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$637.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$491.41
|
| Rate for Payer: Molina Healthcare Passport |
$481.77
|
| Rate for Payer: Multiplan PHCS |
$660.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$828.18
|
| Rate for Payer: UHCCP Medicaid |
$385.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$486.59
|
| Rate for Payer: Wellcare Medicare Advantage |
$637.06
|
|
|
EXC ARM/ELBOW LES SC 3 CM/>
|
Facility
|
IP
|
$6,187.00
|
|
|
Service Code
|
HCPCS 24071
|
| Hospital Charge Code |
76100500
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,856.10 |
| Max. Negotiated Rate |
$5,939.52 |
| Rate for Payer: Aetna Commercial |
$4,763.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,825.86
|
| Rate for Payer: Cash Price |
$3,093.50
|
| Rate for Payer: Cigna Commercial |
$5,135.21
|
| Rate for Payer: First Health Commercial |
$5,877.65
|
| Rate for Payer: Humana Commercial |
$5,258.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,073.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,566.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,856.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,444.56
|
| Rate for Payer: Ohio Health Group HMO |
$4,640.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,949.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,382.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,269.03
|
| Rate for Payer: PHCS Commercial |
$5,939.52
|
| Rate for Payer: United Healthcare All Payer |
$5,444.56
|
|
|
EXC ARM/ELBOW LES SC 3 CM/>
|
Facility
|
OP
|
$6,187.00
|
|
|
Service Code
|
HCPCS 24071
|
| Hospital Charge Code |
76100500
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,127.71 |
| Max. Negotiated Rate |
$5,939.52 |
| Rate for Payer: Aetna Commercial |
$4,763.99
|
| Rate for Payer: Anthem Medicaid |
$2,127.71
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,644.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,825.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,702.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,570.05
|
| Rate for Payer: Cash Price |
$3,093.50
|
| Rate for Payer: Cash Price |
$3,093.50
|
| Rate for Payer: Cigna Commercial |
$5,135.21
|
| Rate for Payer: First Health Commercial |
$5,877.65
|
| Rate for Payer: Humana Commercial |
$5,258.95
|
| Rate for Payer: Humana KY Medicaid |
$2,127.71
|
| Rate for Payer: Humana Medicare Advantage |
$2,644.48
|
| Rate for Payer: Kentucky WC Medicaid |
$2,149.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,073.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,566.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,173.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,170.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,444.56
|
| Rate for Payer: Ohio Health Group HMO |
$4,640.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,949.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,382.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,269.03
|
| Rate for Payer: PHCS Commercial |
$5,939.52
|
| Rate for Payer: United Healthcare All Payer |
$5,444.56
|
|
|
EXC ARM/ELBOW LES SC 3 CM/>
|
Professional
|
Both
|
$6,187.00
|
|
|
Service Code
|
HCPCS 24071
|
| Hospital Charge Code |
76100500
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$292.84 |
| Max. Negotiated Rate |
$3,712.20 |
| Rate for Payer: Aetna Commercial |
$622.35
|
| Rate for Payer: Ambetter Exchange |
$387.78
|
| Rate for Payer: Anthem Medicaid |
$292.84
|
| Rate for Payer: Buckeye Individual/Medicaid |
$387.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$387.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.34
|
| Rate for Payer: Cash Price |
$3,093.50
|
| Rate for Payer: Cash Price |
$3,093.50
|
| Rate for Payer: Cigna Commercial |
$709.09
|
| Rate for Payer: Healthspan PPO |
$444.02
|
| Rate for Payer: Humana Medicaid |
$292.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$517.72
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$387.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$387.78
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$298.70
|
| Rate for Payer: Molina Healthcare Passport |
$292.84
|
| Rate for Payer: Multiplan PHCS |
$3,712.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$504.11
|
| Rate for Payer: UHCCP Medicaid |
$2,165.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$295.77
|
| Rate for Payer: Wellcare Medicare Advantage |
$387.78
|
|
|
EXC ARM/ELBOW LES SC 3 CM/>(P
|
Professional
|
Both
|
$725.00
|
|
|
Service Code
|
HCPCS 24071
|
| Hospital Charge Code |
761P0500
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$253.75 |
| Max. Negotiated Rate |
$709.09 |
| Rate for Payer: Aetna Commercial |
$622.35
|
| Rate for Payer: Ambetter Exchange |
$387.78
|
| Rate for Payer: Anthem Medicaid |
$292.84
|
| Rate for Payer: Buckeye Individual/Medicaid |
$387.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$387.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.34
|
| Rate for Payer: Cash Price |
$362.50
|
| Rate for Payer: Cash Price |
$362.50
|
| Rate for Payer: Cigna Commercial |
$709.09
|
| Rate for Payer: Healthspan PPO |
$444.02
|
| Rate for Payer: Humana Medicaid |
$292.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$517.72
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$387.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$387.78
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$298.70
|
| Rate for Payer: Molina Healthcare Passport |
$292.84
|
| Rate for Payer: Multiplan PHCS |
$435.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$504.11
|
| Rate for Payer: UHCCP Medicaid |
$253.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$295.77
|
| Rate for Payer: Wellcare Medicare Advantage |
$387.78
|
|
|
EXC ARM/ELBOW LES SC 3 CM/>(T
|
Facility
|
IP
|
$5,462.00
|
|
|
Service Code
|
HCPCS 24071
|
| Hospital Charge Code |
761T0500
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,638.60 |
| Max. Negotiated Rate |
$5,243.52 |
| Rate for Payer: Aetna Commercial |
$4,205.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,260.36
|
| Rate for Payer: Cash Price |
$2,731.00
|
| Rate for Payer: Cigna Commercial |
$4,533.46
|
| Rate for Payer: First Health Commercial |
$5,188.90
|
| Rate for Payer: Humana Commercial |
$4,642.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,478.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,030.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,638.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,806.56
|
| Rate for Payer: Ohio Health Group HMO |
$4,096.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,369.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,751.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,768.78
|
| Rate for Payer: PHCS Commercial |
$5,243.52
|
| Rate for Payer: United Healthcare All Payer |
$4,806.56
|
|
|
EXC ARM/ELBOW LES SC 3 CM/>(T
|
Facility
|
OP
|
$5,462.00
|
|
|
Service Code
|
HCPCS 24071
|
| Hospital Charge Code |
761T0500
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,878.38 |
| Max. Negotiated Rate |
$5,243.52 |
| Rate for Payer: Aetna Commercial |
$4,205.74
|
| Rate for Payer: Anthem Medicaid |
$1,878.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,644.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,260.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,702.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,570.05
|
| Rate for Payer: Cash Price |
$2,731.00
|
| Rate for Payer: Cash Price |
$2,731.00
|
| Rate for Payer: Cigna Commercial |
$4,533.46
|
| Rate for Payer: First Health Commercial |
$5,188.90
|
| Rate for Payer: Humana Commercial |
$4,642.70
|
| Rate for Payer: Humana KY Medicaid |
$1,878.38
|
| Rate for Payer: Humana Medicare Advantage |
$2,644.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1,897.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,478.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,030.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,173.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,916.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,806.56
|
| Rate for Payer: Ohio Health Group HMO |
$4,096.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,369.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,751.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,768.78
|
| Rate for Payer: PHCS Commercial |
$5,243.52
|
| Rate for Payer: United Healthcare All Payer |
$4,806.56
|
|
|
EXC BACK LES SC < 3 CM
|
Facility
|
IP
|
$3,184.00
|
|
|
Service Code
|
HCPCS 21930
|
| Hospital Charge Code |
76100412
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$955.20 |
| Max. Negotiated Rate |
$3,056.64 |
| Rate for Payer: Aetna Commercial |
$2,451.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,483.52
|
| Rate for Payer: Cash Price |
$1,592.00
|
| Rate for Payer: Cigna Commercial |
$2,642.72
|
| Rate for Payer: First Health Commercial |
$3,024.80
|
| Rate for Payer: Humana Commercial |
$2,706.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,610.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,349.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$955.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,801.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,388.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,547.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,770.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,196.96
|
| Rate for Payer: PHCS Commercial |
$3,056.64
|
| Rate for Payer: United Healthcare All Payer |
$2,801.92
|
|
|
EXC BACK LES SC < 3 CM
|
Facility
|
IP
|
$2,184.00
|
|
|
Service Code
|
HCPCS 21930
|
| Hospital Charge Code |
45000105
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$655.20 |
| Max. Negotiated Rate |
$2,096.64 |
| Rate for Payer: Aetna Commercial |
$1,681.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,703.52
|
| Rate for Payer: Cash Price |
$1,092.00
|
| Rate for Payer: Cigna Commercial |
$1,812.72
|
| Rate for Payer: First Health Commercial |
$2,074.80
|
| Rate for Payer: Humana Commercial |
$1,856.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,790.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,611.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$655.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,921.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,638.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,747.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,900.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,506.96
|
| Rate for Payer: PHCS Commercial |
$2,096.64
|
| Rate for Payer: United Healthcare All Payer |
$1,921.92
|
|
|
EXC BACK LES SC < 3 CM
|
Facility
|
OP
|
$3,184.00
|
|
|
Service Code
|
HCPCS 21930
|
| Hospital Charge Code |
76100412
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,094.98 |
| Max. Negotiated Rate |
$3,056.64 |
| Rate for Payer: Aetna Commercial |
$2,451.68
|
| Rate for Payer: Anthem Medicaid |
$1,094.98
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,483.52
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,095.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,021.04
|
| Rate for Payer: Cash Price |
$1,592.00
|
| Rate for Payer: Cash Price |
$1,592.00
|
| Rate for Payer: Cigna Commercial |
$2,642.72
|
| Rate for Payer: First Health Commercial |
$3,024.80
|
| Rate for Payer: Humana Commercial |
$2,706.40
|
| Rate for Payer: Humana KY Medicaid |
$1,094.98
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,106.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,610.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,349.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,116.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,801.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,388.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,547.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,770.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,196.96
|
| Rate for Payer: PHCS Commercial |
$3,056.64
|
| Rate for Payer: United Healthcare All Payer |
$2,801.92
|
|
|
EXC BACK LES SC < 3 CM
|
Professional
|
Both
|
$3,184.00
|
|
|
Service Code
|
HCPCS 21930
|
| Hospital Charge Code |
76100412
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$187.22 |
| Max. Negotiated Rate |
$1,910.40 |
| Rate for Payer: Aetna Commercial |
$538.20
|
| Rate for Payer: Ambetter Exchange |
$347.18
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$187.22
|
| Rate for Payer: Anthem Medicaid |
$277.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$347.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$347.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$416.62
|
| Rate for Payer: Cash Price |
$1,592.00
|
| Rate for Payer: Cash Price |
$1,592.00
|
| Rate for Payer: Cigna Commercial |
$583.18
|
| Rate for Payer: Healthspan PPO |
$596.08
|
| Rate for Payer: Humana Medicaid |
$277.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$452.53
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$347.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$347.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$282.60
|
| Rate for Payer: Molina Healthcare Passport |
$277.06
|
| Rate for Payer: Multiplan PHCS |
$1,910.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$451.33
|
| Rate for Payer: UHCCP Medicaid |
$196.58
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$279.83
|
| Rate for Payer: Wellcare Medicare Advantage |
$347.18
|
|
|
EXC BACK LES SC < 3 CM
|
Facility
|
OP
|
$2,184.00
|
|
|
Service Code
|
HCPCS 21930
|
| Hospital Charge Code |
45000105
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$751.08 |
| Max. Negotiated Rate |
$2,096.64 |
| Rate for Payer: Aetna Commercial |
$1,681.68
|
| Rate for Payer: Anthem Medicaid |
$751.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,703.52
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,095.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,021.04
|
| Rate for Payer: Cash Price |
$1,092.00
|
| Rate for Payer: Cash Price |
$1,092.00
|
| Rate for Payer: Cigna Commercial |
$1,812.72
|
| Rate for Payer: First Health Commercial |
$2,074.80
|
| Rate for Payer: Humana Commercial |
$1,856.40
|
| Rate for Payer: Humana KY Medicaid |
$751.08
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$758.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,790.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,611.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$766.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,921.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,638.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,747.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,900.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,506.96
|
| Rate for Payer: PHCS Commercial |
$2,096.64
|
| Rate for Payer: United Healthcare All Payer |
$1,921.92
|
|
|
EXC BACK LES SC = 3 CM
|
Professional
|
Both
|
$7,268.00
|
|
|
Service Code
|
HCPCS 21931
|
| Hospital Charge Code |
76100413
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$340.33 |
| Max. Negotiated Rate |
$4,360.80 |
| Rate for Payer: Aetna Commercial |
$724.63
|
| Rate for Payer: Ambetter Exchange |
$449.73
|
| Rate for Payer: Anthem Medicaid |
$340.33
|
| Rate for Payer: Buckeye Individual/Medicaid |
$449.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$449.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$539.68
|
| Rate for Payer: Cash Price |
$3,634.00
|
| Rate for Payer: Cash Price |
$3,634.00
|
| Rate for Payer: Cigna Commercial |
$824.35
|
| Rate for Payer: Healthspan PPO |
$516.39
|
| Rate for Payer: Humana Medicaid |
$340.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$597.20
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$449.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$449.73
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$347.14
|
| Rate for Payer: Molina Healthcare Passport |
$340.33
|
| Rate for Payer: Multiplan PHCS |
$4,360.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$584.65
|
| Rate for Payer: UHCCP Medicaid |
$2,543.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$343.73
|
| Rate for Payer: Wellcare Medicare Advantage |
$449.73
|
|
|
EXC BACK LES SC = 3 CM
|
Facility
|
OP
|
$7,268.00
|
|
|
Service Code
|
HCPCS 21931
|
| Hospital Charge Code |
76100413
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,497.07 |
| Max. Negotiated Rate |
$6,977.28 |
| Rate for Payer: Aetna Commercial |
$5,596.36
|
| Rate for Payer: Anthem Medicaid |
$2,499.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,669.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,095.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,021.04
|
| Rate for Payer: Cash Price |
$3,634.00
|
| Rate for Payer: Cash Price |
$3,634.00
|
| Rate for Payer: Cigna Commercial |
$6,032.44
|
| Rate for Payer: First Health Commercial |
$6,904.60
|
| Rate for Payer: Humana Commercial |
$6,177.80
|
| Rate for Payer: Humana KY Medicaid |
$2,499.47
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$2,524.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,959.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,363.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,549.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,395.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,451.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,814.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,323.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,014.92
|
| Rate for Payer: PHCS Commercial |
$6,977.28
|
| Rate for Payer: United Healthcare All Payer |
$6,395.84
|
|
|
EXC BACK LES SC = 3 CM
|
Facility
|
IP
|
$7,268.00
|
|
|
Service Code
|
HCPCS 21931
|
| Hospital Charge Code |
76100413
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,180.40 |
| Max. Negotiated Rate |
$6,977.28 |
| Rate for Payer: Aetna Commercial |
$5,596.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,669.04
|
| Rate for Payer: Cash Price |
$3,634.00
|
| Rate for Payer: Cigna Commercial |
$6,032.44
|
| Rate for Payer: First Health Commercial |
$6,904.60
|
| Rate for Payer: Humana Commercial |
$6,177.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,959.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,363.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,180.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,395.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,451.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,814.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,323.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,014.92
|
| Rate for Payer: PHCS Commercial |
$6,977.28
|
| Rate for Payer: United Healthcare All Payer |
$6,395.84
|
|
|
EXC BACK LES SC < 3 CM(P
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 21930
|
| Hospital Charge Code |
761P0412
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$187.22 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial |
$538.20
|
| Rate for Payer: Ambetter Exchange |
$347.18
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$187.22
|
| Rate for Payer: Anthem Medicaid |
$277.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$347.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$347.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$416.62
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$583.18
|
| Rate for Payer: Healthspan PPO |
$596.08
|
| Rate for Payer: Humana Medicaid |
$277.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$452.53
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$347.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$347.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$282.60
|
| Rate for Payer: Molina Healthcare Passport |
$277.06
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$451.33
|
| Rate for Payer: UHCCP Medicaid |
$196.58
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$279.83
|
| Rate for Payer: Wellcare Medicare Advantage |
$347.18
|
|
|
EXC BACK LES SC = 3 CM(P
|
Professional
|
Both
|
$1,100.00
|
|
|
Service Code
|
HCPCS 21931
|
| Hospital Charge Code |
761P0413
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$340.33 |
| Max. Negotiated Rate |
$824.35 |
| Rate for Payer: Aetna Commercial |
$724.63
|
| Rate for Payer: Ambetter Exchange |
$449.73
|
| Rate for Payer: Anthem Medicaid |
$340.33
|
| Rate for Payer: Buckeye Individual/Medicaid |
$449.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$449.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$539.68
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$824.35
|
| Rate for Payer: Healthspan PPO |
$516.39
|
| Rate for Payer: Humana Medicaid |
$340.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$597.20
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$449.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$449.73
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$347.14
|
| Rate for Payer: Molina Healthcare Passport |
$340.33
|
| Rate for Payer: Multiplan PHCS |
$660.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$584.65
|
| Rate for Payer: UHCCP Medicaid |
$385.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$343.73
|
| Rate for Payer: Wellcare Medicare Advantage |
$449.73
|
|
|
EXC BACK LES SC < 3 CM(T
|
Facility
|
IP
|
$2,184.00
|
|
|
Service Code
|
HCPCS 21930
|
| Hospital Charge Code |
761T0412
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$655.20 |
| Max. Negotiated Rate |
$2,096.64 |
| Rate for Payer: Aetna Commercial |
$1,681.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,703.52
|
| Rate for Payer: Cash Price |
$1,092.00
|
| Rate for Payer: Cigna Commercial |
$1,812.72
|
| Rate for Payer: First Health Commercial |
$2,074.80
|
| Rate for Payer: Humana Commercial |
$1,856.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,790.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,611.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$655.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,921.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,638.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,747.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,900.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,506.96
|
| Rate for Payer: PHCS Commercial |
$2,096.64
|
| Rate for Payer: United Healthcare All Payer |
$1,921.92
|
|
