|
3D REND W/INTERP REP OF CT(P
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
HCPCS 76377
|
| Hospital Charge Code |
400P0004
|
|
Hospital Revenue Code
|
400
|
| Min. Negotiated Rate |
$50.14 |
| Max. Negotiated Rate |
$234.40 |
| Rate for Payer: Aetna Commercial |
$179.32
|
| Rate for Payer: Ambetter Exchange |
$72.64
|
| Rate for Payer: Anthem Medicaid |
$127.95
|
| Rate for Payer: Buckeye Individual/Medicaid |
$72.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$72.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$87.17
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cigna Commercial |
$234.40
|
| Rate for Payer: Healthspan PPO |
$123.22
|
| Rate for Payer: Humana Medicaid |
$127.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$50.14
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$72.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$72.64
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$130.51
|
| Rate for Payer: Molina Healthcare Passport |
$127.95
|
| Rate for Payer: Multiplan PHCS |
$105.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$94.43
|
| Rate for Payer: UHCCP Medicaid |
$61.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$129.23
|
| Rate for Payer: Wellcare Medicare Advantage |
$72.64
|
|
|
3D REND W/INTERP REP OF CT(P
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
HCPCS 76377
|
| Hospital Charge Code |
400P0005
|
|
Hospital Revenue Code
|
400
|
| Min. Negotiated Rate |
$50.14 |
| Max. Negotiated Rate |
$234.40 |
| Rate for Payer: Aetna Commercial |
$179.32
|
| Rate for Payer: Ambetter Exchange |
$72.64
|
| Rate for Payer: Anthem Medicaid |
$127.95
|
| Rate for Payer: Buckeye Individual/Medicaid |
$72.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$72.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$87.17
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cigna Commercial |
$234.40
|
| Rate for Payer: Healthspan PPO |
$123.22
|
| Rate for Payer: Humana Medicaid |
$127.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$50.14
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$72.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$72.64
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$130.51
|
| Rate for Payer: Molina Healthcare Passport |
$127.95
|
| Rate for Payer: Multiplan PHCS |
$105.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$94.43
|
| Rate for Payer: UHCCP Medicaid |
$61.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$129.23
|
| Rate for Payer: Wellcare Medicare Advantage |
$72.64
|
|
|
3D REND W/INTERP REP OF CT(T
|
Facility
|
OP
|
$934.00
|
|
|
Service Code
|
HCPCS 76377
|
| Hospital Charge Code |
400T0005
|
|
Hospital Revenue Code
|
400
|
| Min. Negotiated Rate |
$280.20 |
| Max. Negotiated Rate |
$896.64 |
| Rate for Payer: Aetna Commercial |
$719.18
|
| Rate for Payer: Anthem Medicaid |
$321.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$728.52
|
| Rate for Payer: Cash Price |
$467.00
|
| Rate for Payer: Cigna Commercial |
$775.22
|
| Rate for Payer: First Health Commercial |
$887.30
|
| Rate for Payer: Humana Commercial |
$793.90
|
| Rate for Payer: Humana KY Medicaid |
$321.20
|
| Rate for Payer: Kentucky WC Medicaid |
$324.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$765.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$689.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$280.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$327.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$821.92
|
| Rate for Payer: Ohio Health Group HMO |
$700.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$747.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$812.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$644.46
|
| Rate for Payer: PHCS Commercial |
$896.64
|
| Rate for Payer: United Healthcare All Payer |
$821.92
|
|
|
3D REND W/INTERP REP OF CT(T
|
Facility
|
IP
|
$934.00
|
|
|
Service Code
|
HCPCS 76377
|
| Hospital Charge Code |
400T0004
|
|
Hospital Revenue Code
|
400
|
| Min. Negotiated Rate |
$280.20 |
| Max. Negotiated Rate |
$896.64 |
| Rate for Payer: Aetna Commercial |
$719.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$728.52
|
| Rate for Payer: Cash Price |
$467.00
|
| Rate for Payer: Cigna Commercial |
$775.22
|
| Rate for Payer: First Health Commercial |
$887.30
|
| Rate for Payer: Humana Commercial |
$793.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$765.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$689.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$280.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$821.92
|
| Rate for Payer: Ohio Health Group HMO |
$700.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$747.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$812.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$644.46
|
| Rate for Payer: PHCS Commercial |
$896.64
|
| Rate for Payer: United Healthcare All Payer |
$821.92
|
|
|
3D REND W/INTERP REP OF CT(T
|
Facility
|
OP
|
$934.00
|
|
|
Service Code
|
HCPCS 76377
|
| Hospital Charge Code |
400T0004
|
|
Hospital Revenue Code
|
400
|
| Min. Negotiated Rate |
$280.20 |
| Max. Negotiated Rate |
$896.64 |
| Rate for Payer: Aetna Commercial |
$719.18
|
| Rate for Payer: Anthem Medicaid |
$321.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$728.52
|
| Rate for Payer: Cash Price |
$467.00
|
| Rate for Payer: Cigna Commercial |
$775.22
|
| Rate for Payer: First Health Commercial |
$887.30
|
| Rate for Payer: Humana Commercial |
$793.90
|
| Rate for Payer: Humana KY Medicaid |
$321.20
|
| Rate for Payer: Kentucky WC Medicaid |
$324.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$765.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$689.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$280.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$327.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$821.92
|
| Rate for Payer: Ohio Health Group HMO |
$700.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$747.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$812.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$644.46
|
| Rate for Payer: PHCS Commercial |
$896.64
|
| Rate for Payer: United Healthcare All Payer |
$821.92
|
|
|
3D REND W/INTERP REP OF CT(T
|
Facility
|
IP
|
$934.00
|
|
|
Service Code
|
HCPCS 76377
|
| Hospital Charge Code |
400T0005
|
|
Hospital Revenue Code
|
400
|
| Min. Negotiated Rate |
$280.20 |
| Max. Negotiated Rate |
$896.64 |
| Rate for Payer: Aetna Commercial |
$719.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$728.52
|
| Rate for Payer: Cash Price |
$467.00
|
| Rate for Payer: Cigna Commercial |
$775.22
|
| Rate for Payer: First Health Commercial |
$887.30
|
| Rate for Payer: Humana Commercial |
$793.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$765.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$689.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$280.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$821.92
|
| Rate for Payer: Ohio Health Group HMO |
$700.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$747.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$812.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$644.46
|
| Rate for Payer: PHCS Commercial |
$896.64
|
| Rate for Payer: United Healthcare All Payer |
$821.92
|
|
|
3D REND W/O INDEPD WORKSTATION
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 76376
|
| Hospital Charge Code |
350P0015
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$12.95 |
| Max. Negotiated Rate |
$178.97 |
| Rate for Payer: Aetna Commercial |
$121.42
|
| Rate for Payer: Ambetter Exchange |
$23.34
|
| Rate for Payer: Anthem Medicaid |
$97.83
|
| Rate for Payer: Buckeye Individual/Medicaid |
$23.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$23.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$28.01
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$178.97
|
| Rate for Payer: Healthspan PPO |
$83.44
|
| Rate for Payer: Humana Medicaid |
$97.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$12.95
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$23.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$99.79
|
| Rate for Payer: Molina Healthcare Passport |
$97.83
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$30.34
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$98.81
|
| Rate for Payer: Wellcare Medicare Advantage |
$23.34
|
|
|
3D REND W/O INDEPD WORKSTATION
|
Facility
|
OP
|
$918.00
|
|
|
Service Code
|
HCPCS 76376
|
| Hospital Charge Code |
350T0015
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$275.40 |
| Max. Negotiated Rate |
$881.28 |
| Rate for Payer: Aetna Commercial |
$706.86
|
| Rate for Payer: Anthem Medicaid |
$315.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$716.04
|
| Rate for Payer: Cash Price |
$459.00
|
| Rate for Payer: Cigna Commercial |
$761.94
|
| Rate for Payer: First Health Commercial |
$872.10
|
| Rate for Payer: Humana Commercial |
$780.30
|
| Rate for Payer: Humana KY Medicaid |
$315.70
|
| Rate for Payer: Kentucky WC Medicaid |
$318.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$752.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$677.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$275.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$322.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$807.84
|
| Rate for Payer: Ohio Health Group HMO |
$688.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$798.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$633.42
|
| Rate for Payer: PHCS Commercial |
$881.28
|
| Rate for Payer: United Healthcare All Payer |
$807.84
|
|
|
3D REND W/O INDEPD WORKSTATION
|
Facility
|
OP
|
$958.00
|
|
|
Service Code
|
HCPCS 76376
|
| Hospital Charge Code |
35000015
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$287.40 |
| Max. Negotiated Rate |
$919.68 |
| Rate for Payer: Aetna Commercial |
$737.66
|
| Rate for Payer: Anthem Medicaid |
$329.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$747.24
|
| Rate for Payer: Cash Price |
$479.00
|
| Rate for Payer: Cigna Commercial |
$795.14
|
| Rate for Payer: First Health Commercial |
$910.10
|
| Rate for Payer: Humana Commercial |
$814.30
|
| Rate for Payer: Humana KY Medicaid |
$329.46
|
| Rate for Payer: Kentucky WC Medicaid |
$332.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$785.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$707.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$287.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$336.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$843.04
|
| Rate for Payer: Ohio Health Group HMO |
$718.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$766.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$833.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$661.02
|
| Rate for Payer: PHCS Commercial |
$919.68
|
| Rate for Payer: United Healthcare All Payer |
$843.04
|
|
|
3D REND W/O INDEPD WORKSTATION
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 76376
|
| Hospital Charge Code |
402P0004
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$12.95 |
| Max. Negotiated Rate |
$178.97 |
| Rate for Payer: Aetna Commercial |
$121.42
|
| Rate for Payer: Ambetter Exchange |
$23.34
|
| Rate for Payer: Anthem Medicaid |
$97.83
|
| Rate for Payer: Buckeye Individual/Medicaid |
$23.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$23.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$28.01
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$178.97
|
| Rate for Payer: Healthspan PPO |
$83.44
|
| Rate for Payer: Humana Medicaid |
$97.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$12.95
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$23.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$99.79
|
| Rate for Payer: Molina Healthcare Passport |
$97.83
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$30.34
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$98.81
|
| Rate for Payer: Wellcare Medicare Advantage |
$23.34
|
|
|
3D REND W/O INDEPD WORKSTATION
|
Professional
|
Both
|
$927.00
|
|
|
Service Code
|
HCPCS 76376
|
| Hospital Charge Code |
40200004
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$12.95 |
| Max. Negotiated Rate |
$556.20 |
| Rate for Payer: Aetna Commercial |
$121.42
|
| Rate for Payer: Ambetter Exchange |
$23.34
|
| Rate for Payer: Anthem Medicaid |
$97.83
|
| Rate for Payer: Buckeye Individual/Medicaid |
$23.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$23.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$28.01
|
| Rate for Payer: Cash Price |
$463.50
|
| Rate for Payer: Cash Price |
$463.50
|
| Rate for Payer: Cigna Commercial |
$178.97
|
| Rate for Payer: Healthspan PPO |
$83.44
|
| Rate for Payer: Humana Medicaid |
$97.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$12.95
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$23.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$99.79
|
| Rate for Payer: Molina Healthcare Passport |
$97.83
|
| Rate for Payer: Multiplan PHCS |
$556.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$30.34
|
| Rate for Payer: UHCCP Medicaid |
$324.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$98.81
|
| Rate for Payer: Wellcare Medicare Advantage |
$23.34
|
|
|
3D REND W/O INDEPD WORKSTATION
|
Facility
|
OP
|
$887.00
|
|
|
Service Code
|
HCPCS 76376
|
| Hospital Charge Code |
402T0004
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$266.10 |
| Max. Negotiated Rate |
$851.52 |
| Rate for Payer: Aetna Commercial |
$682.99
|
| Rate for Payer: Anthem Medicaid |
$305.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$691.86
|
| Rate for Payer: Cash Price |
$443.50
|
| Rate for Payer: Cigna Commercial |
$736.21
|
| Rate for Payer: First Health Commercial |
$842.65
|
| Rate for Payer: Humana Commercial |
$753.95
|
| Rate for Payer: Humana KY Medicaid |
$305.04
|
| Rate for Payer: Kentucky WC Medicaid |
$308.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$727.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$654.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$266.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$311.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$780.56
|
| Rate for Payer: Ohio Health Group HMO |
$665.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$709.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$771.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$612.03
|
| Rate for Payer: PHCS Commercial |
$851.52
|
| Rate for Payer: United Healthcare All Payer |
$780.56
|
|
|
3D REND W/O INDEPD WORKSTATION
|
Facility
|
IP
|
$918.00
|
|
|
Service Code
|
HCPCS 76376
|
| Hospital Charge Code |
350T0015
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$275.40 |
| Max. Negotiated Rate |
$881.28 |
| Rate for Payer: Aetna Commercial |
$706.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$716.04
|
| Rate for Payer: Cash Price |
$459.00
|
| Rate for Payer: Cigna Commercial |
$761.94
|
| Rate for Payer: First Health Commercial |
$872.10
|
| Rate for Payer: Humana Commercial |
$780.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$752.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$677.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$275.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$807.84
|
| Rate for Payer: Ohio Health Group HMO |
$688.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$798.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$633.42
|
| Rate for Payer: PHCS Commercial |
$881.28
|
| Rate for Payer: United Healthcare All Payer |
$807.84
|
|
|
3D REND W/O INDEPD WORKSTATION
|
Facility
|
IP
|
$887.00
|
|
|
Service Code
|
HCPCS 76376
|
| Hospital Charge Code |
402T0004
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$266.10 |
| Max. Negotiated Rate |
$851.52 |
| Rate for Payer: Aetna Commercial |
$682.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$691.86
|
| Rate for Payer: Cash Price |
$443.50
|
| Rate for Payer: Cigna Commercial |
$736.21
|
| Rate for Payer: First Health Commercial |
$842.65
|
| Rate for Payer: Humana Commercial |
$753.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$727.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$654.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$266.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$780.56
|
| Rate for Payer: Ohio Health Group HMO |
$665.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$709.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$771.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$612.03
|
| Rate for Payer: PHCS Commercial |
$851.52
|
| Rate for Payer: United Healthcare All Payer |
$780.56
|
|
|
3D REND W/O INDEPD WORKSTATION
|
Facility
|
OP
|
$927.00
|
|
|
Service Code
|
HCPCS 76376
|
| Hospital Charge Code |
40200004
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$278.10 |
| Max. Negotiated Rate |
$889.92 |
| Rate for Payer: Aetna Commercial |
$713.79
|
| Rate for Payer: Anthem Medicaid |
$318.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$723.06
|
| Rate for Payer: Cash Price |
$463.50
|
| Rate for Payer: Cigna Commercial |
$769.41
|
| Rate for Payer: First Health Commercial |
$880.65
|
| Rate for Payer: Humana Commercial |
$787.95
|
| Rate for Payer: Humana KY Medicaid |
$318.80
|
| Rate for Payer: Kentucky WC Medicaid |
$322.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$760.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$684.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$278.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$325.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$815.76
|
| Rate for Payer: Ohio Health Group HMO |
$695.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$741.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$806.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$639.63
|
| Rate for Payer: PHCS Commercial |
$889.92
|
| Rate for Payer: United Healthcare All Payer |
$815.76
|
|
|
3D REND W/O INDEPD WORKSTATION
|
Professional
|
Both
|
$958.00
|
|
|
Service Code
|
HCPCS 76376
|
| Hospital Charge Code |
35000015
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$12.95 |
| Max. Negotiated Rate |
$574.80 |
| Rate for Payer: Aetna Commercial |
$121.42
|
| Rate for Payer: Ambetter Exchange |
$23.34
|
| Rate for Payer: Anthem Medicaid |
$97.83
|
| Rate for Payer: Buckeye Individual/Medicaid |
$23.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$23.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$28.01
|
| Rate for Payer: Cash Price |
$479.00
|
| Rate for Payer: Cash Price |
$479.00
|
| Rate for Payer: Cigna Commercial |
$178.97
|
| Rate for Payer: Healthspan PPO |
$83.44
|
| Rate for Payer: Humana Medicaid |
$97.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$12.95
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$23.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$99.79
|
| Rate for Payer: Molina Healthcare Passport |
$97.83
|
| Rate for Payer: Multiplan PHCS |
$574.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$30.34
|
| Rate for Payer: UHCCP Medicaid |
$335.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$98.81
|
| Rate for Payer: Wellcare Medicare Advantage |
$23.34
|
|
|
3D REND W/O INDEPD WORKSTATION
|
Facility
|
IP
|
$958.00
|
|
|
Service Code
|
HCPCS 76376
|
| Hospital Charge Code |
35000015
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$287.40 |
| Max. Negotiated Rate |
$919.68 |
| Rate for Payer: Aetna Commercial |
$737.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$747.24
|
| Rate for Payer: Cash Price |
$479.00
|
| Rate for Payer: Cigna Commercial |
$795.14
|
| Rate for Payer: First Health Commercial |
$910.10
|
| Rate for Payer: Humana Commercial |
$814.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$785.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$707.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$287.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$843.04
|
| Rate for Payer: Ohio Health Group HMO |
$718.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$766.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$833.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$661.02
|
| Rate for Payer: PHCS Commercial |
$919.68
|
| Rate for Payer: United Healthcare All Payer |
$843.04
|
|
|
3D REND W/O INDEPD WORKSTATION
|
Facility
|
IP
|
$927.00
|
|
|
Service Code
|
HCPCS 76376
|
| Hospital Charge Code |
40200004
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$278.10 |
| Max. Negotiated Rate |
$889.92 |
| Rate for Payer: Aetna Commercial |
$713.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$723.06
|
| Rate for Payer: Cash Price |
$463.50
|
| Rate for Payer: Cigna Commercial |
$769.41
|
| Rate for Payer: First Health Commercial |
$880.65
|
| Rate for Payer: Humana Commercial |
$787.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$760.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$684.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$278.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$815.76
|
| Rate for Payer: Ohio Health Group HMO |
$695.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$741.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$806.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$639.63
|
| Rate for Payer: PHCS Commercial |
$889.92
|
| Rate for Payer: United Healthcare All Payer |
$815.76
|
|
|
3D RIGHT GUIDE 6FR
|
Facility
|
OP
|
$1,130.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$339.00 |
| Max. Negotiated Rate |
$1,084.80 |
| Rate for Payer: Aetna Commercial |
$870.10
|
| Rate for Payer: Anthem Medicaid |
$388.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$881.40
|
| Rate for Payer: Cash Price |
$565.00
|
| Rate for Payer: Cigna Commercial |
$937.90
|
| Rate for Payer: First Health Commercial |
$1,073.50
|
| Rate for Payer: Humana Commercial |
$960.50
|
| Rate for Payer: Humana KY Medicaid |
$388.61
|
| Rate for Payer: Kentucky WC Medicaid |
$392.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$926.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$833.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$339.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$396.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$994.40
|
| Rate for Payer: Ohio Health Group HMO |
$847.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$904.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$983.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$779.70
|
| Rate for Payer: PHCS Commercial |
$1,084.80
|
| Rate for Payer: United Healthcare All Payer |
$994.40
|
|
|
3D RIGHT GUIDE 6FR
|
Facility
|
IP
|
$1,130.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$339.00 |
| Max. Negotiated Rate |
$1,084.80 |
| Rate for Payer: Aetna Commercial |
$870.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$881.40
|
| Rate for Payer: Cash Price |
$565.00
|
| Rate for Payer: Cigna Commercial |
$937.90
|
| Rate for Payer: First Health Commercial |
$1,073.50
|
| Rate for Payer: Humana Commercial |
$960.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$926.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$833.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$339.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$994.40
|
| Rate for Payer: Ohio Health Group HMO |
$847.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$904.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$983.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$779.70
|
| Rate for Payer: PHCS Commercial |
$1,084.80
|
| Rate for Payer: United Healthcare All Payer |
$994.40
|
|
|
3 D SIMULATION FIELD SETTING
|
Facility
|
IP
|
$6,683.00
|
|
|
Service Code
|
HCPCS 77295
|
| Hospital Charge Code |
33300005
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$2,004.90 |
| Max. Negotiated Rate |
$6,415.68 |
| Rate for Payer: Aetna Commercial |
$5,145.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,212.74
|
| Rate for Payer: Cash Price |
$3,341.50
|
| Rate for Payer: Cigna Commercial |
$5,546.89
|
| Rate for Payer: First Health Commercial |
$6,348.85
|
| Rate for Payer: Humana Commercial |
$5,680.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,480.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,932.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,004.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,881.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,012.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,346.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,814.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,611.27
|
| Rate for Payer: PHCS Commercial |
$6,415.68
|
| Rate for Payer: United Healthcare All Payer |
$5,881.04
|
|
|
3 D SIMULATION FIELD SETTING
|
Facility
|
OP
|
$6,683.00
|
|
|
Service Code
|
HCPCS 77295
|
| Hospital Charge Code |
33300005
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$1,264.24 |
| Max. Negotiated Rate |
$6,415.68 |
| Rate for Payer: Aetna Commercial |
$5,145.91
|
| Rate for Payer: Anthem Medicaid |
$2,298.28
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,264.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,212.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,769.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,706.72
|
| Rate for Payer: Cash Price |
$3,341.50
|
| Rate for Payer: Cash Price |
$3,341.50
|
| Rate for Payer: Cigna Commercial |
$5,546.89
|
| Rate for Payer: First Health Commercial |
$6,348.85
|
| Rate for Payer: Humana Commercial |
$5,680.55
|
| Rate for Payer: Humana KY Medicaid |
$2,298.28
|
| Rate for Payer: Humana Medicare Advantage |
$1,264.24
|
| Rate for Payer: Kentucky WC Medicaid |
$2,321.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,480.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,932.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,517.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,344.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,881.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,012.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,346.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,814.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,611.27
|
| Rate for Payer: PHCS Commercial |
$6,415.68
|
| Rate for Payer: United Healthcare All Payer |
$5,881.04
|
|
|
3 D SIMULATION FIELD SETTING
|
Professional
|
Both
|
$6,683.00
|
|
|
Service Code
|
HCPCS 77295
|
| Hospital Charge Code |
33300005
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$291.79 |
| Max. Negotiated Rate |
$4,009.80 |
| Rate for Payer: Aetna Commercial |
$1,075.33
|
| Rate for Payer: Ambetter Exchange |
$443.23
|
| Rate for Payer: Anthem Medicaid |
$950.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$443.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$443.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$531.88
|
| Rate for Payer: Cash Price |
$3,341.50
|
| Rate for Payer: Cash Price |
$3,341.50
|
| Rate for Payer: Cigna Commercial |
$1,657.98
|
| Rate for Payer: Healthspan PPO |
$906.85
|
| Rate for Payer: Humana Medicaid |
$950.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$291.79
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$443.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$443.23
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$969.24
|
| Rate for Payer: Molina Healthcare Passport |
$950.24
|
| Rate for Payer: Multiplan PHCS |
$4,009.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$576.20
|
| Rate for Payer: UHCCP Medicaid |
$2,339.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$959.74
|
| Rate for Payer: Wellcare Medicare Advantage |
$443.23
|
|
|
3 D SIMULATION FIELD SETTING(P
|
Professional
|
Both
|
$425.00
|
|
|
Service Code
|
HCPCS 77295
|
| Hospital Charge Code |
333P0005
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$148.75 |
| Max. Negotiated Rate |
$1,657.98 |
| Rate for Payer: Aetna Commercial |
$1,075.33
|
| Rate for Payer: Ambetter Exchange |
$443.23
|
| Rate for Payer: Anthem Medicaid |
$950.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$443.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$443.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$531.88
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cigna Commercial |
$1,657.98
|
| Rate for Payer: Healthspan PPO |
$906.85
|
| Rate for Payer: Humana Medicaid |
$950.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$291.79
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$443.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$443.23
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$969.24
|
| Rate for Payer: Molina Healthcare Passport |
$950.24
|
| Rate for Payer: Multiplan PHCS |
$255.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$576.20
|
| Rate for Payer: UHCCP Medicaid |
$148.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$959.74
|
| Rate for Payer: Wellcare Medicare Advantage |
$443.23
|
|
|
3 D SIMULATION FIELD SETTING(T
|
Facility
|
IP
|
$6,258.00
|
|
|
Service Code
|
HCPCS 77295
|
| Hospital Charge Code |
333T0005
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$1,877.40 |
| Max. Negotiated Rate |
$6,007.68 |
| Rate for Payer: Aetna Commercial |
$4,818.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,881.24
|
| Rate for Payer: Cash Price |
$3,129.00
|
| Rate for Payer: Cigna Commercial |
$5,194.14
|
| Rate for Payer: First Health Commercial |
$5,945.10
|
| Rate for Payer: Humana Commercial |
$5,319.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,131.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,618.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,877.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,507.04
|
| Rate for Payer: Ohio Health Group HMO |
$4,693.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,006.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,444.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,318.02
|
| Rate for Payer: PHCS Commercial |
$6,007.68
|
| Rate for Payer: United Healthcare All Payer |
$5,507.04
|
|
