|
INTMD RPR FACE/MM >30.0 CM
|
Professional
|
Both
|
$1,680.00
|
|
|
Service Code
|
HCPCS 12057
|
| Hospital Charge Code |
76102580
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$213.52 |
| Max. Negotiated Rate |
$1,008.00 |
| Rate for Payer: Aetna Commercial |
$559.53
|
| Rate for Payer: Ambetter Exchange |
$395.89
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$213.52
|
| Rate for Payer: Anthem Medicaid |
$334.48
|
| Rate for Payer: Buckeye Individual/Medicaid |
$395.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$395.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$475.07
|
| Rate for Payer: Cash Price |
$840.00
|
| Rate for Payer: Cash Price |
$840.00
|
| Rate for Payer: Cigna Commercial |
$705.56
|
| Rate for Payer: Healthspan PPO |
$618.57
|
| Rate for Payer: Humana Medicaid |
$334.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$472.90
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$395.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$395.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$341.17
|
| Rate for Payer: Molina Healthcare Passport |
$334.48
|
| Rate for Payer: Multiplan PHCS |
$1,008.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$514.66
|
| Rate for Payer: UHCCP Medicaid |
$224.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$337.82
|
| Rate for Payer: Wellcare Medicare Advantage |
$395.89
|
|
|
INTMD RPR FACE/MM >30.0 CM(P
|
Professional
|
Both
|
$429.00
|
|
|
Service Code
|
HCPCS 12057
|
| Hospital Charge Code |
761P2580
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$213.52 |
| Max. Negotiated Rate |
$705.56 |
| Rate for Payer: Aetna Commercial |
$559.53
|
| Rate for Payer: Ambetter Exchange |
$395.89
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$213.52
|
| Rate for Payer: Anthem Medicaid |
$334.48
|
| Rate for Payer: Buckeye Individual/Medicaid |
$395.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$395.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$475.07
|
| Rate for Payer: Cash Price |
$214.50
|
| Rate for Payer: Cash Price |
$214.50
|
| Rate for Payer: Cigna Commercial |
$705.56
|
| Rate for Payer: Healthspan PPO |
$618.57
|
| Rate for Payer: Humana Medicaid |
$334.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$472.90
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$395.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$395.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$341.17
|
| Rate for Payer: Molina Healthcare Passport |
$334.48
|
| Rate for Payer: Multiplan PHCS |
$257.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$514.66
|
| Rate for Payer: UHCCP Medicaid |
$224.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$337.82
|
| Rate for Payer: Wellcare Medicare Advantage |
$395.89
|
|
|
INTMD RPR FACE/MM >30.0 CM(T
|
Facility
|
IP
|
$1,251.00
|
|
|
Service Code
|
HCPCS 12057
|
| Hospital Charge Code |
761T2580
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$375.30 |
| Max. Negotiated Rate |
$1,200.96 |
| Rate for Payer: Aetna Commercial |
$963.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$975.78
|
| Rate for Payer: Cash Price |
$625.50
|
| Rate for Payer: Cigna Commercial |
$1,038.33
|
| Rate for Payer: First Health Commercial |
$1,188.45
|
| Rate for Payer: Humana Commercial |
$1,063.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,025.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$923.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$375.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,100.88
|
| Rate for Payer: Ohio Health Group HMO |
$938.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,088.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$863.19
|
| Rate for Payer: PHCS Commercial |
$1,200.96
|
| Rate for Payer: United Healthcare All Payer |
$1,100.88
|
|
|
INTMD RPR FACE/MM >30.0 CM(T
|
Facility
|
OP
|
$1,251.00
|
|
|
Service Code
|
HCPCS 12057
|
| Hospital Charge Code |
761T2580
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$369.16 |
| Max. Negotiated Rate |
$1,200.96 |
| Rate for Payer: Aetna Commercial |
$963.27
|
| Rate for Payer: Anthem Medicaid |
$430.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$975.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$625.50
|
| Rate for Payer: Cash Price |
$625.50
|
| Rate for Payer: Cigna Commercial |
$1,038.33
|
| Rate for Payer: First Health Commercial |
$1,188.45
|
| Rate for Payer: Humana Commercial |
$1,063.35
|
| Rate for Payer: Humana KY Medicaid |
$430.22
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$434.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,025.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$923.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$438.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,100.88
|
| Rate for Payer: Ohio Health Group HMO |
$938.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,088.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$863.19
|
| Rate for Payer: PHCS Commercial |
$1,200.96
|
| Rate for Payer: United Healthcare All Payer |
$1,100.88
|
|
|
INTMD RPR N-HF/GENIT12.6-20
|
Facility
|
OP
|
$1,362.00
|
|
|
Service Code
|
HCPCS 12045
|
| Hospital Charge Code |
76100141
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$468.39 |
| Max. Negotiated Rate |
$1,307.52 |
| Rate for Payer: Aetna Commercial |
$1,048.74
|
| Rate for Payer: Anthem Medicaid |
$468.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,062.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$681.00
|
| Rate for Payer: Cash Price |
$681.00
|
| Rate for Payer: Cigna Commercial |
$1,130.46
|
| Rate for Payer: First Health Commercial |
$1,293.90
|
| Rate for Payer: Humana Commercial |
$1,157.70
|
| Rate for Payer: Humana KY Medicaid |
$468.39
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$473.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,116.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,005.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$477.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,198.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,021.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,089.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,184.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$939.78
|
| Rate for Payer: PHCS Commercial |
$1,307.52
|
| Rate for Payer: United Healthcare All Payer |
$1,198.56
|
|
|
INTMD RPR N-HF/GENIT12.6-20
|
Professional
|
Both
|
$1,362.00
|
|
|
Service Code
|
HCPCS 12045
|
| Hospital Charge Code |
76100141
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$138.08 |
| Max. Negotiated Rate |
$817.20 |
| Rate for Payer: Aetna Commercial |
$355.51
|
| Rate for Payer: Ambetter Exchange |
$255.92
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$138.08
|
| Rate for Payer: Anthem Medicaid |
$168.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$255.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$255.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$307.10
|
| Rate for Payer: Cash Price |
$681.00
|
| Rate for Payer: Cash Price |
$681.00
|
| Rate for Payer: Cigna Commercial |
$339.86
|
| Rate for Payer: Healthspan PPO |
$409.65
|
| Rate for Payer: Humana Medicaid |
$168.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$302.15
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$255.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$255.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$171.42
|
| Rate for Payer: Molina Healthcare Passport |
$168.06
|
| Rate for Payer: Multiplan PHCS |
$817.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$332.70
|
| Rate for Payer: UHCCP Medicaid |
$144.98
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$169.74
|
| Rate for Payer: Wellcare Medicare Advantage |
$255.92
|
|
|
INTMD RPR N-HF/GENIT12.6-20
|
Facility
|
IP
|
$1,362.00
|
|
|
Service Code
|
HCPCS 12045
|
| Hospital Charge Code |
76100141
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$408.60 |
| Max. Negotiated Rate |
$1,307.52 |
| Rate for Payer: Aetna Commercial |
$1,048.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,062.36
|
| Rate for Payer: Cash Price |
$681.00
|
| Rate for Payer: Cigna Commercial |
$1,130.46
|
| Rate for Payer: First Health Commercial |
$1,293.90
|
| Rate for Payer: Humana Commercial |
$1,157.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,116.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,005.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$408.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,198.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,021.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,089.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,184.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$939.78
|
| Rate for Payer: PHCS Commercial |
$1,307.52
|
| Rate for Payer: United Healthcare All Payer |
$1,198.56
|
|
|
INTMD RPR N-HF/GENIT12.6-20
|
Facility
|
IP
|
$742.00
|
|
|
Service Code
|
HCPCS 12045
|
| Hospital Charge Code |
45000064
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$222.60 |
| Max. Negotiated Rate |
$712.32 |
| Rate for Payer: Aetna Commercial |
$571.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$578.76
|
| Rate for Payer: Cash Price |
$371.00
|
| Rate for Payer: Cigna Commercial |
$615.86
|
| Rate for Payer: First Health Commercial |
$704.90
|
| Rate for Payer: Humana Commercial |
$630.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$608.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$547.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$222.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$652.96
|
| Rate for Payer: Ohio Health Group HMO |
$556.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$593.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$645.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$511.98
|
| Rate for Payer: PHCS Commercial |
$712.32
|
| Rate for Payer: United Healthcare All Payer |
$652.96
|
|
|
INTMD RPR N-HF/GENIT12.6-20
|
Facility
|
OP
|
$742.00
|
|
|
Service Code
|
HCPCS 12045
|
| Hospital Charge Code |
45000064
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$255.17 |
| Max. Negotiated Rate |
$791.84 |
| Rate for Payer: Aetna Commercial |
$571.34
|
| Rate for Payer: Anthem Medicaid |
$255.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$578.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$371.00
|
| Rate for Payer: Cash Price |
$371.00
|
| Rate for Payer: Cigna Commercial |
$615.86
|
| Rate for Payer: First Health Commercial |
$704.90
|
| Rate for Payer: Humana Commercial |
$630.70
|
| Rate for Payer: Humana KY Medicaid |
$255.17
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$257.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$608.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$547.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$260.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$652.96
|
| Rate for Payer: Ohio Health Group HMO |
$556.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$593.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$645.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$511.98
|
| Rate for Payer: PHCS Commercial |
$712.32
|
| Rate for Payer: United Healthcare All Payer |
$652.96
|
|
|
INTMD RPR N-HF/GENIT12.6-20(P
|
Professional
|
Both
|
$620.00
|
|
|
Service Code
|
HCPCS 12045
|
| Hospital Charge Code |
761P0141
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$138.08 |
| Max. Negotiated Rate |
$409.65 |
| Rate for Payer: Aetna Commercial |
$355.51
|
| Rate for Payer: Ambetter Exchange |
$255.92
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$138.08
|
| Rate for Payer: Anthem Medicaid |
$168.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$255.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$255.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$307.10
|
| Rate for Payer: Cash Price |
$310.00
|
| Rate for Payer: Cash Price |
$310.00
|
| Rate for Payer: Cigna Commercial |
$339.86
|
| Rate for Payer: Healthspan PPO |
$409.65
|
| Rate for Payer: Humana Medicaid |
$168.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$302.15
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$255.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$255.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$171.42
|
| Rate for Payer: Molina Healthcare Passport |
$168.06
|
| Rate for Payer: Multiplan PHCS |
$372.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$332.70
|
| Rate for Payer: UHCCP Medicaid |
$144.98
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$169.74
|
| Rate for Payer: Wellcare Medicare Advantage |
$255.92
|
|
|
INTMD RPR N-HF/GENIT12.6-20(T
|
Facility
|
OP
|
$742.00
|
|
|
Service Code
|
HCPCS 12045
|
| Hospital Charge Code |
761T0141
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$255.17 |
| Max. Negotiated Rate |
$791.84 |
| Rate for Payer: Aetna Commercial |
$571.34
|
| Rate for Payer: Anthem Medicaid |
$255.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$578.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$371.00
|
| Rate for Payer: Cash Price |
$371.00
|
| Rate for Payer: Cigna Commercial |
$615.86
|
| Rate for Payer: First Health Commercial |
$704.90
|
| Rate for Payer: Humana Commercial |
$630.70
|
| Rate for Payer: Humana KY Medicaid |
$255.17
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$257.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$608.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$547.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$260.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$652.96
|
| Rate for Payer: Ohio Health Group HMO |
$556.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$593.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$645.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$511.98
|
| Rate for Payer: PHCS Commercial |
$712.32
|
| Rate for Payer: United Healthcare All Payer |
$652.96
|
|
|
INTMD RPR N-HF/GENIT12.6-20(T
|
Facility
|
IP
|
$742.00
|
|
|
Service Code
|
HCPCS 12045
|
| Hospital Charge Code |
761T0141
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$222.60 |
| Max. Negotiated Rate |
$712.32 |
| Rate for Payer: Aetna Commercial |
$571.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$578.76
|
| Rate for Payer: Cash Price |
$371.00
|
| Rate for Payer: Cigna Commercial |
$615.86
|
| Rate for Payer: First Health Commercial |
$704.90
|
| Rate for Payer: Humana Commercial |
$630.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$608.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$547.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$222.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$652.96
|
| Rate for Payer: Ohio Health Group HMO |
$556.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$593.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$645.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$511.98
|
| Rate for Payer: PHCS Commercial |
$712.32
|
| Rate for Payer: United Healthcare All Payer |
$652.96
|
|
|
INTMD RPR N-HF/GENIT20.1-30
|
Facility
|
IP
|
$1,633.00
|
|
|
Service Code
|
HCPCS 12046
|
| Hospital Charge Code |
76102579
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$489.90 |
| Max. Negotiated Rate |
$1,567.68 |
| Rate for Payer: Aetna Commercial |
$1,257.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,273.74
|
| Rate for Payer: Cash Price |
$816.50
|
| Rate for Payer: Cigna Commercial |
$1,355.39
|
| Rate for Payer: First Health Commercial |
$1,551.35
|
| Rate for Payer: Humana Commercial |
$1,388.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,339.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,205.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$489.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,437.04
|
| Rate for Payer: Ohio Health Group HMO |
$1,224.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,306.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,420.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,126.77
|
| Rate for Payer: PHCS Commercial |
$1,567.68
|
| Rate for Payer: United Healthcare All Payer |
$1,437.04
|
|
|
INTMD RPR N-HF/GENIT20.1-30
|
Facility
|
OP
|
$1,633.00
|
|
|
Service Code
|
HCPCS 12046
|
| Hospital Charge Code |
76102579
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$561.59 |
| Max. Negotiated Rate |
$1,567.68 |
| Rate for Payer: Aetna Commercial |
$1,257.41
|
| Rate for Payer: Anthem Medicaid |
$561.59
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,273.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$816.50
|
| Rate for Payer: Cash Price |
$816.50
|
| Rate for Payer: Cigna Commercial |
$1,355.39
|
| Rate for Payer: First Health Commercial |
$1,551.35
|
| Rate for Payer: Humana Commercial |
$1,388.05
|
| Rate for Payer: Humana KY Medicaid |
$561.59
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$567.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,339.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,205.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$572.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,437.04
|
| Rate for Payer: Ohio Health Group HMO |
$1,224.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,306.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,420.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,126.77
|
| Rate for Payer: PHCS Commercial |
$1,567.68
|
| Rate for Payer: United Healthcare All Payer |
$1,437.04
|
|
|
INTMD RPR N-HF/GENIT20.1-30
|
Professional
|
Both
|
$1,633.00
|
|
|
Service Code
|
HCPCS 12046
|
| Hospital Charge Code |
76102579
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$163.69 |
| Max. Negotiated Rate |
$979.80 |
| Rate for Payer: Aetna Commercial |
$420.84
|
| Rate for Payer: Ambetter Exchange |
$300.79
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$163.69
|
| Rate for Payer: Anthem Medicaid |
$207.87
|
| Rate for Payer: Buckeye Individual/Medicaid |
$300.79
|
| Rate for Payer: Buckeye Medicare Advantage |
$300.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$360.95
|
| Rate for Payer: Cash Price |
$816.50
|
| Rate for Payer: Cash Price |
$816.50
|
| Rate for Payer: Cigna Commercial |
$402.31
|
| Rate for Payer: Healthspan PPO |
$486.72
|
| Rate for Payer: Humana Medicaid |
$207.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$359.75
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$300.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$300.79
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$212.03
|
| Rate for Payer: Molina Healthcare Passport |
$207.87
|
| Rate for Payer: Multiplan PHCS |
$979.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$391.03
|
| Rate for Payer: UHCCP Medicaid |
$171.87
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$209.95
|
| Rate for Payer: Wellcare Medicare Advantage |
$300.79
|
|
|
INTMD RPR N-HF/GENIT20.1-30(P
|
Professional
|
Both
|
$319.00
|
|
|
Service Code
|
HCPCS 12046
|
| Hospital Charge Code |
761P2579
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$163.69 |
| Max. Negotiated Rate |
$486.72 |
| Rate for Payer: Aetna Commercial |
$420.84
|
| Rate for Payer: Ambetter Exchange |
$300.79
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$163.69
|
| Rate for Payer: Anthem Medicaid |
$207.87
|
| Rate for Payer: Buckeye Individual/Medicaid |
$300.79
|
| Rate for Payer: Buckeye Medicare Advantage |
$300.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$360.95
|
| Rate for Payer: Cash Price |
$159.50
|
| Rate for Payer: Cash Price |
$159.50
|
| Rate for Payer: Cigna Commercial |
$402.31
|
| Rate for Payer: Healthspan PPO |
$486.72
|
| Rate for Payer: Humana Medicaid |
$207.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$359.75
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$300.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$300.79
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$212.03
|
| Rate for Payer: Molina Healthcare Passport |
$207.87
|
| Rate for Payer: Multiplan PHCS |
$191.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$391.03
|
| Rate for Payer: UHCCP Medicaid |
$171.87
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$209.95
|
| Rate for Payer: Wellcare Medicare Advantage |
$300.79
|
|
|
INTMD RPR N-HF/GENIT20.1-30(T
|
Facility
|
IP
|
$1,314.00
|
|
|
Service Code
|
HCPCS 12046
|
| Hospital Charge Code |
761T2579
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$394.20 |
| Max. Negotiated Rate |
$1,261.44 |
| Rate for Payer: Aetna Commercial |
$1,011.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,024.92
|
| Rate for Payer: Cash Price |
$657.00
|
| Rate for Payer: Cigna Commercial |
$1,090.62
|
| Rate for Payer: First Health Commercial |
$1,248.30
|
| Rate for Payer: Humana Commercial |
$1,116.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,077.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$969.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$394.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,156.32
|
| Rate for Payer: Ohio Health Group HMO |
$985.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,051.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,143.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$906.66
|
| Rate for Payer: PHCS Commercial |
$1,261.44
|
| Rate for Payer: United Healthcare All Payer |
$1,156.32
|
|
|
INTMD RPR N-HF/GENIT20.1-30(T
|
Facility
|
OP
|
$1,314.00
|
|
|
Service Code
|
HCPCS 12046
|
| Hospital Charge Code |
761T2579
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$451.88 |
| Max. Negotiated Rate |
$1,261.44 |
| Rate for Payer: Aetna Commercial |
$1,011.78
|
| Rate for Payer: Anthem Medicaid |
$451.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,024.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$657.00
|
| Rate for Payer: Cash Price |
$657.00
|
| Rate for Payer: Cigna Commercial |
$1,090.62
|
| Rate for Payer: First Health Commercial |
$1,248.30
|
| Rate for Payer: Humana Commercial |
$1,116.90
|
| Rate for Payer: Humana KY Medicaid |
$451.88
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$456.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,077.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$969.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$460.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,156.32
|
| Rate for Payer: Ohio Health Group HMO |
$985.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,051.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,143.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$906.66
|
| Rate for Payer: PHCS Commercial |
$1,261.44
|
| Rate for Payer: United Healthcare All Payer |
$1,156.32
|
|
|
INTMD RPR N-HF/GENIT >30.0CM
|
Facility
|
IP
|
$5,109.00
|
|
|
Service Code
|
HCPCS 12047
|
| Hospital Charge Code |
76100142
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,532.70 |
| Max. Negotiated Rate |
$4,904.64 |
| Rate for Payer: Aetna Commercial |
$3,933.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,985.02
|
| Rate for Payer: Cash Price |
$2,554.50
|
| Rate for Payer: Cigna Commercial |
$4,240.47
|
| Rate for Payer: First Health Commercial |
$4,853.55
|
| Rate for Payer: Humana Commercial |
$4,342.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,189.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,770.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,532.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,495.92
|
| Rate for Payer: Ohio Health Group HMO |
$3,831.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,087.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,444.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,525.21
|
| Rate for Payer: PHCS Commercial |
$4,904.64
|
| Rate for Payer: United Healthcare All Payer |
$4,495.92
|
|
|
INTMD RPR N-HF/GENIT >30.0CM
|
Professional
|
Both
|
$5,109.00
|
|
|
Service Code
|
HCPCS 12047
|
| Hospital Charge Code |
76100142
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$181.86 |
| Max. Negotiated Rate |
$3,065.40 |
| Rate for Payer: Aetna Commercial |
$460.17
|
| Rate for Payer: Ambetter Exchange |
$333.94
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$181.86
|
| Rate for Payer: Anthem Medicaid |
$256.41
|
| Rate for Payer: Buckeye Individual/Medicaid |
$333.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$333.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$400.73
|
| Rate for Payer: Cash Price |
$2,554.50
|
| Rate for Payer: Cash Price |
$2,554.50
|
| Rate for Payer: Cigna Commercial |
$442.93
|
| Rate for Payer: Healthspan PPO |
$522.43
|
| Rate for Payer: Humana Medicaid |
$256.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$387.69
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$333.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$333.94
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$261.54
|
| Rate for Payer: Molina Healthcare Passport |
$256.41
|
| Rate for Payer: Multiplan PHCS |
$3,065.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$434.12
|
| Rate for Payer: UHCCP Medicaid |
$190.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$258.97
|
| Rate for Payer: Wellcare Medicare Advantage |
$333.94
|
|
|
INTMD RPR N-HF/GENIT >30.0CM
|
Facility
|
OP
|
$5,109.00
|
|
|
Service Code
|
HCPCS 12047
|
| Hospital Charge Code |
76100142
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,690.17 |
| Max. Negotiated Rate |
$4,904.64 |
| Rate for Payer: Aetna Commercial |
$3,933.93
|
| Rate for Payer: Anthem Medicaid |
$1,756.99
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,985.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Cash Price |
$2,554.50
|
| Rate for Payer: Cash Price |
$2,554.50
|
| Rate for Payer: Cigna Commercial |
$4,240.47
|
| Rate for Payer: First Health Commercial |
$4,853.55
|
| Rate for Payer: Humana Commercial |
$4,342.65
|
| Rate for Payer: Humana KY Medicaid |
$1,756.99
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,774.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,189.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,770.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,792.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,495.92
|
| Rate for Payer: Ohio Health Group HMO |
$3,831.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,087.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,444.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,525.21
|
| Rate for Payer: PHCS Commercial |
$4,904.64
|
| Rate for Payer: United Healthcare All Payer |
$4,495.92
|
|
|
INTMD RPR N-HF/GENIT >30.0C(P
|
Professional
|
Both
|
$550.00
|
|
|
Service Code
|
HCPCS 12047
|
| Hospital Charge Code |
761P0142
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$181.86 |
| Max. Negotiated Rate |
$522.43 |
| Rate for Payer: Aetna Commercial |
$460.17
|
| Rate for Payer: Ambetter Exchange |
$333.94
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$181.86
|
| Rate for Payer: Anthem Medicaid |
$256.41
|
| Rate for Payer: Buckeye Individual/Medicaid |
$333.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$333.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$400.73
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$442.93
|
| Rate for Payer: Healthspan PPO |
$522.43
|
| Rate for Payer: Humana Medicaid |
$256.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$387.69
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$333.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$333.94
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$261.54
|
| Rate for Payer: Molina Healthcare Passport |
$256.41
|
| Rate for Payer: Multiplan PHCS |
$330.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$434.12
|
| Rate for Payer: UHCCP Medicaid |
$190.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$258.97
|
| Rate for Payer: Wellcare Medicare Advantage |
$333.94
|
|
|
INTMD RPR N-HF/GENIT >30.0C(T
|
Facility
|
OP
|
$4,559.00
|
|
|
Service Code
|
HCPCS 12047
|
| Hospital Charge Code |
761T0142
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,567.84 |
| Max. Negotiated Rate |
$4,376.64 |
| Rate for Payer: Aetna Commercial |
$3,510.43
|
| Rate for Payer: Anthem Medicaid |
$1,567.84
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,556.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Cash Price |
$2,279.50
|
| Rate for Payer: Cash Price |
$2,279.50
|
| Rate for Payer: Cigna Commercial |
$3,783.97
|
| Rate for Payer: First Health Commercial |
$4,331.05
|
| Rate for Payer: Humana Commercial |
$3,875.15
|
| Rate for Payer: Humana KY Medicaid |
$1,567.84
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,583.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,738.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,364.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,599.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,011.92
|
| Rate for Payer: Ohio Health Group HMO |
$3,419.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,647.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,966.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,145.71
|
| Rate for Payer: PHCS Commercial |
$4,376.64
|
| Rate for Payer: United Healthcare All Payer |
$4,011.92
|
|
|
INTMD RPR N-HF/GENIT >30.0C(T
|
Facility
|
IP
|
$4,559.00
|
|
|
Service Code
|
HCPCS 12047
|
| Hospital Charge Code |
761T0142
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,367.70 |
| Max. Negotiated Rate |
$4,376.64 |
| Rate for Payer: Aetna Commercial |
$3,510.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,556.02
|
| Rate for Payer: Cash Price |
$2,279.50
|
| Rate for Payer: Cigna Commercial |
$3,783.97
|
| Rate for Payer: First Health Commercial |
$4,331.05
|
| Rate for Payer: Humana Commercial |
$3,875.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,738.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,364.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,367.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,011.92
|
| Rate for Payer: Ohio Health Group HMO |
$3,419.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,647.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,966.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,145.71
|
| Rate for Payer: PHCS Commercial |
$4,376.64
|
| Rate for Payer: United Healthcare All Payer |
$4,011.92
|
|
|
INTMD RPR N-HF/GENIT7.6-12.5
|
Facility
|
IP
|
$2,040.00
|
|
|
Service Code
|
HCPCS 12044
|
| Hospital Charge Code |
76100140
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$612.00 |
| Max. Negotiated Rate |
$1,958.40 |
| Rate for Payer: Aetna Commercial |
$1,570.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,591.20
|
| Rate for Payer: Cash Price |
$1,020.00
|
| Rate for Payer: Cigna Commercial |
$1,693.20
|
| Rate for Payer: First Health Commercial |
$1,938.00
|
| Rate for Payer: Humana Commercial |
$1,734.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,672.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,505.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$612.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,795.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,530.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,632.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,774.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,407.60
|
| Rate for Payer: PHCS Commercial |
$1,958.40
|
| Rate for Payer: United Healthcare All Payer |
$1,795.20
|
|
