|
NRV CNDJ TST 3-4 STUDIES
|
Professional
|
Both
|
$712.00
|
|
|
Service Code
|
HCPCS 95908
|
| Hospital Charge Code |
92200012
|
|
Hospital Revenue Code
|
922
|
| Min. Negotiated Rate |
$76.89 |
| Max. Negotiated Rate |
$712.00 |
| Rate for Payer: Anthem Medicaid |
$92.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$712.00
|
| Rate for Payer: Cash Price |
$356.00
|
| Rate for Payer: Cash Price |
$356.00
|
| Rate for Payer: Cigna Commercial |
$199.84
|
| Rate for Payer: Healthspan PPO |
$115.99
|
| Rate for Payer: Humana Medicaid |
$92.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$76.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$93.94
|
| Rate for Payer: Molina Healthcare Passport |
$92.10
|
| Rate for Payer: Multiplan PHCS |
$427.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$498.40
|
| Rate for Payer: UHCCP Medicaid |
$249.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$93.02
|
|
|
NRV CNDJ TST 3-4 STUDIES
|
Facility
|
IP
|
$712.00
|
|
|
Service Code
|
HCPCS 95908
|
| Hospital Charge Code |
92200012
|
|
Hospital Revenue Code
|
922
|
| Min. Negotiated Rate |
$92.56 |
| Max. Negotiated Rate |
$683.52 |
| Rate for Payer: Aetna Commercial |
$548.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$555.36
|
| Rate for Payer: Cash Price |
$356.00
|
| Rate for Payer: Cigna Commercial |
$590.96
|
| Rate for Payer: First Health Commercial |
$676.40
|
| Rate for Payer: Humana Commercial |
$605.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$583.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$525.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$213.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$626.56
|
| Rate for Payer: Ohio Health Group HMO |
$534.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$142.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$92.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$220.72
|
| Rate for Payer: PHCS Commercial |
$683.52
|
| Rate for Payer: United Healthcare All Payer |
$626.56
|
|
|
NRV CNDJ TST 3-4 STUDIES(P
|
Professional
|
Both
|
$94.00
|
|
|
Service Code
|
HCPCS 95908
|
| Hospital Charge Code |
922P0012
|
|
Hospital Revenue Code
|
922
|
| Min. Negotiated Rate |
$32.90 |
| Max. Negotiated Rate |
$199.84 |
| Rate for Payer: Anthem Medicaid |
$92.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$94.00
|
| Rate for Payer: Cash Price |
$47.00
|
| Rate for Payer: Cash Price |
$47.00
|
| Rate for Payer: Cigna Commercial |
$199.84
|
| Rate for Payer: Healthspan PPO |
$115.99
|
| Rate for Payer: Humana Medicaid |
$92.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$76.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$93.94
|
| Rate for Payer: Molina Healthcare Passport |
$92.10
|
| Rate for Payer: Multiplan PHCS |
$56.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$65.80
|
| Rate for Payer: UHCCP Medicaid |
$32.90
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$93.02
|
|
|
NRV CNDJ TST 3-4 STUDIES(T
|
Facility
|
IP
|
$618.00
|
|
|
Service Code
|
HCPCS 95908
|
| Hospital Charge Code |
922T0012
|
|
Hospital Revenue Code
|
922
|
| Min. Negotiated Rate |
$80.34 |
| Max. Negotiated Rate |
$593.28 |
| Rate for Payer: Aetna Commercial |
$475.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$482.04
|
| Rate for Payer: Cash Price |
$309.00
|
| Rate for Payer: Cigna Commercial |
$512.94
|
| Rate for Payer: First Health Commercial |
$587.10
|
| Rate for Payer: Humana Commercial |
$525.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$506.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$456.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$185.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$543.84
|
| Rate for Payer: Ohio Health Group HMO |
$463.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$123.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$191.58
|
| Rate for Payer: PHCS Commercial |
$593.28
|
| Rate for Payer: United Healthcare All Payer |
$543.84
|
|
|
NRV CNDJ TST 3-4 STUDIES(T
|
Facility
|
OP
|
$618.00
|
|
|
Service Code
|
HCPCS 95908
|
| Hospital Charge Code |
922T0012
|
|
Hospital Revenue Code
|
922
|
| Min. Negotiated Rate |
$80.34 |
| Max. Negotiated Rate |
$593.28 |
| Rate for Payer: Aetna Commercial |
$475.86
|
| Rate for Payer: Anthem Medicaid |
$212.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$271.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$482.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$380.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$366.43
|
| Rate for Payer: Cash Price |
$309.00
|
| Rate for Payer: Cash Price |
$309.00
|
| Rate for Payer: Cigna Commercial |
$512.94
|
| Rate for Payer: First Health Commercial |
$587.10
|
| Rate for Payer: Humana Commercial |
$525.30
|
| Rate for Payer: Humana KY Medicaid |
$212.53
|
| Rate for Payer: Humana Medicare Advantage |
$271.43
|
| Rate for Payer: Kentucky WC Medicaid |
$214.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$506.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$456.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$325.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$216.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$543.84
|
| Rate for Payer: Ohio Health Group HMO |
$463.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$123.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$191.58
|
| Rate for Payer: PHCS Commercial |
$593.28
|
| Rate for Payer: United Healthcare All Payer |
$543.84
|
|
|
NRV CNDJ TST 5-6 STUDIES
|
Facility
|
OP
|
$1,044.00
|
|
|
Service Code
|
HCPCS 95909
|
| Hospital Charge Code |
92200013
|
|
Hospital Revenue Code
|
922
|
| Min. Negotiated Rate |
$135.72 |
| Max. Negotiated Rate |
$1,002.24 |
| Rate for Payer: Aetna Commercial |
$803.88
|
| Rate for Payer: Anthem Medicaid |
$359.03
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$271.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$814.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$380.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$366.43
|
| Rate for Payer: Cash Price |
$522.00
|
| Rate for Payer: Cash Price |
$522.00
|
| Rate for Payer: Cigna Commercial |
$866.52
|
| Rate for Payer: First Health Commercial |
$991.80
|
| Rate for Payer: Humana Commercial |
$887.40
|
| Rate for Payer: Humana KY Medicaid |
$359.03
|
| Rate for Payer: Humana Medicare Advantage |
$271.43
|
| Rate for Payer: Kentucky WC Medicaid |
$362.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$856.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$770.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$325.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$366.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$918.72
|
| Rate for Payer: Ohio Health Group HMO |
$783.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$208.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$135.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$323.64
|
| Rate for Payer: PHCS Commercial |
$1,002.24
|
| Rate for Payer: United Healthcare All Payer |
$918.72
|
|
|
NRV CNDJ TST 5-6 STUDIES
|
Professional
|
Both
|
$1,044.00
|
|
|
Service Code
|
HCPCS 95909
|
| Hospital Charge Code |
92200013
|
|
Hospital Revenue Code
|
922
|
| Min. Negotiated Rate |
$91.69 |
| Max. Negotiated Rate |
$1,044.00 |
| Rate for Payer: Anthem Medicaid |
$110.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,044.00
|
| Rate for Payer: Cash Price |
$522.00
|
| Rate for Payer: Cash Price |
$522.00
|
| Rate for Payer: Cigna Commercial |
$239.47
|
| Rate for Payer: Healthspan PPO |
$139.05
|
| Rate for Payer: Humana Medicaid |
$110.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$91.69
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$112.56
|
| Rate for Payer: Molina Healthcare Passport |
$110.35
|
| Rate for Payer: Multiplan PHCS |
$626.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$730.80
|
| Rate for Payer: UHCCP Medicaid |
$365.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$111.45
|
|
|
NRV CNDJ TST 5-6 STUDIES
|
Facility
|
IP
|
$1,044.00
|
|
|
Service Code
|
HCPCS 95909
|
| Hospital Charge Code |
92200013
|
|
Hospital Revenue Code
|
922
|
| Min. Negotiated Rate |
$135.72 |
| Max. Negotiated Rate |
$1,002.24 |
| Rate for Payer: Aetna Commercial |
$803.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$814.32
|
| Rate for Payer: Cash Price |
$522.00
|
| Rate for Payer: Cigna Commercial |
$866.52
|
| Rate for Payer: First Health Commercial |
$991.80
|
| Rate for Payer: Humana Commercial |
$887.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$856.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$770.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$313.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$918.72
|
| Rate for Payer: Ohio Health Group HMO |
$783.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$208.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$135.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$323.64
|
| Rate for Payer: PHCS Commercial |
$1,002.24
|
| Rate for Payer: United Healthcare All Payer |
$918.72
|
|
|
NRV CNDJ TST 5-6 STUDIES(P
|
Professional
|
Both
|
$112.00
|
|
|
Service Code
|
HCPCS 95909
|
| Hospital Charge Code |
922P0013
|
|
Hospital Revenue Code
|
922
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$239.47 |
| Rate for Payer: Anthem Medicaid |
$110.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$112.00
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Cigna Commercial |
$239.47
|
| Rate for Payer: Healthspan PPO |
$139.05
|
| Rate for Payer: Humana Medicaid |
$110.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$91.69
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$112.56
|
| Rate for Payer: Molina Healthcare Passport |
$110.35
|
| Rate for Payer: Multiplan PHCS |
$67.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$78.40
|
| Rate for Payer: UHCCP Medicaid |
$39.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$111.45
|
|
|
NRV CNDJ TST 5-6 STUDIES(T
|
Facility
|
OP
|
$932.00
|
|
|
Service Code
|
HCPCS 95909
|
| Hospital Charge Code |
922T0013
|
|
Hospital Revenue Code
|
922
|
| Min. Negotiated Rate |
$121.16 |
| Max. Negotiated Rate |
$894.72 |
| Rate for Payer: Aetna Commercial |
$717.64
|
| Rate for Payer: Anthem Medicaid |
$320.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$271.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$726.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$380.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$366.43
|
| Rate for Payer: Cash Price |
$466.00
|
| Rate for Payer: Cash Price |
$466.00
|
| Rate for Payer: Cigna Commercial |
$773.56
|
| Rate for Payer: First Health Commercial |
$885.40
|
| Rate for Payer: Humana Commercial |
$792.20
|
| Rate for Payer: Humana KY Medicaid |
$320.51
|
| Rate for Payer: Humana Medicare Advantage |
$271.43
|
| Rate for Payer: Kentucky WC Medicaid |
$323.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$764.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$687.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$325.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$326.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$820.16
|
| Rate for Payer: Ohio Health Group HMO |
$699.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$186.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$121.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$288.92
|
| Rate for Payer: PHCS Commercial |
$894.72
|
| Rate for Payer: United Healthcare All Payer |
$820.16
|
|
|
NRV CNDJ TST 5-6 STUDIES(T
|
Facility
|
IP
|
$932.00
|
|
|
Service Code
|
HCPCS 95909
|
| Hospital Charge Code |
922T0013
|
|
Hospital Revenue Code
|
922
|
| Min. Negotiated Rate |
$121.16 |
| Max. Negotiated Rate |
$894.72 |
| Rate for Payer: Aetna Commercial |
$717.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$726.96
|
| Rate for Payer: Cash Price |
$466.00
|
| Rate for Payer: Cigna Commercial |
$773.56
|
| Rate for Payer: First Health Commercial |
$885.40
|
| Rate for Payer: Humana Commercial |
$792.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$764.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$687.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$279.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$820.16
|
| Rate for Payer: Ohio Health Group HMO |
$699.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$186.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$121.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$288.92
|
| Rate for Payer: PHCS Commercial |
$894.72
|
| Rate for Payer: United Healthcare All Payer |
$820.16
|
|
|
NSF CHARGE
|
Professional
|
Both
|
$30.00
|
|
| Hospital Charge Code |
99999999
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$30.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Multiplan PHCS |
$18.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$21.00
|
| Rate for Payer: UHCCP Medicaid |
$10.50
|
|
|
NSL/SINS NDSC TOTAL
|
Facility
|
IP
|
$705.00
|
|
|
Service Code
|
HCPCS 31253
|
| Hospital Charge Code |
76101152
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$91.65 |
| Max. Negotiated Rate |
$676.80 |
| Rate for Payer: Aetna Commercial |
$542.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$549.90
|
| Rate for Payer: Cash Price |
$352.50
|
| Rate for Payer: Cigna Commercial |
$585.15
|
| Rate for Payer: First Health Commercial |
$669.75
|
| Rate for Payer: Humana Commercial |
$599.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$578.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$520.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$211.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$620.40
|
| Rate for Payer: Ohio Health Group HMO |
$528.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$141.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$91.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$218.55
|
| Rate for Payer: PHCS Commercial |
$676.80
|
| Rate for Payer: United Healthcare All Payer |
$620.40
|
|
|
NSL/SINS NDSC TOTAL
|
Facility
|
OP
|
$705.00
|
|
|
Service Code
|
HCPCS 31253
|
| Hospital Charge Code |
76101152
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$91.65 |
| Max. Negotiated Rate |
$8,286.08 |
| Rate for Payer: Aetna Commercial |
$542.85
|
| Rate for Payer: Anthem Medicaid |
$242.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,918.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$549.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,286.08
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,990.15
|
| Rate for Payer: Cash Price |
$352.50
|
| Rate for Payer: Cash Price |
$352.50
|
| Rate for Payer: Cigna Commercial |
$585.15
|
| Rate for Payer: First Health Commercial |
$669.75
|
| Rate for Payer: Humana Commercial |
$599.25
|
| Rate for Payer: Humana KY Medicaid |
$242.45
|
| Rate for Payer: Humana Medicare Advantage |
$5,918.63
|
| Rate for Payer: Kentucky WC Medicaid |
$244.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$578.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$520.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,102.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$247.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$620.40
|
| Rate for Payer: Ohio Health Group HMO |
$528.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$141.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$91.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$218.55
|
| Rate for Payer: PHCS Commercial |
$676.80
|
| Rate for Payer: United Healthcare All Payer |
$620.40
|
|
|
NSL/SINS NDSC TOTAL
|
Professional
|
Both
|
$705.00
|
|
|
Service Code
|
HCPCS 31253
|
| Hospital Charge Code |
76101152
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$246.75 |
| Max. Negotiated Rate |
$854.49 |
| Rate for Payer: Anthem Medicaid |
$398.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$705.00
|
| Rate for Payer: Cash Price |
$352.50
|
| Rate for Payer: Cash Price |
$352.50
|
| Rate for Payer: Cigna Commercial |
$854.49
|
| Rate for Payer: Humana Medicaid |
$398.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$659.78
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$406.16
|
| Rate for Payer: Molina Healthcare Passport |
$398.20
|
| Rate for Payer: Multiplan PHCS |
$423.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$493.50
|
| Rate for Payer: UHCCP Medicaid |
$246.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$402.18
|
|
|
NSL/SINS NDSC TOTAL(P
|
Professional
|
Both
|
$705.00
|
|
|
Service Code
|
HCPCS 31253
|
| Hospital Charge Code |
761P1152
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$246.75 |
| Max. Negotiated Rate |
$854.49 |
| Rate for Payer: Anthem Medicaid |
$398.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$705.00
|
| Rate for Payer: Cash Price |
$352.50
|
| Rate for Payer: Cash Price |
$352.50
|
| Rate for Payer: Cigna Commercial |
$854.49
|
| Rate for Payer: Humana Medicaid |
$398.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$659.78
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$406.16
|
| Rate for Payer: Molina Healthcare Passport |
$398.20
|
| Rate for Payer: Multiplan PHCS |
$423.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$493.50
|
| Rate for Payer: UHCCP Medicaid |
$246.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$402.18
|
|
|
NSL/SINS NDSC W/ARTERY LIG
|
Facility
|
OP
|
$650.00
|
|
|
Service Code
|
HCPCS 31241
|
| Hospital Charge Code |
76101151
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$84.50 |
| Max. Negotiated Rate |
$2,054.81 |
| Rate for Payer: Aetna Commercial |
$500.50
|
| Rate for Payer: Anthem Medicaid |
$223.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,467.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$507.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,054.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,981.42
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$539.50
|
| Rate for Payer: First Health Commercial |
$617.50
|
| Rate for Payer: Humana Commercial |
$552.50
|
| Rate for Payer: Humana KY Medicaid |
$223.54
|
| Rate for Payer: Humana Medicare Advantage |
$1,467.72
|
| Rate for Payer: Kentucky WC Medicaid |
$225.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$533.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$479.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,761.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$228.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$572.00
|
| Rate for Payer: Ohio Health Group HMO |
$487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$84.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$201.50
|
| Rate for Payer: PHCS Commercial |
$624.00
|
| Rate for Payer: United Healthcare All Payer |
$572.00
|
|
|
NSL/SINS NDSC W/ARTERY LIG
|
Facility
|
IP
|
$650.00
|
|
|
Service Code
|
HCPCS 31241
|
| Hospital Charge Code |
76101151
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$84.50 |
| Max. Negotiated Rate |
$624.00 |
| Rate for Payer: Aetna Commercial |
$500.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$507.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$539.50
|
| Rate for Payer: First Health Commercial |
$617.50
|
| Rate for Payer: Humana Commercial |
$552.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$533.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$479.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$195.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$572.00
|
| Rate for Payer: Ohio Health Group HMO |
$487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$84.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$201.50
|
| Rate for Payer: PHCS Commercial |
$624.00
|
| Rate for Payer: United Healthcare All Payer |
$572.00
|
|
|
NSL/SINS NDSC W/ARTERY LIG
|
Professional
|
Both
|
$650.00
|
|
|
Service Code
|
HCPCS 31241
|
| Hospital Charge Code |
76101151
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$762.37 |
| Rate for Payer: Anthem Medicaid |
$355.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$650.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$762.37
|
| Rate for Payer: Humana Medicaid |
$355.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$588.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$362.19
|
| Rate for Payer: Molina Healthcare Passport |
$355.09
|
| Rate for Payer: Multiplan PHCS |
$390.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$455.00
|
| Rate for Payer: UHCCP Medicaid |
$227.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$358.64
|
|
|
NSL/SINS NDSC W/ARTERY LIG(P
|
Professional
|
Both
|
$650.00
|
|
|
Service Code
|
HCPCS 31241
|
| Hospital Charge Code |
761P1151
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$762.37 |
| Rate for Payer: Anthem Medicaid |
$355.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$650.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$762.37
|
| Rate for Payer: Humana Medicaid |
$355.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$588.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$362.19
|
| Rate for Payer: Molina Healthcare Passport |
$355.09
|
| Rate for Payer: Multiplan PHCS |
$390.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$455.00
|
| Rate for Payer: UHCCP Medicaid |
$227.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$358.64
|
|
|
NSL/SINS NDSC W/TOT ETHMDCT
|
Facility
|
OP
|
$1,900.00
|
|
|
Service Code
|
HCPCS 31255
|
| Hospital Charge Code |
76101154
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$247.00 |
| Max. Negotiated Rate |
$8,286.08 |
| Rate for Payer: Aetna Commercial |
$1,463.00
|
| Rate for Payer: Anthem Medicaid |
$653.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,918.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,482.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,286.08
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,990.15
|
| Rate for Payer: Cash Price |
$950.00
|
| Rate for Payer: Cash Price |
$950.00
|
| Rate for Payer: Cigna Commercial |
$1,577.00
|
| Rate for Payer: First Health Commercial |
$1,805.00
|
| Rate for Payer: Humana Commercial |
$1,615.00
|
| Rate for Payer: Humana KY Medicaid |
$653.41
|
| Rate for Payer: Humana Medicare Advantage |
$5,918.63
|
| Rate for Payer: Kentucky WC Medicaid |
$660.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,558.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,402.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,102.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$666.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,672.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,425.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$380.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$589.00
|
| Rate for Payer: PHCS Commercial |
$1,824.00
|
| Rate for Payer: United Healthcare All Payer |
$1,672.00
|
|
|
NSL/SINS NDSC W/TOT ETHMDCT
|
Professional
|
Both
|
$1,900.00
|
|
|
Service Code
|
HCPCS 31255
|
| Hospital Charge Code |
76101154
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$470.91 |
| Max. Negotiated Rate |
$1,900.00 |
| Rate for Payer: Aetna Commercial |
$623.39
|
| Rate for Payer: Anthem Medicaid |
$470.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,900.00
|
| Rate for Payer: Cash Price |
$950.00
|
| Rate for Payer: Cash Price |
$950.00
|
| Rate for Payer: Cigna Commercial |
$629.88
|
| Rate for Payer: Healthspan PPO |
$525.72
|
| Rate for Payer: Humana Medicaid |
$470.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$524.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$480.33
|
| Rate for Payer: Molina Healthcare Passport |
$470.91
|
| Rate for Payer: Multiplan PHCS |
$1,140.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,330.00
|
| Rate for Payer: UHCCP Medicaid |
$665.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$475.62
|
|
|
NSL/SINS NDSC W/TOT ETHMDCT
|
Facility
|
IP
|
$1,900.00
|
|
|
Service Code
|
HCPCS 31255
|
| Hospital Charge Code |
76101154
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$247.00 |
| Max. Negotiated Rate |
$1,824.00 |
| Rate for Payer: Aetna Commercial |
$1,463.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,482.00
|
| Rate for Payer: Cash Price |
$950.00
|
| Rate for Payer: Cigna Commercial |
$1,577.00
|
| Rate for Payer: First Health Commercial |
$1,805.00
|
| Rate for Payer: Humana Commercial |
$1,615.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,558.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,402.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$570.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,672.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,425.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$380.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$589.00
|
| Rate for Payer: PHCS Commercial |
$1,824.00
|
| Rate for Payer: United Healthcare All Payer |
$1,672.00
|
|
|
NSL/SINS NDSC W/TOT ETHMDCT(P
|
Professional
|
Both
|
$1,900.00
|
|
|
Service Code
|
HCPCS 31255
|
| Hospital Charge Code |
761P1154
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$470.91 |
| Max. Negotiated Rate |
$1,900.00 |
| Rate for Payer: Aetna Commercial |
$623.39
|
| Rate for Payer: Anthem Medicaid |
$470.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,900.00
|
| Rate for Payer: Cash Price |
$950.00
|
| Rate for Payer: Cash Price |
$950.00
|
| Rate for Payer: Cigna Commercial |
$629.88
|
| Rate for Payer: Healthspan PPO |
$525.72
|
| Rate for Payer: Humana Medicaid |
$470.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$524.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$480.33
|
| Rate for Payer: Molina Healthcare Passport |
$470.91
|
| Rate for Payer: Multiplan PHCS |
$1,140.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,330.00
|
| Rate for Payer: UHCCP Medicaid |
$665.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$475.62
|
|
|
NSPACE BALLOON IMPLANT - SMALL
|
Facility
|
IP
|
$28,525.00
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,708.25 |
| Max. Negotiated Rate |
$27,384.00 |
| Rate for Payer: Aetna Commercial |
$21,964.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,249.50
|
| Rate for Payer: Cash Price |
$14,262.50
|
| Rate for Payer: Cigna Commercial |
$23,675.75
|
| Rate for Payer: First Health Commercial |
$27,098.75
|
| Rate for Payer: Humana Commercial |
$24,246.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,390.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,051.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,557.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,102.00
|
| Rate for Payer: Ohio Health Group HMO |
$21,393.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,705.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,708.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,842.75
|
| Rate for Payer: PHCS Commercial |
$27,384.00
|
| Rate for Payer: United Healthcare All Payer |
$25,102.00
|
|
