|
NJX PX DISCOGRAPHY LUMBAR
|
Facility
|
IP
|
$2,880.00
|
|
|
Service Code
|
HCPCS 62290
|
| Hospital Charge Code |
76102295
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$864.00 |
| Max. Negotiated Rate |
$2,764.80 |
| Rate for Payer: Aetna Commercial |
$2,217.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,246.40
|
| Rate for Payer: Cash Price |
$1,440.00
|
| Rate for Payer: Cigna Commercial |
$2,390.40
|
| Rate for Payer: First Health Commercial |
$2,736.00
|
| Rate for Payer: Humana Commercial |
$2,448.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,361.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,125.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$864.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,534.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,160.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,304.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,505.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,987.20
|
| Rate for Payer: PHCS Commercial |
$2,764.80
|
| Rate for Payer: United Healthcare All Payer |
$2,534.40
|
|
|
NJX PX DISCOGRAPHY LUMBAR(P
|
Professional
|
Both
|
$850.00
|
|
|
Service Code
|
HCPCS 62290
|
| Hospital Charge Code |
761P2295
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$81.15 |
| Max. Negotiated Rate |
$510.00 |
| Rate for Payer: Aetna Commercial |
$277.01
|
| Rate for Payer: Ambetter Exchange |
$147.65
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$81.15
|
| Rate for Payer: Anthem Medicaid |
$160.77
|
| Rate for Payer: Buckeye Individual/Medicaid |
$147.65
|
| Rate for Payer: Buckeye Medicare Advantage |
$147.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$177.18
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$255.32
|
| Rate for Payer: Healthspan PPO |
$392.31
|
| Rate for Payer: Humana Medicaid |
$160.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$217.76
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$147.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.65
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$163.99
|
| Rate for Payer: Molina Healthcare Passport |
$160.77
|
| Rate for Payer: Multiplan PHCS |
$510.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$191.94
|
| Rate for Payer: UHCCP Medicaid |
$85.21
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$162.38
|
| Rate for Payer: Wellcare Medicare Advantage |
$147.65
|
|
|
NJX PX DISCOGRAPHY LUMBAR(T
|
Facility
|
OP
|
$2,030.00
|
|
|
Service Code
|
HCPCS 62290
|
| Hospital Charge Code |
761T2295
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$609.00 |
| Max. Negotiated Rate |
$1,948.80 |
| Rate for Payer: Aetna Commercial |
$1,563.10
|
| Rate for Payer: Anthem Medicaid |
$698.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,583.40
|
| Rate for Payer: Cash Price |
$1,015.00
|
| Rate for Payer: Cigna Commercial |
$1,684.90
|
| Rate for Payer: First Health Commercial |
$1,928.50
|
| Rate for Payer: Humana Commercial |
$1,725.50
|
| Rate for Payer: Humana KY Medicaid |
$698.12
|
| Rate for Payer: Kentucky WC Medicaid |
$705.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,664.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,498.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$609.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$712.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,786.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,522.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,624.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,766.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,400.70
|
| Rate for Payer: PHCS Commercial |
$1,948.80
|
| Rate for Payer: United Healthcare All Payer |
$1,786.40
|
|
|
NJX PX DISCOGRAPHY LUMBAR(T
|
Facility
|
IP
|
$2,030.00
|
|
|
Service Code
|
HCPCS 62290
|
| Hospital Charge Code |
761T2295
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$609.00 |
| Max. Negotiated Rate |
$1,948.80 |
| Rate for Payer: Aetna Commercial |
$1,563.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,583.40
|
| Rate for Payer: Cash Price |
$1,015.00
|
| Rate for Payer: Cigna Commercial |
$1,684.90
|
| Rate for Payer: First Health Commercial |
$1,928.50
|
| Rate for Payer: Humana Commercial |
$1,725.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,664.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,498.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$609.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,786.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,522.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,624.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,766.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,400.70
|
| Rate for Payer: PHCS Commercial |
$1,948.80
|
| Rate for Payer: United Healthcare All Payer |
$1,786.40
|
|
|
NJX PX NFROSGRM &/URTRGRM
|
Facility
|
IP
|
$4,017.00
|
|
|
Service Code
|
HCPCS 50430
|
| Hospital Charge Code |
76102892
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,205.10 |
| Max. Negotiated Rate |
$3,856.32 |
| Rate for Payer: Aetna Commercial |
$3,093.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,133.26
|
| Rate for Payer: Cash Price |
$2,008.50
|
| Rate for Payer: Cigna Commercial |
$3,334.11
|
| Rate for Payer: First Health Commercial |
$3,816.15
|
| Rate for Payer: Humana Commercial |
$3,414.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,293.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,964.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,205.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,534.96
|
| Rate for Payer: Ohio Health Group HMO |
$3,012.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,213.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,494.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,771.73
|
| Rate for Payer: PHCS Commercial |
$3,856.32
|
| Rate for Payer: United Healthcare All Payer |
$3,534.96
|
|
|
NJX PX NFROSGRM &/URTRGRM
|
Facility
|
OP
|
$763.00
|
|
|
Service Code
|
HCPCS 50431
|
| Hospital Charge Code |
76102908
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$262.40 |
| Max. Negotiated Rate |
$863.42 |
| Rate for Payer: Aetna Commercial |
$587.51
|
| Rate for Payer: Anthem Medicaid |
$262.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$616.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$595.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$863.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$832.59
|
| Rate for Payer: Cash Price |
$381.50
|
| Rate for Payer: Cash Price |
$381.50
|
| Rate for Payer: Cigna Commercial |
$633.29
|
| Rate for Payer: First Health Commercial |
$724.85
|
| Rate for Payer: Humana Commercial |
$648.55
|
| Rate for Payer: Humana KY Medicaid |
$262.40
|
| Rate for Payer: Humana Medicare Advantage |
$616.73
|
| Rate for Payer: Kentucky WC Medicaid |
$265.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$625.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$563.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$740.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$267.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$671.44
|
| Rate for Payer: Ohio Health Group HMO |
$572.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$610.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$663.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$526.47
|
| Rate for Payer: PHCS Commercial |
$732.48
|
| Rate for Payer: United Healthcare All Payer |
$671.44
|
|
|
NJX PX NFROSGRM &/URTRGRM
|
Professional
|
Both
|
$4,017.00
|
|
|
Service Code
|
HCPCS 50430
|
| Hospital Charge Code |
76102892
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$135.09 |
| Max. Negotiated Rate |
$2,410.20 |
| Rate for Payer: Ambetter Exchange |
$143.32
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$135.09
|
| Rate for Payer: Anthem Medicaid |
$393.71
|
| Rate for Payer: Buckeye Individual/Medicaid |
$143.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$143.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$171.98
|
| Rate for Payer: Cash Price |
$2,008.50
|
| Rate for Payer: Cash Price |
$2,008.50
|
| Rate for Payer: Cigna Commercial |
$827.67
|
| Rate for Payer: Humana Medicaid |
$393.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$227.79
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$143.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$143.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$401.58
|
| Rate for Payer: Molina Healthcare Passport |
$393.71
|
| Rate for Payer: Multiplan PHCS |
$2,410.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$186.32
|
| Rate for Payer: UHCCP Medicaid |
$141.84
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$397.65
|
| Rate for Payer: Wellcare Medicare Advantage |
$143.32
|
|
|
NJX PX NFROSGRM &/URTRGRM
|
Facility
|
IP
|
$763.00
|
|
|
Service Code
|
HCPCS 50431
|
| Hospital Charge Code |
76102908
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$228.90 |
| Max. Negotiated Rate |
$732.48 |
| Rate for Payer: Aetna Commercial |
$587.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$595.14
|
| Rate for Payer: Cash Price |
$381.50
|
| Rate for Payer: Cigna Commercial |
$633.29
|
| Rate for Payer: First Health Commercial |
$724.85
|
| Rate for Payer: Humana Commercial |
$648.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$625.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$563.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$228.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$671.44
|
| Rate for Payer: Ohio Health Group HMO |
$572.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$610.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$663.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$526.47
|
| Rate for Payer: PHCS Commercial |
$732.48
|
| Rate for Payer: United Healthcare All Payer |
$671.44
|
|
|
NJX PX NFROSGRM &/URTRGRM
|
Facility
|
OP
|
$4,017.00
|
|
|
Service Code
|
HCPCS 50430
|
| Hospital Charge Code |
76102892
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$616.73 |
| Max. Negotiated Rate |
$3,856.32 |
| Rate for Payer: Aetna Commercial |
$3,093.09
|
| Rate for Payer: Anthem Medicaid |
$1,381.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$616.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,133.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$863.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$832.59
|
| Rate for Payer: Cash Price |
$2,008.50
|
| Rate for Payer: Cash Price |
$2,008.50
|
| Rate for Payer: Cigna Commercial |
$3,334.11
|
| Rate for Payer: First Health Commercial |
$3,816.15
|
| Rate for Payer: Humana Commercial |
$3,414.45
|
| Rate for Payer: Humana KY Medicaid |
$1,381.45
|
| Rate for Payer: Humana Medicare Advantage |
$616.73
|
| Rate for Payer: Kentucky WC Medicaid |
$1,395.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,293.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,964.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$740.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,409.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,534.96
|
| Rate for Payer: Ohio Health Group HMO |
$3,012.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,213.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,494.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,771.73
|
| Rate for Payer: PHCS Commercial |
$3,856.32
|
| Rate for Payer: United Healthcare All Payer |
$3,534.96
|
|
|
NJX PX NFROSGRM &/URTRGRM
|
Professional
|
Both
|
$763.00
|
|
|
Service Code
|
HCPCS 50431
|
| Hospital Charge Code |
76102908
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$53.32 |
| Max. Negotiated Rate |
$457.80 |
| Rate for Payer: Ambetter Exchange |
$62.03
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$53.32
|
| Rate for Payer: Anthem Medicaid |
$122.70
|
| Rate for Payer: Buckeye Individual/Medicaid |
$62.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$62.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$74.44
|
| Rate for Payer: Cash Price |
$381.50
|
| Rate for Payer: Cash Price |
$381.50
|
| Rate for Payer: Cigna Commercial |
$110.02
|
| Rate for Payer: Humana Medicaid |
$122.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$89.74
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$62.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$62.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$125.15
|
| Rate for Payer: Molina Healthcare Passport |
$122.70
|
| Rate for Payer: Multiplan PHCS |
$457.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$80.64
|
| Rate for Payer: UHCCP Medicaid |
$55.99
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$123.93
|
| Rate for Payer: Wellcare Medicare Advantage |
$62.03
|
|
|
NJX PX NFROSGRM &/URTRGRM (P
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 50430
|
| Hospital Charge Code |
761P2892
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$135.09 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Ambetter Exchange |
$143.32
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$135.09
|
| Rate for Payer: Anthem Medicaid |
$393.71
|
| Rate for Payer: Buckeye Individual/Medicaid |
$143.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$143.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$171.98
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$827.67
|
| Rate for Payer: Humana Medicaid |
$393.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$227.79
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$143.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$143.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$401.58
|
| Rate for Payer: Molina Healthcare Passport |
$393.71
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$186.32
|
| Rate for Payer: UHCCP Medicaid |
$141.84
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$397.65
|
| Rate for Payer: Wellcare Medicare Advantage |
$143.32
|
|
|
NJX PX NFROSGRM &/URTRGRM (T
|
Facility
|
OP
|
$2,517.00
|
|
|
Service Code
|
HCPCS 50430
|
| Hospital Charge Code |
761T2892
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$616.73 |
| Max. Negotiated Rate |
$2,416.32 |
| Rate for Payer: Aetna Commercial |
$1,938.09
|
| Rate for Payer: Anthem Medicaid |
$865.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$616.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,963.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$863.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$832.59
|
| Rate for Payer: Cash Price |
$1,258.50
|
| Rate for Payer: Cash Price |
$1,258.50
|
| Rate for Payer: Cigna Commercial |
$2,089.11
|
| Rate for Payer: First Health Commercial |
$2,391.15
|
| Rate for Payer: Humana Commercial |
$2,139.45
|
| Rate for Payer: Humana KY Medicaid |
$865.60
|
| Rate for Payer: Humana Medicare Advantage |
$616.73
|
| Rate for Payer: Kentucky WC Medicaid |
$874.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,063.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,857.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$740.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$882.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,214.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,887.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,013.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,189.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,736.73
|
| Rate for Payer: PHCS Commercial |
$2,416.32
|
| Rate for Payer: United Healthcare All Payer |
$2,214.96
|
|
|
NJX PX NFROSGRM &/URTRGRM (T
|
Facility
|
IP
|
$2,517.00
|
|
|
Service Code
|
HCPCS 50430
|
| Hospital Charge Code |
761T2892
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$755.10 |
| Max. Negotiated Rate |
$2,416.32 |
| Rate for Payer: Aetna Commercial |
$1,938.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,963.26
|
| Rate for Payer: Cash Price |
$1,258.50
|
| Rate for Payer: Cigna Commercial |
$2,089.11
|
| Rate for Payer: First Health Commercial |
$2,391.15
|
| Rate for Payer: Humana Commercial |
$2,139.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,063.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,857.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$755.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,214.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,887.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,013.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,189.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,736.73
|
| Rate for Payer: PHCS Commercial |
$2,416.32
|
| Rate for Payer: United Healthcare All Payer |
$2,214.96
|
|
|
NJX SBST INTLMNR LMBR/SAC WIMG
|
Facility
|
OP
|
$2,089.00
|
|
|
Service Code
|
HCPCS 62323
|
| Hospital Charge Code |
761T2298
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$639.87 |
| Max. Negotiated Rate |
$2,005.44 |
| Rate for Payer: Aetna Commercial |
$1,608.53
|
| Rate for Payer: Anthem Medicaid |
$718.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$639.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,629.42
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$895.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$863.82
|
| Rate for Payer: Cash Price |
$1,044.50
|
| Rate for Payer: Cash Price |
$1,044.50
|
| Rate for Payer: Cigna Commercial |
$1,733.87
|
| Rate for Payer: First Health Commercial |
$1,984.55
|
| Rate for Payer: Humana Commercial |
$1,775.65
|
| Rate for Payer: Humana KY Medicaid |
$718.41
|
| Rate for Payer: Humana Medicare Advantage |
$639.87
|
| Rate for Payer: Kentucky WC Medicaid |
$725.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,712.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,541.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$767.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$732.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,838.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,566.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,671.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,817.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,441.41
|
| Rate for Payer: PHCS Commercial |
$2,005.44
|
| Rate for Payer: United Healthcare All Payer |
$1,838.32
|
|
|
NJX SBST INTLMNR LMBR/SAC WIMG
|
Professional
|
Both
|
$425.00
|
|
|
Service Code
|
HCPCS 62323
|
| Hospital Charge Code |
761P2298
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$80.87 |
| Max. Negotiated Rate |
$255.00 |
| Rate for Payer: Ambetter Exchange |
$93.37
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$80.87
|
| Rate for Payer: Anthem Medicaid |
$186.33
|
| Rate for Payer: Buckeye Individual/Medicaid |
$93.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$93.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$112.04
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cigna Commercial |
$174.27
|
| Rate for Payer: Humana Medicaid |
$186.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$128.54
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$93.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$93.37
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$190.06
|
| Rate for Payer: Molina Healthcare Passport |
$186.33
|
| Rate for Payer: Multiplan PHCS |
$255.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$121.38
|
| Rate for Payer: UHCCP Medicaid |
$84.91
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$188.19
|
| Rate for Payer: Wellcare Medicare Advantage |
$93.37
|
|
|
NJX SBST INTLMNR LMBR/SAC WIMG
|
Facility
|
IP
|
$2,514.00
|
|
|
Service Code
|
HCPCS 62323
|
| Hospital Charge Code |
76102298
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$754.20 |
| Max. Negotiated Rate |
$2,413.44 |
| Rate for Payer: Aetna Commercial |
$1,935.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,960.92
|
| Rate for Payer: Cash Price |
$1,257.00
|
| Rate for Payer: Cigna Commercial |
$2,086.62
|
| Rate for Payer: First Health Commercial |
$2,388.30
|
| Rate for Payer: Humana Commercial |
$2,136.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,061.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,855.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$754.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,212.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,885.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,011.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,187.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,734.66
|
| Rate for Payer: PHCS Commercial |
$2,413.44
|
| Rate for Payer: United Healthcare All Payer |
$2,212.32
|
|
|
NJX SBST INTLMNR LMBR/SAC WIMG
|
Facility
|
IP
|
$2,089.00
|
|
|
Service Code
|
HCPCS 62323
|
| Hospital Charge Code |
761T2298
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$626.70 |
| Max. Negotiated Rate |
$2,005.44 |
| Rate for Payer: Aetna Commercial |
$1,608.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,629.42
|
| Rate for Payer: Cash Price |
$1,044.50
|
| Rate for Payer: Cigna Commercial |
$1,733.87
|
| Rate for Payer: First Health Commercial |
$1,984.55
|
| Rate for Payer: Humana Commercial |
$1,775.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,712.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,541.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$626.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,838.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,566.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,671.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,817.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,441.41
|
| Rate for Payer: PHCS Commercial |
$2,005.44
|
| Rate for Payer: United Healthcare All Payer |
$1,838.32
|
|
|
NJX SBST INTLMNR LMBR/SAC WIMG
|
Facility
|
OP
|
$2,514.00
|
|
|
Service Code
|
HCPCS 62323
|
| Hospital Charge Code |
76102298
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$639.87 |
| Max. Negotiated Rate |
$2,413.44 |
| Rate for Payer: Aetna Commercial |
$1,935.78
|
| Rate for Payer: Anthem Medicaid |
$864.56
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$639.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,960.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$895.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$863.82
|
| Rate for Payer: Cash Price |
$1,257.00
|
| Rate for Payer: Cash Price |
$1,257.00
|
| Rate for Payer: Cigna Commercial |
$2,086.62
|
| Rate for Payer: First Health Commercial |
$2,388.30
|
| Rate for Payer: Humana Commercial |
$2,136.90
|
| Rate for Payer: Humana KY Medicaid |
$864.56
|
| Rate for Payer: Humana Medicare Advantage |
$639.87
|
| Rate for Payer: Kentucky WC Medicaid |
$873.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,061.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,855.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$767.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$881.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,212.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,885.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,011.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,187.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,734.66
|
| Rate for Payer: PHCS Commercial |
$2,413.44
|
| Rate for Payer: United Healthcare All Payer |
$2,212.32
|
|
|
NJX SBST INTLMNR LMBR/SAC WIMG
|
Professional
|
Both
|
$2,514.00
|
|
|
Service Code
|
HCPCS 62323
|
| Hospital Charge Code |
76102298
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$80.87 |
| Max. Negotiated Rate |
$1,508.40 |
| Rate for Payer: Ambetter Exchange |
$93.37
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$80.87
|
| Rate for Payer: Anthem Medicaid |
$186.33
|
| Rate for Payer: Buckeye Individual/Medicaid |
$93.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$93.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$112.04
|
| Rate for Payer: Cash Price |
$1,257.00
|
| Rate for Payer: Cash Price |
$1,257.00
|
| Rate for Payer: Cigna Commercial |
$174.27
|
| Rate for Payer: Humana Medicaid |
$186.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$128.54
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$93.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$93.37
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$190.06
|
| Rate for Payer: Molina Healthcare Passport |
$186.33
|
| Rate for Payer: Multiplan PHCS |
$1,508.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$121.38
|
| Rate for Payer: UHCCP Medicaid |
$84.91
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$188.19
|
| Rate for Payer: Wellcare Medicare Advantage |
$93.37
|
|
|
NJX SBST INTLMNR LMBRSAC WOIMG
|
Facility
|
OP
|
$1,932.00
|
|
|
Service Code
|
HCPCS 62322
|
| Hospital Charge Code |
761T2297
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$664.41 |
| Max. Negotiated Rate |
$1,854.72 |
| Rate for Payer: Aetna Commercial |
$1,487.64
|
| Rate for Payer: Anthem Medicaid |
$664.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$822.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,506.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,151.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,110.52
|
| Rate for Payer: Cash Price |
$966.00
|
| Rate for Payer: Cash Price |
$966.00
|
| Rate for Payer: Cigna Commercial |
$1,603.56
|
| Rate for Payer: First Health Commercial |
$1,835.40
|
| Rate for Payer: Humana Commercial |
$1,642.20
|
| Rate for Payer: Humana KY Medicaid |
$664.41
|
| Rate for Payer: Humana Medicare Advantage |
$822.61
|
| Rate for Payer: Kentucky WC Medicaid |
$671.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,584.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,425.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$987.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$677.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,700.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,449.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,545.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,680.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,333.08
|
| Rate for Payer: PHCS Commercial |
$1,854.72
|
| Rate for Payer: United Healthcare All Payer |
$1,700.16
|
|
|
NJX SBST INTLMNR LMBRSAC WOIMG
|
Professional
|
Both
|
$290.00
|
|
|
Service Code
|
HCPCS 62322
|
| Hospital Charge Code |
761P2297
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$70.75 |
| Max. Negotiated Rate |
$174.00 |
| Rate for Payer: Ambetter Exchange |
$74.05
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$70.75
|
| Rate for Payer: Anthem Medicaid |
$120.47
|
| Rate for Payer: Buckeye Individual/Medicaid |
$74.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$74.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$88.86
|
| Rate for Payer: Cash Price |
$145.00
|
| Rate for Payer: Cash Price |
$145.00
|
| Rate for Payer: Cigna Commercial |
$152.46
|
| Rate for Payer: Humana Medicaid |
$120.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$112.45
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$74.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$74.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$122.88
|
| Rate for Payer: Molina Healthcare Passport |
$120.47
|
| Rate for Payer: Multiplan PHCS |
$174.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$96.27
|
| Rate for Payer: UHCCP Medicaid |
$74.29
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$121.67
|
| Rate for Payer: Wellcare Medicare Advantage |
$74.05
|
|
|
NJX SBST INTLMNR LMBRSAC WOIMG
|
Facility
|
IP
|
$2,222.00
|
|
|
Service Code
|
HCPCS 62322
|
| Hospital Charge Code |
76102297
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$666.60 |
| Max. Negotiated Rate |
$2,133.12 |
| Rate for Payer: Aetna Commercial |
$1,710.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,733.16
|
| Rate for Payer: Cash Price |
$1,111.00
|
| Rate for Payer: Cigna Commercial |
$1,844.26
|
| Rate for Payer: First Health Commercial |
$2,110.90
|
| Rate for Payer: Humana Commercial |
$1,888.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,822.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,639.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$666.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,955.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,666.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,777.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,933.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,533.18
|
| Rate for Payer: PHCS Commercial |
$2,133.12
|
| Rate for Payer: United Healthcare All Payer |
$1,955.36
|
|
|
NJX SBST INTLMNR LMBRSAC WOIMG
|
Facility
|
OP
|
$2,222.00
|
|
|
Service Code
|
HCPCS 62322
|
| Hospital Charge Code |
76102297
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$764.15 |
| Max. Negotiated Rate |
$2,133.12 |
| Rate for Payer: Aetna Commercial |
$1,710.94
|
| Rate for Payer: Anthem Medicaid |
$764.15
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$822.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,733.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,151.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,110.52
|
| Rate for Payer: Cash Price |
$1,111.00
|
| Rate for Payer: Cash Price |
$1,111.00
|
| Rate for Payer: Cigna Commercial |
$1,844.26
|
| Rate for Payer: First Health Commercial |
$2,110.90
|
| Rate for Payer: Humana Commercial |
$1,888.70
|
| Rate for Payer: Humana KY Medicaid |
$764.15
|
| Rate for Payer: Humana Medicare Advantage |
$822.61
|
| Rate for Payer: Kentucky WC Medicaid |
$771.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,822.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,639.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$987.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$779.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,955.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,666.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,777.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,933.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,533.18
|
| Rate for Payer: PHCS Commercial |
$2,133.12
|
| Rate for Payer: United Healthcare All Payer |
$1,955.36
|
|
|
NJX SBST INTLMNR LMBRSAC WOIMG
|
Professional
|
Both
|
$2,222.00
|
|
|
Service Code
|
HCPCS 62322
|
| Hospital Charge Code |
76102297
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$70.75 |
| Max. Negotiated Rate |
$1,333.20 |
| Rate for Payer: Ambetter Exchange |
$74.05
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$70.75
|
| Rate for Payer: Anthem Medicaid |
$120.47
|
| Rate for Payer: Buckeye Individual/Medicaid |
$74.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$74.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$88.86
|
| Rate for Payer: Cash Price |
$1,111.00
|
| Rate for Payer: Cash Price |
$1,111.00
|
| Rate for Payer: Cigna Commercial |
$152.46
|
| Rate for Payer: Humana Medicaid |
$120.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$112.45
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$74.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$74.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$122.88
|
| Rate for Payer: Molina Healthcare Passport |
$120.47
|
| Rate for Payer: Multiplan PHCS |
$1,333.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$96.27
|
| Rate for Payer: UHCCP Medicaid |
$74.29
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$121.67
|
| Rate for Payer: Wellcare Medicare Advantage |
$74.05
|
|
|
NJX SBST INTLMNR LMBRSAC WOIMG
|
Facility
|
IP
|
$1,932.00
|
|
|
Service Code
|
HCPCS 62322
|
| Hospital Charge Code |
761T2297
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$579.60 |
| Max. Negotiated Rate |
$1,854.72 |
| Rate for Payer: Aetna Commercial |
$1,487.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,506.96
|
| Rate for Payer: Cash Price |
$966.00
|
| Rate for Payer: Cigna Commercial |
$1,603.56
|
| Rate for Payer: First Health Commercial |
$1,835.40
|
| Rate for Payer: Humana Commercial |
$1,642.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,584.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,425.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$579.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,700.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,449.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,545.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,680.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,333.08
|
| Rate for Payer: PHCS Commercial |
$1,854.72
|
| Rate for Payer: United Healthcare All Payer |
$1,700.16
|
|
