|
OB US < 14 WKS ADDL FETUS
|
Facility
|
OP
|
$530.00
|
|
|
Service Code
|
HCPCS 76802
|
| Hospital Charge Code |
40200032
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$159.00 |
| Max. Negotiated Rate |
$508.80 |
| Rate for Payer: Aetna Commercial |
$408.10
|
| Rate for Payer: Anthem Medicaid |
$182.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$413.40
|
| Rate for Payer: Cash Price |
$265.00
|
| Rate for Payer: Cigna Commercial |
$439.90
|
| Rate for Payer: First Health Commercial |
$503.50
|
| Rate for Payer: Humana Commercial |
$450.50
|
| Rate for Payer: Humana KY Medicaid |
$182.27
|
| Rate for Payer: Kentucky WC Medicaid |
$184.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$434.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$185.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$466.40
|
| Rate for Payer: Ohio Health Group HMO |
$397.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$365.70
|
| Rate for Payer: PHCS Commercial |
$508.80
|
| Rate for Payer: United Healthcare All Payer |
$466.40
|
|
|
OB US < 14 WKS ADDL FETUS
|
Professional
|
Both
|
$530.00
|
|
|
Service Code
|
HCPCS 76802
|
| Hospital Charge Code |
40200032
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$52.17 |
| Max. Negotiated Rate |
$318.00 |
| Rate for Payer: Aetna Commercial |
$116.57
|
| Rate for Payer: Ambetter Exchange |
$55.25
|
| Rate for Payer: Anthem Medicaid |
$53.48
|
| Rate for Payer: Buckeye Individual/Medicaid |
$55.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$55.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$66.30
|
| Rate for Payer: Cash Price |
$265.00
|
| Rate for Payer: Cash Price |
$265.00
|
| Rate for Payer: Cigna Commercial |
$121.73
|
| Rate for Payer: Healthspan PPO |
$109.23
|
| Rate for Payer: Humana Medicaid |
$53.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$52.17
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$55.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.25
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$54.55
|
| Rate for Payer: Molina Healthcare Passport |
$53.48
|
| Rate for Payer: Multiplan PHCS |
$318.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$71.83
|
| Rate for Payer: UHCCP Medicaid |
$185.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$54.01
|
| Rate for Payer: Wellcare Medicare Advantage |
$55.25
|
|
|
OB US < 14 WKS ADDL FETUS
|
Facility
|
IP
|
$530.00
|
|
|
Service Code
|
HCPCS 76802
|
| Hospital Charge Code |
40200032
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$159.00 |
| Max. Negotiated Rate |
$508.80 |
| Rate for Payer: Aetna Commercial |
$408.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$413.40
|
| Rate for Payer: Cash Price |
$265.00
|
| Rate for Payer: Cigna Commercial |
$439.90
|
| Rate for Payer: First Health Commercial |
$503.50
|
| Rate for Payer: Humana Commercial |
$450.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$434.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$466.40
|
| Rate for Payer: Ohio Health Group HMO |
$397.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$365.70
|
| Rate for Payer: PHCS Commercial |
$508.80
|
| Rate for Payer: United Healthcare All Payer |
$466.40
|
|
|
OB US >/= 14 WKS ADDL FETUS
|
Facility
|
OP
|
$909.00
|
|
|
Service Code
|
HCPCS 76810
|
| Hospital Charge Code |
40200034
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$272.70 |
| Max. Negotiated Rate |
$872.64 |
| Rate for Payer: Aetna Commercial |
$699.93
|
| Rate for Payer: Anthem Medicaid |
$312.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$709.02
|
| Rate for Payer: Cash Price |
$454.50
|
| Rate for Payer: Cigna Commercial |
$754.47
|
| Rate for Payer: First Health Commercial |
$863.55
|
| Rate for Payer: Humana Commercial |
$772.65
|
| Rate for Payer: Humana KY Medicaid |
$312.61
|
| Rate for Payer: Kentucky WC Medicaid |
$315.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$745.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$670.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$272.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$318.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$799.92
|
| Rate for Payer: Ohio Health Group HMO |
$681.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$727.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$790.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$627.21
|
| Rate for Payer: PHCS Commercial |
$872.64
|
| Rate for Payer: United Healthcare All Payer |
$799.92
|
|
|
OB US >/= 14 WKS ADDL FETUS
|
Facility
|
IP
|
$909.00
|
|
|
Service Code
|
HCPCS 76810
|
| Hospital Charge Code |
40200034
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$272.70 |
| Max. Negotiated Rate |
$872.64 |
| Rate for Payer: Aetna Commercial |
$699.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$709.02
|
| Rate for Payer: Cash Price |
$454.50
|
| Rate for Payer: Cigna Commercial |
$754.47
|
| Rate for Payer: First Health Commercial |
$863.55
|
| Rate for Payer: Humana Commercial |
$772.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$745.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$670.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$272.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$799.92
|
| Rate for Payer: Ohio Health Group HMO |
$681.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$727.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$790.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$627.21
|
| Rate for Payer: PHCS Commercial |
$872.64
|
| Rate for Payer: United Healthcare All Payer |
$799.92
|
|
|
OB US >/= 14 WKS ADDL FETUS
|
Professional
|
Both
|
$909.00
|
|
|
Service Code
|
HCPCS 76810
|
| Hospital Charge Code |
40200034
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$61.18 |
| Max. Negotiated Rate |
$545.40 |
| Rate for Payer: Aetna Commercial |
$159.63
|
| Rate for Payer: Ambetter Exchange |
$79.26
|
| Rate for Payer: Anthem Medicaid |
$197.93
|
| Rate for Payer: Buckeye Individual/Medicaid |
$79.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$79.26
|
| Rate for Payer: CareSource Just4Me Medicare |
$95.11
|
| Rate for Payer: Cash Price |
$454.50
|
| Rate for Payer: Cash Price |
$454.50
|
| Rate for Payer: Cigna Commercial |
$146.10
|
| Rate for Payer: Healthspan PPO |
$149.58
|
| Rate for Payer: Humana Medicaid |
$197.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$61.18
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$79.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$79.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$201.89
|
| Rate for Payer: Molina Healthcare Passport |
$197.93
|
| Rate for Payer: Multiplan PHCS |
$545.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$103.04
|
| Rate for Payer: UHCCP Medicaid |
$318.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$199.91
|
| Rate for Payer: Wellcare Medicare Advantage |
$79.26
|
|
|
OB US < 14 WKS ADDL FETUS(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 76802
|
| Hospital Charge Code |
402P0032
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$52.17 |
| Max. Negotiated Rate |
$121.73 |
| Rate for Payer: Aetna Commercial |
$116.57
|
| Rate for Payer: Ambetter Exchange |
$55.25
|
| Rate for Payer: Anthem Medicaid |
$53.48
|
| Rate for Payer: Buckeye Individual/Medicaid |
$55.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$55.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$66.30
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$121.73
|
| Rate for Payer: Healthspan PPO |
$109.23
|
| Rate for Payer: Humana Medicaid |
$53.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$52.17
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$55.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.25
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$54.55
|
| Rate for Payer: Molina Healthcare Passport |
$53.48
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$71.83
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$54.01
|
| Rate for Payer: Wellcare Medicare Advantage |
$55.25
|
|
|
OB US >/= 14 WKS ADDL FETUS(P
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 76810
|
| Hospital Charge Code |
402P0034
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$61.18 |
| Max. Negotiated Rate |
$201.89 |
| Rate for Payer: Aetna Commercial |
$159.63
|
| Rate for Payer: Ambetter Exchange |
$79.26
|
| Rate for Payer: Anthem Medicaid |
$197.93
|
| Rate for Payer: Buckeye Individual/Medicaid |
$79.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$79.26
|
| Rate for Payer: CareSource Just4Me Medicare |
$95.11
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$146.10
|
| Rate for Payer: Healthspan PPO |
$149.58
|
| Rate for Payer: Humana Medicaid |
$197.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$61.18
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$79.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$79.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$201.89
|
| Rate for Payer: Molina Healthcare Passport |
$197.93
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$103.04
|
| Rate for Payer: UHCCP Medicaid |
$105.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$199.91
|
| Rate for Payer: Wellcare Medicare Advantage |
$79.26
|
|
|
OB US < 14 WKS ADDL FETUS(T
|
Facility
|
IP
|
$380.00
|
|
|
Service Code
|
HCPCS 76802
|
| Hospital Charge Code |
402T0032
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$114.00 |
| Max. Negotiated Rate |
$364.80 |
| Rate for Payer: Aetna Commercial |
$292.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$296.40
|
| Rate for Payer: Cash Price |
$190.00
|
| Rate for Payer: Cigna Commercial |
$315.40
|
| Rate for Payer: First Health Commercial |
$361.00
|
| Rate for Payer: Humana Commercial |
$323.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$311.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$280.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$334.40
|
| Rate for Payer: Ohio Health Group HMO |
$285.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$304.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$330.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$262.20
|
| Rate for Payer: PHCS Commercial |
$364.80
|
| Rate for Payer: United Healthcare All Payer |
$334.40
|
|
|
OB US < 14 WKS ADDL FETUS(T
|
Facility
|
OP
|
$380.00
|
|
|
Service Code
|
HCPCS 76802
|
| Hospital Charge Code |
402T0032
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$114.00 |
| Max. Negotiated Rate |
$364.80 |
| Rate for Payer: Aetna Commercial |
$292.60
|
| Rate for Payer: Anthem Medicaid |
$130.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$296.40
|
| Rate for Payer: Cash Price |
$190.00
|
| Rate for Payer: Cigna Commercial |
$315.40
|
| Rate for Payer: First Health Commercial |
$361.00
|
| Rate for Payer: Humana Commercial |
$323.00
|
| Rate for Payer: Humana KY Medicaid |
$130.68
|
| Rate for Payer: Kentucky WC Medicaid |
$132.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$311.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$280.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$133.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$334.40
|
| Rate for Payer: Ohio Health Group HMO |
$285.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$304.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$330.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$262.20
|
| Rate for Payer: PHCS Commercial |
$364.80
|
| Rate for Payer: United Healthcare All Payer |
$334.40
|
|
|
OB US >/= 14 WKS ADDL FETUS(T
|
Facility
|
OP
|
$609.00
|
|
|
Service Code
|
HCPCS 76810
|
| Hospital Charge Code |
402T0034
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$182.70 |
| Max. Negotiated Rate |
$584.64 |
| Rate for Payer: Aetna Commercial |
$468.93
|
| Rate for Payer: Anthem Medicaid |
$209.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$475.02
|
| Rate for Payer: Cash Price |
$304.50
|
| Rate for Payer: Cigna Commercial |
$505.47
|
| Rate for Payer: First Health Commercial |
$578.55
|
| Rate for Payer: Humana Commercial |
$517.65
|
| Rate for Payer: Humana KY Medicaid |
$209.44
|
| Rate for Payer: Kentucky WC Medicaid |
$211.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$499.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$449.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$182.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$213.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$535.92
|
| Rate for Payer: Ohio Health Group HMO |
$456.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$487.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$529.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$420.21
|
| Rate for Payer: PHCS Commercial |
$584.64
|
| Rate for Payer: United Healthcare All Payer |
$535.92
|
|
|
OB US >/= 14 WKS ADDL FETUS(T
|
Facility
|
IP
|
$609.00
|
|
|
Service Code
|
HCPCS 76810
|
| Hospital Charge Code |
402T0034
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$182.70 |
| Max. Negotiated Rate |
$584.64 |
| Rate for Payer: Aetna Commercial |
$468.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$475.02
|
| Rate for Payer: Cash Price |
$304.50
|
| Rate for Payer: Cigna Commercial |
$505.47
|
| Rate for Payer: First Health Commercial |
$578.55
|
| Rate for Payer: Humana Commercial |
$517.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$499.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$449.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$182.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$535.92
|
| Rate for Payer: Ohio Health Group HMO |
$456.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$487.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$529.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$420.21
|
| Rate for Payer: PHCS Commercial |
$584.64
|
| Rate for Payer: United Healthcare All Payer |
$535.92
|
|
|
OB US DETAILED ADDL FETUS
|
Facility
|
OP
|
$834.00
|
|
|
Service Code
|
HCPCS 76812
|
| Hospital Charge Code |
40200036
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$250.20 |
| Max. Negotiated Rate |
$800.64 |
| Rate for Payer: Aetna Commercial |
$642.18
|
| Rate for Payer: Anthem Medicaid |
$286.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$650.52
|
| Rate for Payer: Cash Price |
$417.00
|
| Rate for Payer: Cigna Commercial |
$692.22
|
| Rate for Payer: First Health Commercial |
$792.30
|
| Rate for Payer: Humana Commercial |
$708.90
|
| Rate for Payer: Humana KY Medicaid |
$286.81
|
| Rate for Payer: Kentucky WC Medicaid |
$289.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$683.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$615.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$250.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$292.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$733.92
|
| Rate for Payer: Ohio Health Group HMO |
$625.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$667.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$725.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$575.46
|
| Rate for Payer: PHCS Commercial |
$800.64
|
| Rate for Payer: United Healthcare All Payer |
$733.92
|
|
|
OB US DETAILED ADDL FETUS
|
Professional
|
Both
|
$834.00
|
|
|
Service Code
|
HCPCS 76812
|
| Hospital Charge Code |
40200036
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$106.62 |
| Max. Negotiated Rate |
$500.40 |
| Rate for Payer: Aetna Commercial |
$235.43
|
| Rate for Payer: Ambetter Exchange |
$172.44
|
| Rate for Payer: Anthem Medicaid |
$106.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$172.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$172.44
|
| Rate for Payer: CareSource Just4Me Medicare |
$206.93
|
| Rate for Payer: Cash Price |
$417.00
|
| Rate for Payer: Cash Price |
$417.00
|
| Rate for Payer: Cigna Commercial |
$246.31
|
| Rate for Payer: Healthspan PPO |
$220.60
|
| Rate for Payer: Humana Medicaid |
$106.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$111.11
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$172.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$172.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$108.75
|
| Rate for Payer: Molina Healthcare Passport |
$106.62
|
| Rate for Payer: Multiplan PHCS |
$500.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$224.17
|
| Rate for Payer: UHCCP Medicaid |
$291.90
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$107.69
|
| Rate for Payer: Wellcare Medicare Advantage |
$172.44
|
|
|
OB US DETAILED ADDL FETUS
|
Facility
|
IP
|
$834.00
|
|
|
Service Code
|
HCPCS 76812
|
| Hospital Charge Code |
40200036
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$250.20 |
| Max. Negotiated Rate |
$800.64 |
| Rate for Payer: Aetna Commercial |
$642.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$650.52
|
| Rate for Payer: Cash Price |
$417.00
|
| Rate for Payer: Cigna Commercial |
$692.22
|
| Rate for Payer: First Health Commercial |
$792.30
|
| Rate for Payer: Humana Commercial |
$708.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$683.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$615.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$250.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$733.92
|
| Rate for Payer: Ohio Health Group HMO |
$625.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$667.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$725.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$575.46
|
| Rate for Payer: PHCS Commercial |
$800.64
|
| Rate for Payer: United Healthcare All Payer |
$733.92
|
|
|
OB US DETAILED ADDL FETUS(P
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 76812
|
| Hospital Charge Code |
402P0036
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$246.31 |
| Rate for Payer: Aetna Commercial |
$235.43
|
| Rate for Payer: Ambetter Exchange |
$172.44
|
| Rate for Payer: Anthem Medicaid |
$106.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$172.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$172.44
|
| Rate for Payer: CareSource Just4Me Medicare |
$206.93
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$246.31
|
| Rate for Payer: Healthspan PPO |
$220.60
|
| Rate for Payer: Humana Medicaid |
$106.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$111.11
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$172.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$172.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$108.75
|
| Rate for Payer: Molina Healthcare Passport |
$106.62
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$224.17
|
| Rate for Payer: UHCCP Medicaid |
$70.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$107.69
|
| Rate for Payer: Wellcare Medicare Advantage |
$172.44
|
|
|
OB US DETAILED ADDL FETUS(T
|
Facility
|
OP
|
$634.00
|
|
|
Service Code
|
HCPCS 76812
|
| Hospital Charge Code |
402T0036
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$190.20 |
| Max. Negotiated Rate |
$608.64 |
| Rate for Payer: Aetna Commercial |
$488.18
|
| Rate for Payer: Anthem Medicaid |
$218.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$494.52
|
| Rate for Payer: Cash Price |
$317.00
|
| Rate for Payer: Cigna Commercial |
$526.22
|
| Rate for Payer: First Health Commercial |
$602.30
|
| Rate for Payer: Humana Commercial |
$538.90
|
| Rate for Payer: Humana KY Medicaid |
$218.03
|
| Rate for Payer: Kentucky WC Medicaid |
$220.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$519.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$467.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$222.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$557.92
|
| Rate for Payer: Ohio Health Group HMO |
$475.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$507.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$551.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$437.46
|
| Rate for Payer: PHCS Commercial |
$608.64
|
| Rate for Payer: United Healthcare All Payer |
$557.92
|
|
|
OB US DETAILED ADDL FETUS(T
|
Facility
|
IP
|
$634.00
|
|
|
Service Code
|
HCPCS 76812
|
| Hospital Charge Code |
402T0036
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$190.20 |
| Max. Negotiated Rate |
$608.64 |
| Rate for Payer: Aetna Commercial |
$488.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$494.52
|
| Rate for Payer: Cash Price |
$317.00
|
| Rate for Payer: Cigna Commercial |
$526.22
|
| Rate for Payer: First Health Commercial |
$602.30
|
| Rate for Payer: Humana Commercial |
$538.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$519.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$467.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$557.92
|
| Rate for Payer: Ohio Health Group HMO |
$475.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$507.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$551.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$437.46
|
| Rate for Payer: PHCS Commercial |
$608.64
|
| Rate for Payer: United Healthcare All Payer |
$557.92
|
|
|
OB US DETAILED SNGL FETUS
|
Facility
|
OP
|
$1,248.00
|
|
|
Service Code
|
HCPCS 76811
|
| Hospital Charge Code |
40200035
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$223.34 |
| Max. Negotiated Rate |
$1,198.08 |
| Rate for Payer: Aetna Commercial |
$960.96
|
| Rate for Payer: Anthem Medicaid |
$429.19
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$223.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$973.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$312.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$301.51
|
| Rate for Payer: Cash Price |
$624.00
|
| Rate for Payer: Cash Price |
$624.00
|
| Rate for Payer: Cigna Commercial |
$1,035.84
|
| Rate for Payer: First Health Commercial |
$1,185.60
|
| Rate for Payer: Humana Commercial |
$1,060.80
|
| Rate for Payer: Humana KY Medicaid |
$429.19
|
| Rate for Payer: Humana Medicare Advantage |
$223.34
|
| Rate for Payer: Kentucky WC Medicaid |
$433.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,023.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$921.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$268.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$437.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,098.24
|
| Rate for Payer: Ohio Health Group HMO |
$936.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$998.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,085.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$861.12
|
| Rate for Payer: PHCS Commercial |
$1,198.08
|
| Rate for Payer: United Healthcare All Payer |
$1,098.24
|
|
|
OB US DETAILED SNGL FETUS
|
Facility
|
IP
|
$1,248.00
|
|
|
Service Code
|
HCPCS 76811
|
| Hospital Charge Code |
40200035
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$374.40 |
| Max. Negotiated Rate |
$1,198.08 |
| Rate for Payer: Aetna Commercial |
$960.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$973.44
|
| Rate for Payer: Cash Price |
$624.00
|
| Rate for Payer: Cigna Commercial |
$1,035.84
|
| Rate for Payer: First Health Commercial |
$1,185.60
|
| Rate for Payer: Humana Commercial |
$1,060.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,023.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$921.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$374.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,098.24
|
| Rate for Payer: Ohio Health Group HMO |
$936.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$998.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,085.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$861.12
|
| Rate for Payer: PHCS Commercial |
$1,198.08
|
| Rate for Payer: United Healthcare All Payer |
$1,098.24
|
|
|
OB US DETAILED SNGL FETUS
|
Professional
|
Both
|
$1,248.00
|
|
|
Service Code
|
HCPCS 76811
|
| Hospital Charge Code |
40200035
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$118.81 |
| Max. Negotiated Rate |
$748.80 |
| Rate for Payer: Aetna Commercial |
$324.92
|
| Rate for Payer: Ambetter Exchange |
$162.51
|
| Rate for Payer: Anthem Medicaid |
$139.29
|
| Rate for Payer: Buckeye Individual/Medicaid |
$162.51
|
| Rate for Payer: Buckeye Medicare Advantage |
$162.51
|
| Rate for Payer: CareSource Just4Me Medicare |
$195.01
|
| Rate for Payer: Cash Price |
$624.00
|
| Rate for Payer: Cash Price |
$624.00
|
| Rate for Payer: Cigna Commercial |
$347.14
|
| Rate for Payer: Healthspan PPO |
$304.45
|
| Rate for Payer: Humana Medicaid |
$139.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$118.81
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$162.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.51
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$142.08
|
| Rate for Payer: Molina Healthcare Passport |
$139.29
|
| Rate for Payer: Multiplan PHCS |
$748.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$211.26
|
| Rate for Payer: UHCCP Medicaid |
$436.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$140.68
|
| Rate for Payer: Wellcare Medicare Advantage |
$162.51
|
|
|
OB US DETAILED SNGL FETUS(P
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 76811
|
| Hospital Charge Code |
402P0035
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$347.14 |
| Rate for Payer: Aetna Commercial |
$324.92
|
| Rate for Payer: Ambetter Exchange |
$162.51
|
| Rate for Payer: Anthem Medicaid |
$139.29
|
| Rate for Payer: Buckeye Individual/Medicaid |
$162.51
|
| Rate for Payer: Buckeye Medicare Advantage |
$162.51
|
| Rate for Payer: CareSource Just4Me Medicare |
$195.01
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$347.14
|
| Rate for Payer: Healthspan PPO |
$304.45
|
| Rate for Payer: Humana Medicaid |
$139.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$118.81
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$162.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.51
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$142.08
|
| Rate for Payer: Molina Healthcare Passport |
$139.29
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$211.26
|
| Rate for Payer: UHCCP Medicaid |
$105.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$140.68
|
| Rate for Payer: Wellcare Medicare Advantage |
$162.51
|
|
|
OB US DETAILED SNGL FETUS(T
|
Facility
|
OP
|
$948.00
|
|
|
Service Code
|
HCPCS 76811
|
| Hospital Charge Code |
402T0035
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$223.34 |
| Max. Negotiated Rate |
$910.08 |
| Rate for Payer: Aetna Commercial |
$729.96
|
| Rate for Payer: Anthem Medicaid |
$326.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$223.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$739.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$312.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$301.51
|
| Rate for Payer: Cash Price |
$474.00
|
| Rate for Payer: Cash Price |
$474.00
|
| Rate for Payer: Cigna Commercial |
$786.84
|
| Rate for Payer: First Health Commercial |
$900.60
|
| Rate for Payer: Humana Commercial |
$805.80
|
| Rate for Payer: Humana KY Medicaid |
$326.02
|
| Rate for Payer: Humana Medicare Advantage |
$223.34
|
| Rate for Payer: Kentucky WC Medicaid |
$329.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$777.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$699.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$268.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$332.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$834.24
|
| Rate for Payer: Ohio Health Group HMO |
$711.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$758.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$824.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$654.12
|
| Rate for Payer: PHCS Commercial |
$910.08
|
| Rate for Payer: United Healthcare All Payer |
$834.24
|
|
|
OB US DETAILED SNGL FETUS(T
|
Facility
|
IP
|
$948.00
|
|
|
Service Code
|
HCPCS 76811
|
| Hospital Charge Code |
402T0035
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$284.40 |
| Max. Negotiated Rate |
$910.08 |
| Rate for Payer: Aetna Commercial |
$729.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$739.44
|
| Rate for Payer: Cash Price |
$474.00
|
| Rate for Payer: Cigna Commercial |
$786.84
|
| Rate for Payer: First Health Commercial |
$900.60
|
| Rate for Payer: Humana Commercial |
$805.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$777.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$699.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$284.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$834.24
|
| Rate for Payer: Ohio Health Group HMO |
$711.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$758.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$824.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$654.12
|
| Rate for Payer: PHCS Commercial |
$910.08
|
| Rate for Payer: United Healthcare All Payer |
$834.24
|
|
|
OCCIPITAL NERVE BLOCK
|
Professional
|
Both
|
$1,117.00
|
|
|
Service Code
|
HCPCS 64405
|
| Hospital Charge Code |
76102311
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$32.08 |
| Max. Negotiated Rate |
$670.20 |
| Rate for Payer: Aetna Commercial |
$117.37
|
| Rate for Payer: Ambetter Exchange |
$50.43
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$32.08
|
| Rate for Payer: Anthem Medicaid |
$56.46
|
| Rate for Payer: Buckeye Individual/Medicaid |
$50.43
|
| Rate for Payer: Buckeye Medicare Advantage |
$50.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$60.52
|
| Rate for Payer: Cash Price |
$558.50
|
| Rate for Payer: Cash Price |
$558.50
|
| Rate for Payer: Cigna Commercial |
$158.03
|
| Rate for Payer: Healthspan PPO |
$124.59
|
| Rate for Payer: Humana Medicaid |
$56.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$102.77
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$50.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50.43
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$57.59
|
| Rate for Payer: Molina Healthcare Passport |
$56.46
|
| Rate for Payer: Multiplan PHCS |
$670.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$65.56
|
| Rate for Payer: UHCCP Medicaid |
$33.68
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$57.02
|
| Rate for Payer: Wellcare Medicare Advantage |
$50.43
|
|
