|
RPR/EXC ANEURYSM/PSEUDO PART
|
Professional
|
Both
|
$2,515.00
|
|
|
Service Code
|
HCPCS 35103
|
| Hospital Charge Code |
76101362
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$880.25 |
| Max. Negotiated Rate |
$3,974.93 |
| Rate for Payer: Aetna Commercial |
$3,974.93
|
| Rate for Payer: Ambetter Exchange |
$2,039.45
|
| Rate for Payer: Anthem Medicaid |
$1,747.01
|
| Rate for Payer: Buckeye Individual/Medicaid |
$2,039.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,039.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,447.34
|
| Rate for Payer: Cash Price |
$1,257.50
|
| Rate for Payer: Cash Price |
$1,257.50
|
| Rate for Payer: Cigna Commercial |
$3,775.11
|
| Rate for Payer: Healthspan PPO |
$3,908.13
|
| Rate for Payer: Humana Medicaid |
$1,747.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$3,076.19
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$2,039.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,039.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,781.95
|
| Rate for Payer: Molina Healthcare Passport |
$1,747.01
|
| Rate for Payer: Multiplan PHCS |
$1,509.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,651.28
|
| Rate for Payer: UHCCP Medicaid |
$880.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,764.48
|
| Rate for Payer: Wellcare Medicare Advantage |
$2,039.45
|
|
|
RPR/EXC ANEURYSM/PSEUDO PART
|
Professional
|
Both
|
$2,796.00
|
|
|
Service Code
|
HCPCS 35131
|
| Hospital Charge Code |
76101363
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$978.60 |
| Max. Negotiated Rate |
$2,484.65 |
| Rate for Payer: Aetna Commercial |
$2,484.65
|
| Rate for Payer: Ambetter Exchange |
$1,299.87
|
| Rate for Payer: Anthem Medicaid |
$1,001.31
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,299.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,299.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,559.84
|
| Rate for Payer: Cash Price |
$1,398.00
|
| Rate for Payer: Cash Price |
$1,398.00
|
| Rate for Payer: Cigna Commercial |
$2,367.96
|
| Rate for Payer: Healthspan PPO |
$2,442.90
|
| Rate for Payer: Humana Medicaid |
$1,001.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,911.36
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,299.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,299.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,021.34
|
| Rate for Payer: Molina Healthcare Passport |
$1,001.31
|
| Rate for Payer: Multiplan PHCS |
$1,677.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,689.83
|
| Rate for Payer: UHCCP Medicaid |
$978.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,011.32
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,299.87
|
|
|
RPR/EXC ANEURYSM/PSEUDO PART
|
Facility
|
OP
|
$2,796.00
|
|
|
Service Code
|
HCPCS 35131
|
| Hospital Charge Code |
76101363
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$838.80 |
| Max. Negotiated Rate |
$2,684.16 |
| Rate for Payer: Aetna Commercial |
$2,152.92
|
| Rate for Payer: Anthem Medicaid |
$961.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,180.88
|
| Rate for Payer: Cash Price |
$1,398.00
|
| Rate for Payer: Cigna Commercial |
$2,320.68
|
| Rate for Payer: First Health Commercial |
$2,656.20
|
| Rate for Payer: Humana Commercial |
$2,376.60
|
| Rate for Payer: Humana KY Medicaid |
$961.54
|
| Rate for Payer: Kentucky WC Medicaid |
$971.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,292.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,063.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$838.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$980.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,460.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,097.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,236.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,432.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,929.24
|
| Rate for Payer: PHCS Commercial |
$2,684.16
|
| Rate for Payer: United Healthcare All Payer |
$2,460.48
|
|
|
RPR/EXC ANEURYSM/PSEUDO PART
|
Facility
|
IP
|
$2,800.00
|
|
|
Service Code
|
HCPCS 35151
|
| Hospital Charge Code |
76101367
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$840.00 |
| Max. Negotiated Rate |
$2,688.00 |
| Rate for Payer: Aetna Commercial |
$2,156.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,184.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,324.00
|
| Rate for Payer: First Health Commercial |
$2,660.00
|
| Rate for Payer: Humana Commercial |
$2,380.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,296.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,066.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$840.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,464.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,100.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,436.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,932.00
|
| Rate for Payer: PHCS Commercial |
$2,688.00
|
| Rate for Payer: United Healthcare All Payer |
$2,464.00
|
|
|
RPR/EXC ANEURYSM/PSEUDO PART
|
Facility
|
IP
|
$2,515.00
|
|
|
Service Code
|
HCPCS 35103
|
| Hospital Charge Code |
76101362
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$754.50 |
| Max. Negotiated Rate |
$2,414.40 |
| Rate for Payer: Aetna Commercial |
$1,936.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,961.70
|
| Rate for Payer: Cash Price |
$1,257.50
|
| Rate for Payer: Cigna Commercial |
$2,087.45
|
| Rate for Payer: First Health Commercial |
$2,389.25
|
| Rate for Payer: Humana Commercial |
$2,137.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,062.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,856.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$754.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,213.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,886.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,012.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,188.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,735.35
|
| Rate for Payer: PHCS Commercial |
$2,414.40
|
| Rate for Payer: United Healthcare All Payer |
$2,213.20
|
|
|
RPR/EXC ANEURYSM/PSEUDO PART
|
Facility
|
OP
|
$3,500.00
|
|
|
Service Code
|
HCPCS 35001
|
| Hospital Charge Code |
76101354
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$3,360.00 |
| Rate for Payer: Aetna Commercial |
$2,695.00
|
| Rate for Payer: Anthem Medicaid |
$1,203.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,730.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$2,905.00
|
| Rate for Payer: First Health Commercial |
$3,325.00
|
| Rate for Payer: Humana Commercial |
$2,975.00
|
| Rate for Payer: Humana KY Medicaid |
$1,203.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1,215.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,870.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,583.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,050.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,227.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,080.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,045.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,415.00
|
| Rate for Payer: PHCS Commercial |
$3,360.00
|
| Rate for Payer: United Healthcare All Payer |
$3,080.00
|
|
|
RPR/EXC ANEURYSM/PSEUDO PART
|
Facility
|
IP
|
$2,796.00
|
|
|
Service Code
|
HCPCS 35131
|
| Hospital Charge Code |
76101363
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$838.80 |
| Max. Negotiated Rate |
$2,684.16 |
| Rate for Payer: Aetna Commercial |
$2,152.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,180.88
|
| Rate for Payer: Cash Price |
$1,398.00
|
| Rate for Payer: Cigna Commercial |
$2,320.68
|
| Rate for Payer: First Health Commercial |
$2,656.20
|
| Rate for Payer: Humana Commercial |
$2,376.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,292.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,063.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$838.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,460.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,097.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,236.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,432.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,929.24
|
| Rate for Payer: PHCS Commercial |
$2,684.16
|
| Rate for Payer: United Healthcare All Payer |
$2,460.48
|
|
|
RPR/EXC ANEURYSM/PSEUDO PART
|
Facility
|
OP
|
$2,800.00
|
|
|
Service Code
|
HCPCS 35151
|
| Hospital Charge Code |
76101367
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$840.00 |
| Max. Negotiated Rate |
$2,688.00 |
| Rate for Payer: Aetna Commercial |
$2,156.00
|
| Rate for Payer: Anthem Medicaid |
$962.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,184.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,324.00
|
| Rate for Payer: First Health Commercial |
$2,660.00
|
| Rate for Payer: Humana Commercial |
$2,380.00
|
| Rate for Payer: Humana KY Medicaid |
$962.92
|
| Rate for Payer: Kentucky WC Medicaid |
$972.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,296.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,066.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$840.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$982.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,464.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,100.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,436.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,932.00
|
| Rate for Payer: PHCS Commercial |
$2,688.00
|
| Rate for Payer: United Healthcare All Payer |
$2,464.00
|
|
|
RPR/EXC ANEURYSM/PSEUDO PART
|
Professional
|
Both
|
$3,500.00
|
|
|
Service Code
|
HCPCS 35001
|
| Hospital Charge Code |
76101354
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,036.03 |
| Max. Negotiated Rate |
$2,100.00 |
| Rate for Payer: Aetna Commercial |
$1,994.67
|
| Rate for Payer: Ambetter Exchange |
$1,040.27
|
| Rate for Payer: Anthem Medicaid |
$1,036.03
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,040.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,040.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,248.32
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$1,911.65
|
| Rate for Payer: Healthspan PPO |
$1,961.15
|
| Rate for Payer: Humana Medicaid |
$1,036.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,541.16
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,040.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,040.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,056.75
|
| Rate for Payer: Molina Healthcare Passport |
$1,036.03
|
| Rate for Payer: Multiplan PHCS |
$2,100.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,352.35
|
| Rate for Payer: UHCCP Medicaid |
$1,225.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,046.39
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,040.27
|
|
|
RPR/EXC ANEURYSM/PSEUDO PART(P
|
Professional
|
Both
|
$3,500.00
|
|
|
Service Code
|
HCPCS 35001
|
| Hospital Charge Code |
761P1354
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,036.03 |
| Max. Negotiated Rate |
$2,100.00 |
| Rate for Payer: Aetna Commercial |
$1,994.67
|
| Rate for Payer: Ambetter Exchange |
$1,040.27
|
| Rate for Payer: Anthem Medicaid |
$1,036.03
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,040.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,040.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,248.32
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$1,911.65
|
| Rate for Payer: Healthspan PPO |
$1,961.15
|
| Rate for Payer: Humana Medicaid |
$1,036.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,541.16
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,040.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,040.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,056.75
|
| Rate for Payer: Molina Healthcare Passport |
$1,036.03
|
| Rate for Payer: Multiplan PHCS |
$2,100.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,352.35
|
| Rate for Payer: UHCCP Medicaid |
$1,225.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,046.39
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,040.27
|
|
|
RPR/EXC ANEURYSM/PSEUDO PART(P
|
Professional
|
Both
|
$2,800.00
|
|
|
Service Code
|
HCPCS 35151
|
| Hospital Charge Code |
761P1367
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$945.88 |
| Max. Negotiated Rate |
$2,216.70 |
| Rate for Payer: Aetna Commercial |
$2,216.70
|
| Rate for Payer: Ambetter Exchange |
$1,161.26
|
| Rate for Payer: Anthem Medicaid |
$945.88
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,161.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,161.26
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,393.51
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,129.02
|
| Rate for Payer: Healthspan PPO |
$2,179.45
|
| Rate for Payer: Humana Medicaid |
$945.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,715.56
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,161.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,161.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$964.80
|
| Rate for Payer: Molina Healthcare Passport |
$945.88
|
| Rate for Payer: Multiplan PHCS |
$1,680.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,509.64
|
| Rate for Payer: UHCCP Medicaid |
$980.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$955.34
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,161.26
|
|
|
RPR/EXC ANEURYSM/PSEUDO PART(P
|
Professional
|
Both
|
$2,796.00
|
|
|
Service Code
|
HCPCS 35131
|
| Hospital Charge Code |
761P1363
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$978.60 |
| Max. Negotiated Rate |
$2,484.65 |
| Rate for Payer: Aetna Commercial |
$2,484.65
|
| Rate for Payer: Ambetter Exchange |
$1,299.87
|
| Rate for Payer: Anthem Medicaid |
$1,001.31
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,299.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,299.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,559.84
|
| Rate for Payer: Cash Price |
$1,398.00
|
| Rate for Payer: Cash Price |
$1,398.00
|
| Rate for Payer: Cigna Commercial |
$2,367.96
|
| Rate for Payer: Healthspan PPO |
$2,442.90
|
| Rate for Payer: Humana Medicaid |
$1,001.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,911.36
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,299.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,299.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,021.34
|
| Rate for Payer: Molina Healthcare Passport |
$1,001.31
|
| Rate for Payer: Multiplan PHCS |
$1,677.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,689.83
|
| Rate for Payer: UHCCP Medicaid |
$978.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,011.32
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,299.87
|
|
|
RPR/EXC ANEURYSM/PSEUDO PART(P
|
Professional
|
Both
|
$2,515.00
|
|
|
Service Code
|
HCPCS 35103
|
| Hospital Charge Code |
761P1362
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$880.25 |
| Max. Negotiated Rate |
$3,974.93 |
| Rate for Payer: Aetna Commercial |
$3,974.93
|
| Rate for Payer: Ambetter Exchange |
$2,039.45
|
| Rate for Payer: Anthem Medicaid |
$1,747.01
|
| Rate for Payer: Buckeye Individual/Medicaid |
$2,039.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,039.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,447.34
|
| Rate for Payer: Cash Price |
$1,257.50
|
| Rate for Payer: Cash Price |
$1,257.50
|
| Rate for Payer: Cigna Commercial |
$3,775.11
|
| Rate for Payer: Healthspan PPO |
$3,908.13
|
| Rate for Payer: Humana Medicaid |
$1,747.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$3,076.19
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$2,039.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,039.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,781.95
|
| Rate for Payer: Molina Healthcare Passport |
$1,747.01
|
| Rate for Payer: Multiplan PHCS |
$1,509.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,651.28
|
| Rate for Payer: UHCCP Medicaid |
$880.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,764.48
|
| Rate for Payer: Wellcare Medicare Advantage |
$2,039.45
|
|
|
RPR EXT TNDN DIS INSERT WO GRF
|
Facility
|
OP
|
$1,130.00
|
|
|
Service Code
|
HCPCS 26433
|
| Hospital Charge Code |
76100698
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$388.61 |
| Max. Negotiated Rate |
$4,197.13 |
| Rate for Payer: Aetna Commercial |
$870.10
|
| Rate for Payer: Anthem Medicaid |
$388.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,997.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$881.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| Rate for Payer: Cash Price |
$565.00
|
| Rate for Payer: Cash Price |
$565.00
|
| Rate for Payer: Cigna Commercial |
$937.90
|
| Rate for Payer: First Health Commercial |
$1,073.50
|
| Rate for Payer: Humana Commercial |
$960.50
|
| Rate for Payer: Humana KY Medicaid |
$388.61
|
| Rate for Payer: Humana Medicare Advantage |
$2,997.95
|
| Rate for Payer: Kentucky WC Medicaid |
$392.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$926.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$833.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,597.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$396.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$994.40
|
| Rate for Payer: Ohio Health Group HMO |
$847.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$904.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$983.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$779.70
|
| Rate for Payer: PHCS Commercial |
$1,084.80
|
| Rate for Payer: United Healthcare All Payer |
$994.40
|
|
|
RPR EXT TNDN DIS INSERT WO GRF
|
Professional
|
Both
|
$1,130.00
|
|
|
Service Code
|
HCPCS 26433
|
| Hospital Charge Code |
76100698
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$251.12 |
| Max. Negotiated Rate |
$935.86 |
| Rate for Payer: Aetna Commercial |
$741.80
|
| Rate for Payer: Ambetter Exchange |
$526.20
|
| Rate for Payer: Anthem Medicaid |
$251.12
|
| Rate for Payer: Buckeye Individual/Medicaid |
$526.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$526.20
|
| Rate for Payer: CareSource Just4Me Medicare |
$631.44
|
| Rate for Payer: Cash Price |
$565.00
|
| Rate for Payer: Cash Price |
$565.00
|
| Rate for Payer: Cigna Commercial |
$935.86
|
| Rate for Payer: Healthspan PPO |
$671.92
|
| Rate for Payer: Humana Medicaid |
$251.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$638.95
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$526.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$526.20
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$256.14
|
| Rate for Payer: Molina Healthcare Passport |
$251.12
|
| Rate for Payer: Multiplan PHCS |
$678.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$684.06
|
| Rate for Payer: UHCCP Medicaid |
$395.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$253.63
|
| Rate for Payer: Wellcare Medicare Advantage |
$526.20
|
|
|
RPR EXT TNDN DIS INSERT WO GRF
|
Facility
|
IP
|
$1,130.00
|
|
|
Service Code
|
HCPCS 26433
|
| Hospital Charge Code |
76100698
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$339.00 |
| Max. Negotiated Rate |
$1,084.80 |
| Rate for Payer: Aetna Commercial |
$870.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$881.40
|
| Rate for Payer: Cash Price |
$565.00
|
| Rate for Payer: Cigna Commercial |
$937.90
|
| Rate for Payer: First Health Commercial |
$1,073.50
|
| Rate for Payer: Humana Commercial |
$960.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$926.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$833.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$339.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$994.40
|
| Rate for Payer: Ohio Health Group HMO |
$847.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$904.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$983.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$779.70
|
| Rate for Payer: PHCS Commercial |
$1,084.80
|
| Rate for Payer: United Healthcare All Payer |
$994.40
|
|
|
RPR EXT TNDN DIS INSERT WO GRF
|
Professional
|
Both
|
$1,130.00
|
|
|
Service Code
|
HCPCS 26433
|
| Hospital Charge Code |
761P0698
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$251.12 |
| Max. Negotiated Rate |
$935.86 |
| Rate for Payer: Aetna Commercial |
$741.80
|
| Rate for Payer: Ambetter Exchange |
$526.20
|
| Rate for Payer: Anthem Medicaid |
$251.12
|
| Rate for Payer: Buckeye Individual/Medicaid |
$526.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$526.20
|
| Rate for Payer: CareSource Just4Me Medicare |
$631.44
|
| Rate for Payer: Cash Price |
$565.00
|
| Rate for Payer: Cash Price |
$565.00
|
| Rate for Payer: Cigna Commercial |
$935.86
|
| Rate for Payer: Healthspan PPO |
$671.92
|
| Rate for Payer: Humana Medicaid |
$251.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$638.95
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$526.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$526.20
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$256.14
|
| Rate for Payer: Molina Healthcare Passport |
$251.12
|
| Rate for Payer: Multiplan PHCS |
$678.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$684.06
|
| Rate for Payer: UHCCP Medicaid |
$395.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$253.63
|
| Rate for Payer: Wellcare Medicare Advantage |
$526.20
|
|
|
RPR FE/E/EN/L/M 12.6-20.0 CM
|
Facility
|
IP
|
$509.00
|
|
|
Service Code
|
HCPCS 12016
|
| Hospital Charge Code |
45000051
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$152.70 |
| Max. Negotiated Rate |
$488.64 |
| Rate for Payer: Aetna Commercial |
$391.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$397.02
|
| Rate for Payer: Cash Price |
$254.50
|
| Rate for Payer: Cigna Commercial |
$422.47
|
| Rate for Payer: First Health Commercial |
$483.55
|
| Rate for Payer: Humana Commercial |
$432.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$417.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$375.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$152.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$447.92
|
| Rate for Payer: Ohio Health Group HMO |
$381.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$407.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$442.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$351.21
|
| Rate for Payer: PHCS Commercial |
$488.64
|
| Rate for Payer: United Healthcare All Payer |
$447.92
|
|
|
RPR FE/E/EN/L/M 12.6-20.0 CM
|
Professional
|
Both
|
$959.00
|
|
|
Service Code
|
HCPCS 12016
|
| Hospital Charge Code |
76100130
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$98.41 |
| Max. Negotiated Rate |
$575.40 |
| Rate for Payer: Aetna Commercial |
$327.13
|
| Rate for Payer: Ambetter Exchange |
$122.16
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$98.41
|
| Rate for Payer: Anthem Medicaid |
$179.09
|
| Rate for Payer: Buckeye Individual/Medicaid |
$122.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$122.16
|
| Rate for Payer: CareSource Just4Me Medicare |
$146.59
|
| Rate for Payer: Cash Price |
$479.50
|
| Rate for Payer: Cash Price |
$479.50
|
| Rate for Payer: Cigna Commercial |
$311.04
|
| Rate for Payer: Healthspan PPO |
$342.45
|
| Rate for Payer: Humana Medicaid |
$179.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$190.18
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$122.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$122.16
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$182.67
|
| Rate for Payer: Molina Healthcare Passport |
$179.09
|
| Rate for Payer: Multiplan PHCS |
$575.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$158.81
|
| Rate for Payer: UHCCP Medicaid |
$103.33
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$180.88
|
| Rate for Payer: Wellcare Medicare Advantage |
$122.16
|
|
|
RPR FE/E/EN/L/M 12.6-20.0 CM
|
Facility
|
IP
|
$959.00
|
|
|
Service Code
|
HCPCS 12016
|
| Hospital Charge Code |
76100130
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$287.70 |
| Max. Negotiated Rate |
$920.64 |
| Rate for Payer: Aetna Commercial |
$738.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$748.02
|
| Rate for Payer: Cash Price |
$479.50
|
| Rate for Payer: Cigna Commercial |
$795.97
|
| Rate for Payer: First Health Commercial |
$911.05
|
| Rate for Payer: Humana Commercial |
$815.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$786.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$707.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$287.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$843.92
|
| Rate for Payer: Ohio Health Group HMO |
$719.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$767.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$834.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$661.71
|
| Rate for Payer: PHCS Commercial |
$920.64
|
| Rate for Payer: United Healthcare All Payer |
$843.92
|
|
|
RPR FE/E/EN/L/M 12.6-20.0 CM
|
Facility
|
OP
|
$959.00
|
|
|
Service Code
|
HCPCS 12016
|
| Hospital Charge Code |
76100130
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$329.80 |
| Max. Negotiated Rate |
$920.64 |
| Rate for Payer: Aetna Commercial |
$738.43
|
| Rate for Payer: Anthem Medicaid |
$329.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$748.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$479.50
|
| Rate for Payer: Cash Price |
$479.50
|
| Rate for Payer: Cigna Commercial |
$795.97
|
| Rate for Payer: First Health Commercial |
$911.05
|
| Rate for Payer: Humana Commercial |
$815.15
|
| Rate for Payer: Humana KY Medicaid |
$329.80
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$333.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$786.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$707.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$336.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$843.92
|
| Rate for Payer: Ohio Health Group HMO |
$719.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$767.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$834.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$661.71
|
| Rate for Payer: PHCS Commercial |
$920.64
|
| Rate for Payer: United Healthcare All Payer |
$843.92
|
|
|
RPR FE/E/EN/L/M 12.6-20.0 CM
|
Facility
|
OP
|
$509.00
|
|
|
Service Code
|
HCPCS 12016
|
| Hospital Charge Code |
45000051
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$175.05 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Aetna Commercial |
$391.93
|
| Rate for Payer: Anthem Medicaid |
$175.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$397.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$254.50
|
| Rate for Payer: Cash Price |
$254.50
|
| Rate for Payer: Cigna Commercial |
$422.47
|
| Rate for Payer: First Health Commercial |
$483.55
|
| Rate for Payer: Humana Commercial |
$432.65
|
| Rate for Payer: Humana KY Medicaid |
$175.05
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$176.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$417.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$375.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$178.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$447.92
|
| Rate for Payer: Ohio Health Group HMO |
$381.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$407.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$442.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$351.21
|
| Rate for Payer: PHCS Commercial |
$488.64
|
| Rate for Payer: United Healthcare All Payer |
$447.92
|
|
|
RPR FE/E/EN/L/M 12.6-20.0 C(P
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 12016
|
| Hospital Charge Code |
761P0130
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$98.41 |
| Max. Negotiated Rate |
$342.45 |
| Rate for Payer: Aetna Commercial |
$327.13
|
| Rate for Payer: Ambetter Exchange |
$122.16
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$98.41
|
| Rate for Payer: Anthem Medicaid |
$179.09
|
| Rate for Payer: Buckeye Individual/Medicaid |
$122.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$122.16
|
| Rate for Payer: CareSource Just4Me Medicare |
$146.59
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$311.04
|
| Rate for Payer: Healthspan PPO |
$342.45
|
| Rate for Payer: Humana Medicaid |
$179.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$190.18
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$122.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$122.16
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$182.67
|
| Rate for Payer: Molina Healthcare Passport |
$179.09
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$158.81
|
| Rate for Payer: UHCCP Medicaid |
$103.33
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$180.88
|
| Rate for Payer: Wellcare Medicare Advantage |
$122.16
|
|
|
RPR FE/E/EN/L/M 12.6-20.0 C(T
|
Facility
|
IP
|
$509.00
|
|
|
Service Code
|
HCPCS 12016
|
| Hospital Charge Code |
761T0130
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$152.70 |
| Max. Negotiated Rate |
$488.64 |
| Rate for Payer: Aetna Commercial |
$391.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$397.02
|
| Rate for Payer: Cash Price |
$254.50
|
| Rate for Payer: Cigna Commercial |
$422.47
|
| Rate for Payer: First Health Commercial |
$483.55
|
| Rate for Payer: Humana Commercial |
$432.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$417.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$375.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$152.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$447.92
|
| Rate for Payer: Ohio Health Group HMO |
$381.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$407.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$442.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$351.21
|
| Rate for Payer: PHCS Commercial |
$488.64
|
| Rate for Payer: United Healthcare All Payer |
$447.92
|
|
|
RPR FE/E/EN/L/M 12.6-20.0 C(T
|
Facility
|
OP
|
$509.00
|
|
|
Service Code
|
HCPCS 12016
|
| Hospital Charge Code |
761T0130
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$175.05 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Aetna Commercial |
$391.93
|
| Rate for Payer: Anthem Medicaid |
$175.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$397.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$254.50
|
| Rate for Payer: Cash Price |
$254.50
|
| Rate for Payer: Cigna Commercial |
$422.47
|
| Rate for Payer: First Health Commercial |
$483.55
|
| Rate for Payer: Humana Commercial |
$432.65
|
| Rate for Payer: Humana KY Medicaid |
$175.05
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$176.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$417.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$375.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$178.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$447.92
|
| Rate for Payer: Ohio Health Group HMO |
$381.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$407.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$442.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$351.21
|
| Rate for Payer: PHCS Commercial |
$488.64
|
| Rate for Payer: United Healthcare All Payer |
$447.92
|
|
