|
RPR FE/E/EN/L/M 20.1-30.0 CM
|
Facility
|
IP
|
$962.00
|
|
|
Service Code
|
HCPCS 12017
|
| Hospital Charge Code |
45000052
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$288.60 |
| Max. Negotiated Rate |
$923.52 |
| Rate for Payer: Aetna Commercial |
$740.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$750.36
|
| Rate for Payer: Cash Price |
$481.00
|
| Rate for Payer: Cigna Commercial |
$798.46
|
| Rate for Payer: First Health Commercial |
$913.90
|
| Rate for Payer: Humana Commercial |
$817.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$788.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$709.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$288.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$846.56
|
| Rate for Payer: Ohio Health Group HMO |
$721.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$769.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$836.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$663.78
|
| Rate for Payer: PHCS Commercial |
$923.52
|
| Rate for Payer: United Healthcare All Payer |
$846.56
|
|
|
RPR FE/E/EN/L/M 20.1-30.0 CM
|
Facility
|
OP
|
$962.00
|
|
|
Service Code
|
HCPCS 12017
|
| Hospital Charge Code |
45000052
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$330.83 |
| Max. Negotiated Rate |
$923.52 |
| Rate for Payer: Aetna Commercial |
$740.74
|
| Rate for Payer: Anthem Medicaid |
$330.83
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$750.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$481.00
|
| Rate for Payer: Cash Price |
$481.00
|
| Rate for Payer: Cigna Commercial |
$798.46
|
| Rate for Payer: First Health Commercial |
$913.90
|
| Rate for Payer: Humana Commercial |
$817.70
|
| Rate for Payer: Humana KY Medicaid |
$330.83
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$334.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$788.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$709.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$337.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$846.56
|
| Rate for Payer: Ohio Health Group HMO |
$721.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$769.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$836.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$663.78
|
| Rate for Payer: PHCS Commercial |
$923.52
|
| Rate for Payer: United Healthcare All Payer |
$846.56
|
|
|
RPR FE/E/EN/L/M 20.1-30.0 CM
|
Facility
|
IP
|
$1,812.00
|
|
|
Service Code
|
HCPCS 12017
|
| Hospital Charge Code |
76100131
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$543.60 |
| Max. Negotiated Rate |
$1,739.52 |
| Rate for Payer: Aetna Commercial |
$1,395.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,413.36
|
| Rate for Payer: Cash Price |
$906.00
|
| Rate for Payer: Cigna Commercial |
$1,503.96
|
| Rate for Payer: First Health Commercial |
$1,721.40
|
| Rate for Payer: Humana Commercial |
$1,540.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,485.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,337.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$543.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,594.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,359.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,449.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,576.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,250.28
|
| Rate for Payer: PHCS Commercial |
$1,739.52
|
| Rate for Payer: United Healthcare All Payer |
$1,594.56
|
|
|
RPR FE/E/EN/L/M 20.1-30.0 CM
|
Professional
|
Both
|
$1,812.00
|
|
|
Service Code
|
HCPCS 12017
|
| Hospital Charge Code |
76100131
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$147.35 |
| Max. Negotiated Rate |
$1,087.20 |
| Rate for Payer: Aetna Commercial |
$390.50
|
| Rate for Payer: Ambetter Exchange |
$147.35
|
| Rate for Payer: Anthem Medicaid |
$234.40
|
| Rate for Payer: Buckeye Individual/Medicaid |
$147.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$147.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$176.82
|
| Rate for Payer: Cash Price |
$906.00
|
| Rate for Payer: Cash Price |
$906.00
|
| Rate for Payer: Cigna Commercial |
$376.26
|
| Rate for Payer: Healthspan PPO |
$312.24
|
| Rate for Payer: Humana Medicaid |
$234.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$218.63
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$147.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.35
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$239.09
|
| Rate for Payer: Molina Healthcare Passport |
$234.40
|
| Rate for Payer: Multiplan PHCS |
$1,087.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$191.56
|
| Rate for Payer: UHCCP Medicaid |
$634.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$236.74
|
| Rate for Payer: Wellcare Medicare Advantage |
$147.35
|
|
|
RPR FE/E/EN/L/M 20.1-30.0 CM
|
Facility
|
OP
|
$1,812.00
|
|
|
Service Code
|
HCPCS 12017
|
| Hospital Charge Code |
76100131
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$369.16 |
| Max. Negotiated Rate |
$1,739.52 |
| Rate for Payer: Aetna Commercial |
$1,395.24
|
| Rate for Payer: Anthem Medicaid |
$623.15
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,413.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$906.00
|
| Rate for Payer: Cash Price |
$906.00
|
| Rate for Payer: Cigna Commercial |
$1,503.96
|
| Rate for Payer: First Health Commercial |
$1,721.40
|
| Rate for Payer: Humana Commercial |
$1,540.20
|
| Rate for Payer: Humana KY Medicaid |
$623.15
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$629.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,485.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,337.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$635.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,594.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,359.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,449.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,576.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,250.28
|
| Rate for Payer: PHCS Commercial |
$1,739.52
|
| Rate for Payer: United Healthcare All Payer |
$1,594.56
|
|
|
RPR FE/E/EN/L/M 20.1-30.0 C(P
|
Professional
|
Both
|
$850.00
|
|
|
Service Code
|
HCPCS 12017
|
| Hospital Charge Code |
761P0131
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$147.35 |
| Max. Negotiated Rate |
$510.00 |
| Rate for Payer: Aetna Commercial |
$390.50
|
| Rate for Payer: Ambetter Exchange |
$147.35
|
| Rate for Payer: Anthem Medicaid |
$234.40
|
| Rate for Payer: Buckeye Individual/Medicaid |
$147.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$147.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$176.82
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$376.26
|
| Rate for Payer: Healthspan PPO |
$312.24
|
| Rate for Payer: Humana Medicaid |
$234.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$218.63
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$147.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.35
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$239.09
|
| Rate for Payer: Molina Healthcare Passport |
$234.40
|
| Rate for Payer: Multiplan PHCS |
$510.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$191.56
|
| Rate for Payer: UHCCP Medicaid |
$297.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$236.74
|
| Rate for Payer: Wellcare Medicare Advantage |
$147.35
|
|
|
RPR FE/E/EN/L/M 20.1-30.0 C(T
|
Facility
|
IP
|
$962.00
|
|
|
Service Code
|
HCPCS 12017
|
| Hospital Charge Code |
761T0131
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$288.60 |
| Max. Negotiated Rate |
$923.52 |
| Rate for Payer: Aetna Commercial |
$740.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$750.36
|
| Rate for Payer: Cash Price |
$481.00
|
| Rate for Payer: Cigna Commercial |
$798.46
|
| Rate for Payer: First Health Commercial |
$913.90
|
| Rate for Payer: Humana Commercial |
$817.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$788.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$709.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$288.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$846.56
|
| Rate for Payer: Ohio Health Group HMO |
$721.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$769.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$836.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$663.78
|
| Rate for Payer: PHCS Commercial |
$923.52
|
| Rate for Payer: United Healthcare All Payer |
$846.56
|
|
|
RPR FE/E/EN/L/M 20.1-30.0 C(T
|
Facility
|
OP
|
$962.00
|
|
|
Service Code
|
HCPCS 12017
|
| Hospital Charge Code |
761T0131
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$330.83 |
| Max. Negotiated Rate |
$923.52 |
| Rate for Payer: Aetna Commercial |
$740.74
|
| Rate for Payer: Anthem Medicaid |
$330.83
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$750.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$481.00
|
| Rate for Payer: Cash Price |
$481.00
|
| Rate for Payer: Cigna Commercial |
$798.46
|
| Rate for Payer: First Health Commercial |
$913.90
|
| Rate for Payer: Humana Commercial |
$817.70
|
| Rate for Payer: Humana KY Medicaid |
$330.83
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$334.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$788.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$709.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$337.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$846.56
|
| Rate for Payer: Ohio Health Group HMO |
$721.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$769.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$836.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$663.78
|
| Rate for Payer: PHCS Commercial |
$923.52
|
| Rate for Payer: United Healthcare All Payer |
$846.56
|
|
|
RPR F/E/E/N/L/M 2.5 CM/<
|
Facility
|
OP
|
$487.00
|
|
|
Service Code
|
HCPCS 12011
|
| Hospital Charge Code |
76100126
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$167.48 |
| Max. Negotiated Rate |
$467.52 |
| Rate for Payer: Aetna Commercial |
$374.99
|
| Rate for Payer: Anthem Medicaid |
$167.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$379.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$243.50
|
| Rate for Payer: Cash Price |
$243.50
|
| Rate for Payer: Cigna Commercial |
$404.21
|
| Rate for Payer: First Health Commercial |
$462.65
|
| Rate for Payer: Humana Commercial |
$413.95
|
| Rate for Payer: Humana KY Medicaid |
$167.48
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$169.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$399.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$359.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$170.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$428.56
|
| Rate for Payer: Ohio Health Group HMO |
$365.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$389.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$423.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$336.03
|
| Rate for Payer: PHCS Commercial |
$467.52
|
| Rate for Payer: United Healthcare All Payer |
$428.56
|
|
|
RPR F/E/E/N/L/M 2.5 CM/<
|
Facility
|
IP
|
$287.00
|
|
|
Service Code
|
HCPCS 12011
|
| Hospital Charge Code |
45000047
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$86.10 |
| Max. Negotiated Rate |
$275.52 |
| Rate for Payer: Aetna Commercial |
$220.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$223.86
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cigna Commercial |
$238.21
|
| Rate for Payer: First Health Commercial |
$272.65
|
| Rate for Payer: Humana Commercial |
$243.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$235.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$211.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$86.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$252.56
|
| Rate for Payer: Ohio Health Group HMO |
$215.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$229.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$249.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$198.03
|
| Rate for Payer: PHCS Commercial |
$275.52
|
| Rate for Payer: United Healthcare All Payer |
$252.56
|
|
|
RPR F/E/E/N/L/M 2.5 CM/<
|
Facility
|
IP
|
$487.00
|
|
|
Service Code
|
HCPCS 12011
|
| Hospital Charge Code |
76100126
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$146.10 |
| Max. Negotiated Rate |
$467.52 |
| Rate for Payer: Aetna Commercial |
$374.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$379.86
|
| Rate for Payer: Cash Price |
$243.50
|
| Rate for Payer: Cigna Commercial |
$404.21
|
| Rate for Payer: First Health Commercial |
$462.65
|
| Rate for Payer: Humana Commercial |
$413.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$399.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$359.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$146.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$428.56
|
| Rate for Payer: Ohio Health Group HMO |
$365.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$389.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$423.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$336.03
|
| Rate for Payer: PHCS Commercial |
$467.52
|
| Rate for Payer: United Healthcare All Payer |
$428.56
|
|
|
RPR F/E/E/N/L/M 2.5 CM/<
|
Professional
|
Both
|
$487.00
|
|
|
Service Code
|
HCPCS 12011
|
| Hospital Charge Code |
76100126
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$34.73 |
| Max. Negotiated Rate |
$292.20 |
| Rate for Payer: Aetna Commercial |
$154.83
|
| Rate for Payer: Ambetter Exchange |
$53.12
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$34.73
|
| Rate for Payer: Anthem Medicaid |
$71.48
|
| Rate for Payer: Buckeye Individual/Medicaid |
$53.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$53.12
|
| Rate for Payer: CareSource Just4Me Medicare |
$63.74
|
| Rate for Payer: Cash Price |
$243.50
|
| Rate for Payer: Cash Price |
$243.50
|
| Rate for Payer: Cigna Commercial |
$146.54
|
| Rate for Payer: Healthspan PPO |
$173.88
|
| Rate for Payer: Humana Medicaid |
$71.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$82.99
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$53.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.12
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$72.91
|
| Rate for Payer: Molina Healthcare Passport |
$71.48
|
| Rate for Payer: Multiplan PHCS |
$292.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$69.06
|
| Rate for Payer: UHCCP Medicaid |
$36.47
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.19
|
| Rate for Payer: Wellcare Medicare Advantage |
$53.12
|
|
|
RPR F/E/E/N/L/M 2.5 CM/<
|
Facility
|
OP
|
$287.00
|
|
|
Service Code
|
HCPCS 12011
|
| Hospital Charge Code |
45000047
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$98.70 |
| Max. Negotiated Rate |
$275.52 |
| Rate for Payer: Aetna Commercial |
$220.99
|
| Rate for Payer: Anthem Medicaid |
$98.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$223.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cigna Commercial |
$238.21
|
| Rate for Payer: First Health Commercial |
$272.65
|
| Rate for Payer: Humana Commercial |
$243.95
|
| Rate for Payer: Humana KY Medicaid |
$98.70
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$99.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$235.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$211.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$100.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$252.56
|
| Rate for Payer: Ohio Health Group HMO |
$215.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$229.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$249.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$198.03
|
| Rate for Payer: PHCS Commercial |
$275.52
|
| Rate for Payer: United Healthcare All Payer |
$252.56
|
|
|
RPR F/E/E/N/L/M 2.5 CM/<(P
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 12011
|
| Hospital Charge Code |
761P0126
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$34.73 |
| Max. Negotiated Rate |
$173.88 |
| Rate for Payer: Aetna Commercial |
$154.83
|
| Rate for Payer: Ambetter Exchange |
$53.12
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$34.73
|
| Rate for Payer: Anthem Medicaid |
$71.48
|
| Rate for Payer: Buckeye Individual/Medicaid |
$53.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$53.12
|
| Rate for Payer: CareSource Just4Me Medicare |
$63.74
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$146.54
|
| Rate for Payer: Healthspan PPO |
$173.88
|
| Rate for Payer: Humana Medicaid |
$71.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$82.99
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$53.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.12
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$72.91
|
| Rate for Payer: Molina Healthcare Passport |
$71.48
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$69.06
|
| Rate for Payer: UHCCP Medicaid |
$36.47
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.19
|
| Rate for Payer: Wellcare Medicare Advantage |
$53.12
|
|
|
RPR F/E/E/N/L/M 2.5 CM/<(T
|
Facility
|
IP
|
$287.00
|
|
|
Service Code
|
HCPCS 12011
|
| Hospital Charge Code |
761T0126
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$86.10 |
| Max. Negotiated Rate |
$275.52 |
| Rate for Payer: Aetna Commercial |
$220.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$223.86
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cigna Commercial |
$238.21
|
| Rate for Payer: First Health Commercial |
$272.65
|
| Rate for Payer: Humana Commercial |
$243.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$235.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$211.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$86.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$252.56
|
| Rate for Payer: Ohio Health Group HMO |
$215.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$229.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$249.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$198.03
|
| Rate for Payer: PHCS Commercial |
$275.52
|
| Rate for Payer: United Healthcare All Payer |
$252.56
|
|
|
RPR F/E/E/N/L/M 2.5 CM/<(T
|
Facility
|
OP
|
$287.00
|
|
|
Service Code
|
HCPCS 12011
|
| Hospital Charge Code |
761T0126
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$98.70 |
| Max. Negotiated Rate |
$275.52 |
| Rate for Payer: Aetna Commercial |
$220.99
|
| Rate for Payer: Anthem Medicaid |
$98.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$223.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cigna Commercial |
$238.21
|
| Rate for Payer: First Health Commercial |
$272.65
|
| Rate for Payer: Humana Commercial |
$243.95
|
| Rate for Payer: Humana KY Medicaid |
$98.70
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$99.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$235.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$211.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$100.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$252.56
|
| Rate for Payer: Ohio Health Group HMO |
$215.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$229.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$249.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$198.03
|
| Rate for Payer: PHCS Commercial |
$275.52
|
| Rate for Payer: United Healthcare All Payer |
$252.56
|
|
|
RPR F/E/E/N/L/M 2.6-5.0 CM
|
Facility
|
OP
|
$594.00
|
|
|
Service Code
|
HCPCS 12013
|
| Hospital Charge Code |
76100127
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$183.59 |
| Max. Negotiated Rate |
$570.24 |
| Rate for Payer: Aetna Commercial |
$457.38
|
| Rate for Payer: Anthem Medicaid |
$204.28
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$463.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$297.00
|
| Rate for Payer: Cash Price |
$297.00
|
| Rate for Payer: Cigna Commercial |
$493.02
|
| Rate for Payer: First Health Commercial |
$564.30
|
| Rate for Payer: Humana Commercial |
$504.90
|
| Rate for Payer: Humana KY Medicaid |
$204.28
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$206.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$487.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$438.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$208.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$522.72
|
| Rate for Payer: Ohio Health Group HMO |
$445.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$475.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$516.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$409.86
|
| Rate for Payer: PHCS Commercial |
$570.24
|
| Rate for Payer: United Healthcare All Payer |
$522.72
|
|
|
RPR F/E/E/N/L/M 2.6-5.0 CM
|
Facility
|
IP
|
$594.00
|
|
|
Service Code
|
HCPCS 12013
|
| Hospital Charge Code |
76100127
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$178.20 |
| Max. Negotiated Rate |
$570.24 |
| Rate for Payer: Aetna Commercial |
$457.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$463.32
|
| Rate for Payer: Cash Price |
$297.00
|
| Rate for Payer: Cigna Commercial |
$493.02
|
| Rate for Payer: First Health Commercial |
$564.30
|
| Rate for Payer: Humana Commercial |
$504.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$487.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$438.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$178.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$522.72
|
| Rate for Payer: Ohio Health Group HMO |
$445.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$475.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$516.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$409.86
|
| Rate for Payer: PHCS Commercial |
$570.24
|
| Rate for Payer: United Healthcare All Payer |
$522.72
|
|
|
RPR F/E/E/N/L/M 2.6-5.0 CM
|
Facility
|
OP
|
$344.00
|
|
|
Service Code
|
HCPCS 12013
|
| Hospital Charge Code |
45000048
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$118.30 |
| Max. Negotiated Rate |
$330.24 |
| Rate for Payer: Aetna Commercial |
$264.88
|
| Rate for Payer: Anthem Medicaid |
$118.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$268.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$172.00
|
| Rate for Payer: Cash Price |
$172.00
|
| Rate for Payer: Cigna Commercial |
$285.52
|
| Rate for Payer: First Health Commercial |
$326.80
|
| Rate for Payer: Humana Commercial |
$292.40
|
| Rate for Payer: Humana KY Medicaid |
$118.30
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$119.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$282.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$253.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$120.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$302.72
|
| Rate for Payer: Ohio Health Group HMO |
$258.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$275.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$299.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$237.36
|
| Rate for Payer: PHCS Commercial |
$330.24
|
| Rate for Payer: United Healthcare All Payer |
$302.72
|
|
|
RPR F/E/E/N/L/M 2.6-5.0 CM
|
Professional
|
Both
|
$594.00
|
|
|
Service Code
|
HCPCS 12013
|
| Hospital Charge Code |
76100127
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$41.80 |
| Max. Negotiated Rate |
$356.40 |
| Rate for Payer: Aetna Commercial |
$176.49
|
| Rate for Payer: Ambetter Exchange |
$55.44
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$41.80
|
| Rate for Payer: Anthem Medicaid |
$86.50
|
| Rate for Payer: Buckeye Individual/Medicaid |
$55.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$55.44
|
| Rate for Payer: CareSource Just4Me Medicare |
$66.53
|
| Rate for Payer: Cash Price |
$297.00
|
| Rate for Payer: Cash Price |
$297.00
|
| Rate for Payer: Cigna Commercial |
$167.79
|
| Rate for Payer: Healthspan PPO |
$192.04
|
| Rate for Payer: Humana Medicaid |
$86.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$93.52
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$55.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$88.23
|
| Rate for Payer: Molina Healthcare Passport |
$86.50
|
| Rate for Payer: Multiplan PHCS |
$356.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$72.07
|
| Rate for Payer: UHCCP Medicaid |
$43.89
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$87.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$55.44
|
|
|
RPR F/E/E/N/L/M 2.6-5.0 CM
|
Facility
|
IP
|
$344.00
|
|
|
Service Code
|
HCPCS 12013
|
| Hospital Charge Code |
45000048
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$103.20 |
| Max. Negotiated Rate |
$330.24 |
| Rate for Payer: Aetna Commercial |
$264.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$268.32
|
| Rate for Payer: Cash Price |
$172.00
|
| Rate for Payer: Cigna Commercial |
$285.52
|
| Rate for Payer: First Health Commercial |
$326.80
|
| Rate for Payer: Humana Commercial |
$292.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$282.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$253.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$103.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$302.72
|
| Rate for Payer: Ohio Health Group HMO |
$258.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$275.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$299.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$237.36
|
| Rate for Payer: PHCS Commercial |
$330.24
|
| Rate for Payer: United Healthcare All Payer |
$302.72
|
|
|
RPR F/E/E/N/L/M 2.6-5.0 CM(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 12013
|
| Hospital Charge Code |
761P0127
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$41.80 |
| Max. Negotiated Rate |
$192.04 |
| Rate for Payer: Aetna Commercial |
$176.49
|
| Rate for Payer: Ambetter Exchange |
$55.44
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$41.80
|
| Rate for Payer: Anthem Medicaid |
$86.50
|
| Rate for Payer: Buckeye Individual/Medicaid |
$55.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$55.44
|
| Rate for Payer: CareSource Just4Me Medicare |
$66.53
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$167.79
|
| Rate for Payer: Healthspan PPO |
$192.04
|
| Rate for Payer: Humana Medicaid |
$86.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$93.52
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$55.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$88.23
|
| Rate for Payer: Molina Healthcare Passport |
$86.50
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$72.07
|
| Rate for Payer: UHCCP Medicaid |
$43.89
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$87.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$55.44
|
|
|
RPR F/E/E/N/L/M 2.6-5.0 CM(T
|
Facility
|
IP
|
$344.00
|
|
|
Service Code
|
HCPCS 12013
|
| Hospital Charge Code |
761T0127
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$103.20 |
| Max. Negotiated Rate |
$330.24 |
| Rate for Payer: Aetna Commercial |
$264.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$268.32
|
| Rate for Payer: Cash Price |
$172.00
|
| Rate for Payer: Cigna Commercial |
$285.52
|
| Rate for Payer: First Health Commercial |
$326.80
|
| Rate for Payer: Humana Commercial |
$292.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$282.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$253.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$103.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$302.72
|
| Rate for Payer: Ohio Health Group HMO |
$258.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$275.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$299.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$237.36
|
| Rate for Payer: PHCS Commercial |
$330.24
|
| Rate for Payer: United Healthcare All Payer |
$302.72
|
|
|
RPR F/E/E/N/L/M 2.6-5.0 CM(T
|
Facility
|
OP
|
$344.00
|
|
|
Service Code
|
HCPCS 12013
|
| Hospital Charge Code |
761T0127
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$118.30 |
| Max. Negotiated Rate |
$330.24 |
| Rate for Payer: Aetna Commercial |
$264.88
|
| Rate for Payer: Anthem Medicaid |
$118.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$268.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$172.00
|
| Rate for Payer: Cash Price |
$172.00
|
| Rate for Payer: Cigna Commercial |
$285.52
|
| Rate for Payer: First Health Commercial |
$326.80
|
| Rate for Payer: Humana Commercial |
$292.40
|
| Rate for Payer: Humana KY Medicaid |
$118.30
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$119.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$282.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$253.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$120.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$302.72
|
| Rate for Payer: Ohio Health Group HMO |
$258.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$275.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$299.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$237.36
|
| Rate for Payer: PHCS Commercial |
$330.24
|
| Rate for Payer: United Healthcare All Payer |
$302.72
|
|
|
RPR LAC 2.5CM OR LESS
|
Facility
|
OP
|
$1,089.16
|
|
|
Service Code
|
HCPCS 41250
|
| Hospital Charge Code |
76101661
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$368.70 |
| Max. Negotiated Rate |
$1,045.59 |
| Rate for Payer: Aetna Commercial |
$838.65
|
| Rate for Payer: Anthem Medicaid |
$374.56
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$368.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$849.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$497.75
|
| Rate for Payer: Cash Price |
$544.58
|
| Rate for Payer: Cash Price |
$544.58
|
| Rate for Payer: Cigna Commercial |
$904.00
|
| Rate for Payer: First Health Commercial |
$1,034.70
|
| Rate for Payer: Humana Commercial |
$925.79
|
| Rate for Payer: Humana KY Medicaid |
$374.56
|
| Rate for Payer: Humana Medicare Advantage |
$368.70
|
| Rate for Payer: Kentucky WC Medicaid |
$378.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$893.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$803.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$382.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$958.46
|
| Rate for Payer: Ohio Health Group HMO |
$816.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$871.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$947.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$751.52
|
| Rate for Payer: PHCS Commercial |
$1,045.59
|
| Rate for Payer: United Healthcare All Payer |
$958.46
|
|
