|
UNILATERAL LT MAG VIEW W/CAD
|
Facility
|
IP
|
$768.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
40100004
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$230.40 |
| Max. Negotiated Rate |
$737.28 |
| Rate for Payer: Aetna Commercial |
$591.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$599.04
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cigna Commercial |
$637.44
|
| Rate for Payer: First Health Commercial |
$729.60
|
| Rate for Payer: Humana Commercial |
$652.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$629.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$566.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$230.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$675.84
|
| Rate for Payer: Ohio Health Group HMO |
$576.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$614.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$668.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$529.92
|
| Rate for Payer: PHCS Commercial |
$737.28
|
| Rate for Payer: United Healthcare All Payer |
$675.84
|
|
|
UNILATERAL LT MAG VIEW W/CAD
|
Facility
|
OP
|
$768.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
40100004
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$230.40 |
| Max. Negotiated Rate |
$737.28 |
| Rate for Payer: Aetna Commercial |
$591.36
|
| Rate for Payer: Anthem Medicaid |
$264.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$599.04
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cigna Commercial |
$637.44
|
| Rate for Payer: First Health Commercial |
$729.60
|
| Rate for Payer: Humana Commercial |
$652.80
|
| Rate for Payer: Humana KY Medicaid |
$264.12
|
| Rate for Payer: Kentucky WC Medicaid |
$266.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$629.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$566.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$230.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$269.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$675.84
|
| Rate for Payer: Ohio Health Group HMO |
$576.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$614.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$668.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$529.92
|
| Rate for Payer: PHCS Commercial |
$737.28
|
| Rate for Payer: United Healthcare All Payer |
$675.84
|
|
|
UNILATERAL LT MAG VIEW W/CAD
|
Professional
|
Both
|
$768.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
40100004
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$47.87 |
| Max. Negotiated Rate |
$460.80 |
| Rate for Payer: Ambetter Exchange |
$113.66
|
| Rate for Payer: Anthem Medicaid |
$101.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$113.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$113.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$136.39
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cigna Commercial |
$210.02
|
| Rate for Payer: Humana Medicaid |
$101.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.87
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$113.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$113.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.13
|
| Rate for Payer: Molina Healthcare Passport |
$101.11
|
| Rate for Payer: Multiplan PHCS |
$460.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$147.76
|
| Rate for Payer: UHCCP Medicaid |
$268.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$113.66
|
|
|
UNILATERAL LT MAG VIEW W/CAD(P
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
401P0004
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$47.87 |
| Max. Negotiated Rate |
$210.02 |
| Rate for Payer: Ambetter Exchange |
$113.66
|
| Rate for Payer: Anthem Medicaid |
$101.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$113.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$113.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$136.39
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$210.02
|
| Rate for Payer: Humana Medicaid |
$101.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.87
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$113.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$113.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.13
|
| Rate for Payer: Molina Healthcare Passport |
$101.11
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$147.76
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$113.66
|
|
|
UNILATERAL LT MAG VIEW W/CAD(T
|
Facility
|
IP
|
$543.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
401T0004
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$162.90 |
| Max. Negotiated Rate |
$521.28 |
| Rate for Payer: Aetna Commercial |
$418.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$423.54
|
| Rate for Payer: Cash Price |
$271.50
|
| Rate for Payer: Cigna Commercial |
$450.69
|
| Rate for Payer: First Health Commercial |
$515.85
|
| Rate for Payer: Humana Commercial |
$461.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$445.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$400.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$477.84
|
| Rate for Payer: Ohio Health Group HMO |
$407.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$434.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$472.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$374.67
|
| Rate for Payer: PHCS Commercial |
$521.28
|
| Rate for Payer: United Healthcare All Payer |
$477.84
|
|
|
UNILATERAL LT MAG VIEW W/CAD(T
|
Facility
|
OP
|
$543.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
401T0004
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$162.90 |
| Max. Negotiated Rate |
$521.28 |
| Rate for Payer: Aetna Commercial |
$418.11
|
| Rate for Payer: Anthem Medicaid |
$186.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$423.54
|
| Rate for Payer: Cash Price |
$271.50
|
| Rate for Payer: Cigna Commercial |
$450.69
|
| Rate for Payer: First Health Commercial |
$515.85
|
| Rate for Payer: Humana Commercial |
$461.55
|
| Rate for Payer: Humana KY Medicaid |
$186.74
|
| Rate for Payer: Kentucky WC Medicaid |
$188.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$445.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$400.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$190.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$477.84
|
| Rate for Payer: Ohio Health Group HMO |
$407.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$434.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$472.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$374.67
|
| Rate for Payer: PHCS Commercial |
$521.28
|
| Rate for Payer: United Healthcare All Payer |
$477.84
|
|
|
UNILATERAL RT DIAGNOSTIC W/CAD
|
Facility
|
OP
|
$510.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
401T0006
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$153.00 |
| Max. Negotiated Rate |
$489.60 |
| Rate for Payer: Aetna Commercial |
$392.70
|
| Rate for Payer: Anthem Medicaid |
$175.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$397.80
|
| Rate for Payer: Cash Price |
$255.00
|
| Rate for Payer: Cigna Commercial |
$423.30
|
| Rate for Payer: First Health Commercial |
$484.50
|
| Rate for Payer: Humana Commercial |
$433.50
|
| Rate for Payer: Humana KY Medicaid |
$175.39
|
| Rate for Payer: Kentucky WC Medicaid |
$177.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$418.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$376.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$153.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$178.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$448.80
|
| Rate for Payer: Ohio Health Group HMO |
$382.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$408.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$443.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$351.90
|
| Rate for Payer: PHCS Commercial |
$489.60
|
| Rate for Payer: United Healthcare All Payer |
$448.80
|
|
|
UNILATERAL RT DIAGNOSTIC W/CAD
|
Facility
|
IP
|
$510.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
401T0006
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$153.00 |
| Max. Negotiated Rate |
$489.60 |
| Rate for Payer: Aetna Commercial |
$392.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$397.80
|
| Rate for Payer: Cash Price |
$255.00
|
| Rate for Payer: Cigna Commercial |
$423.30
|
| Rate for Payer: First Health Commercial |
$484.50
|
| Rate for Payer: Humana Commercial |
$433.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$418.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$376.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$153.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$448.80
|
| Rate for Payer: Ohio Health Group HMO |
$382.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$408.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$443.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$351.90
|
| Rate for Payer: PHCS Commercial |
$489.60
|
| Rate for Payer: United Healthcare All Payer |
$448.80
|
|
|
UNILATERAL RT DIAGNOSTIC W/CAD
|
Facility
|
IP
|
$735.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
40100006
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$220.50 |
| Max. Negotiated Rate |
$705.60 |
| Rate for Payer: Aetna Commercial |
$565.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$573.30
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cigna Commercial |
$610.05
|
| Rate for Payer: First Health Commercial |
$698.25
|
| Rate for Payer: Humana Commercial |
$624.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$602.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$542.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$646.80
|
| Rate for Payer: Ohio Health Group HMO |
$551.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$588.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$639.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$507.15
|
| Rate for Payer: PHCS Commercial |
$705.60
|
| Rate for Payer: United Healthcare All Payer |
$646.80
|
|
|
UNILATERAL RT DIAGNOSTIC W/CAD
|
Facility
|
OP
|
$735.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
40100006
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$220.50 |
| Max. Negotiated Rate |
$705.60 |
| Rate for Payer: Aetna Commercial |
$565.95
|
| Rate for Payer: Anthem Medicaid |
$252.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$573.30
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cigna Commercial |
$610.05
|
| Rate for Payer: First Health Commercial |
$698.25
|
| Rate for Payer: Humana Commercial |
$624.75
|
| Rate for Payer: Humana KY Medicaid |
$252.77
|
| Rate for Payer: Kentucky WC Medicaid |
$255.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$602.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$542.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$257.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$646.80
|
| Rate for Payer: Ohio Health Group HMO |
$551.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$588.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$639.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$507.15
|
| Rate for Payer: PHCS Commercial |
$705.60
|
| Rate for Payer: United Healthcare All Payer |
$646.80
|
|
|
UNILATERAL RT DIAGNOSTIC W/CAD
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
401P0006
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$47.87 |
| Max. Negotiated Rate |
$210.02 |
| Rate for Payer: Ambetter Exchange |
$113.66
|
| Rate for Payer: Anthem Medicaid |
$101.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$113.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$113.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$136.39
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$210.02
|
| Rate for Payer: Humana Medicaid |
$101.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.87
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$113.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$113.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.13
|
| Rate for Payer: Molina Healthcare Passport |
$101.11
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$147.76
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$113.66
|
|
|
UNILATERAL RT DIAGNOSTIC W/CAD
|
Professional
|
Both
|
$735.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
40100006
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$47.87 |
| Max. Negotiated Rate |
$441.00 |
| Rate for Payer: Ambetter Exchange |
$113.66
|
| Rate for Payer: Anthem Medicaid |
$101.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$113.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$113.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$136.39
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cigna Commercial |
$210.02
|
| Rate for Payer: Humana Medicaid |
$101.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.87
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$113.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$113.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.13
|
| Rate for Payer: Molina Healthcare Passport |
$101.11
|
| Rate for Payer: Multiplan PHCS |
$441.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$147.76
|
| Rate for Payer: UHCCP Medicaid |
$257.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$113.66
|
|
|
UNILATERAL RT MAG VIEW W/CAD
|
Facility
|
OP
|
$768.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
40100003
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$230.40 |
| Max. Negotiated Rate |
$737.28 |
| Rate for Payer: Aetna Commercial |
$591.36
|
| Rate for Payer: Anthem Medicaid |
$264.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$599.04
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cigna Commercial |
$637.44
|
| Rate for Payer: First Health Commercial |
$729.60
|
| Rate for Payer: Humana Commercial |
$652.80
|
| Rate for Payer: Humana KY Medicaid |
$264.12
|
| Rate for Payer: Kentucky WC Medicaid |
$266.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$629.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$566.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$230.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$269.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$675.84
|
| Rate for Payer: Ohio Health Group HMO |
$576.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$614.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$668.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$529.92
|
| Rate for Payer: PHCS Commercial |
$737.28
|
| Rate for Payer: United Healthcare All Payer |
$675.84
|
|
|
UNILATERAL RT MAG VIEW W/CAD
|
Professional
|
Both
|
$768.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
40100003
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$47.87 |
| Max. Negotiated Rate |
$460.80 |
| Rate for Payer: Ambetter Exchange |
$113.66
|
| Rate for Payer: Anthem Medicaid |
$101.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$113.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$113.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$136.39
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cigna Commercial |
$210.02
|
| Rate for Payer: Humana Medicaid |
$101.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.87
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$113.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$113.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.13
|
| Rate for Payer: Molina Healthcare Passport |
$101.11
|
| Rate for Payer: Multiplan PHCS |
$460.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$147.76
|
| Rate for Payer: UHCCP Medicaid |
$268.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$113.66
|
|
|
UNILATERAL RT MAG VIEW W/CAD
|
Facility
|
IP
|
$768.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
40100003
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$230.40 |
| Max. Negotiated Rate |
$737.28 |
| Rate for Payer: Aetna Commercial |
$591.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$599.04
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cigna Commercial |
$637.44
|
| Rate for Payer: First Health Commercial |
$729.60
|
| Rate for Payer: Humana Commercial |
$652.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$629.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$566.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$230.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$675.84
|
| Rate for Payer: Ohio Health Group HMO |
$576.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$614.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$668.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$529.92
|
| Rate for Payer: PHCS Commercial |
$737.28
|
| Rate for Payer: United Healthcare All Payer |
$675.84
|
|
|
UNILATERAL RT MAG VIEW W/CAD(P
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
401P0003
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$47.87 |
| Max. Negotiated Rate |
$210.02 |
| Rate for Payer: Ambetter Exchange |
$113.66
|
| Rate for Payer: Anthem Medicaid |
$101.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$113.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$113.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$136.39
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$210.02
|
| Rate for Payer: Humana Medicaid |
$101.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.87
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$113.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$113.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.13
|
| Rate for Payer: Molina Healthcare Passport |
$101.11
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$147.76
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$113.66
|
|
|
UNILATERAL RT MAG VIEW W/CAD(T
|
Facility
|
OP
|
$543.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
401T0003
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$162.90 |
| Max. Negotiated Rate |
$521.28 |
| Rate for Payer: Aetna Commercial |
$418.11
|
| Rate for Payer: Anthem Medicaid |
$186.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$423.54
|
| Rate for Payer: Cash Price |
$271.50
|
| Rate for Payer: Cigna Commercial |
$450.69
|
| Rate for Payer: First Health Commercial |
$515.85
|
| Rate for Payer: Humana Commercial |
$461.55
|
| Rate for Payer: Humana KY Medicaid |
$186.74
|
| Rate for Payer: Kentucky WC Medicaid |
$188.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$445.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$400.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$190.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$477.84
|
| Rate for Payer: Ohio Health Group HMO |
$407.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$434.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$472.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$374.67
|
| Rate for Payer: PHCS Commercial |
$521.28
|
| Rate for Payer: United Healthcare All Payer |
$477.84
|
|
|
UNILATERAL RT MAG VIEW W/CAD(T
|
Facility
|
IP
|
$543.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
401T0003
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$162.90 |
| Max. Negotiated Rate |
$521.28 |
| Rate for Payer: Aetna Commercial |
$418.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$423.54
|
| Rate for Payer: Cash Price |
$271.50
|
| Rate for Payer: Cigna Commercial |
$450.69
|
| Rate for Payer: First Health Commercial |
$515.85
|
| Rate for Payer: Humana Commercial |
$461.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$445.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$400.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$477.84
|
| Rate for Payer: Ohio Health Group HMO |
$407.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$434.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$472.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$374.67
|
| Rate for Payer: PHCS Commercial |
$521.28
|
| Rate for Payer: United Healthcare All Payer |
$477.84
|
|
|
UNILAT LT FOLLOWUP PROC W/CAD
|
Professional
|
Both
|
$753.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
40100007
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$47.87 |
| Max. Negotiated Rate |
$451.80 |
| Rate for Payer: Ambetter Exchange |
$113.66
|
| Rate for Payer: Anthem Medicaid |
$101.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$113.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$113.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$136.39
|
| Rate for Payer: Cash Price |
$376.50
|
| Rate for Payer: Cash Price |
$376.50
|
| Rate for Payer: Cigna Commercial |
$210.02
|
| Rate for Payer: Humana Medicaid |
$101.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.87
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$113.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$113.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.13
|
| Rate for Payer: Molina Healthcare Passport |
$101.11
|
| Rate for Payer: Multiplan PHCS |
$451.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$147.76
|
| Rate for Payer: UHCCP Medicaid |
$263.55
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$113.66
|
|
|
UNILAT LT FOLLOWUP PROC W/CAD
|
Facility
|
IP
|
$753.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
40100007
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$225.90 |
| Max. Negotiated Rate |
$722.88 |
| Rate for Payer: Aetna Commercial |
$579.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$587.34
|
| Rate for Payer: Cash Price |
$376.50
|
| Rate for Payer: Cigna Commercial |
$624.99
|
| Rate for Payer: First Health Commercial |
$715.35
|
| Rate for Payer: Humana Commercial |
$640.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$617.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$555.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$225.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$662.64
|
| Rate for Payer: Ohio Health Group HMO |
$564.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$602.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$655.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$519.57
|
| Rate for Payer: PHCS Commercial |
$722.88
|
| Rate for Payer: United Healthcare All Payer |
$662.64
|
|
|
UNILAT LT FOLLOWUP PROC W/CAD
|
Facility
|
OP
|
$753.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
40100007
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$225.90 |
| Max. Negotiated Rate |
$722.88 |
| Rate for Payer: Aetna Commercial |
$579.81
|
| Rate for Payer: Anthem Medicaid |
$258.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$587.34
|
| Rate for Payer: Cash Price |
$376.50
|
| Rate for Payer: Cigna Commercial |
$624.99
|
| Rate for Payer: First Health Commercial |
$715.35
|
| Rate for Payer: Humana Commercial |
$640.05
|
| Rate for Payer: Humana KY Medicaid |
$258.96
|
| Rate for Payer: Kentucky WC Medicaid |
$261.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$617.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$555.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$225.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$264.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$662.64
|
| Rate for Payer: Ohio Health Group HMO |
$564.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$602.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$655.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$519.57
|
| Rate for Payer: PHCS Commercial |
$722.88
|
| Rate for Payer: United Healthcare All Payer |
$662.64
|
|
|
UNILAT LT FOLLOWUP PROC W/CA(P
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
401P0007
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$47.87 |
| Max. Negotiated Rate |
$210.02 |
| Rate for Payer: Ambetter Exchange |
$113.66
|
| Rate for Payer: Anthem Medicaid |
$101.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$113.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$113.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$136.39
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$210.02
|
| Rate for Payer: Humana Medicaid |
$101.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.87
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$113.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$113.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.13
|
| Rate for Payer: Molina Healthcare Passport |
$101.11
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$147.76
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$113.66
|
|
|
UNILAT LT FOLLOWUP PROC W/CA(T
|
Facility
|
IP
|
$528.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
401T0007
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$158.40 |
| Max. Negotiated Rate |
$506.88 |
| Rate for Payer: Aetna Commercial |
$406.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$411.84
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Cigna Commercial |
$438.24
|
| Rate for Payer: First Health Commercial |
$501.60
|
| Rate for Payer: Humana Commercial |
$448.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$432.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$389.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$158.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$464.64
|
| Rate for Payer: Ohio Health Group HMO |
$396.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$422.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$459.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$364.32
|
| Rate for Payer: PHCS Commercial |
$506.88
|
| Rate for Payer: United Healthcare All Payer |
$464.64
|
|
|
UNILAT LT FOLLOWUP PROC W/CA(T
|
Facility
|
OP
|
$528.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
401T0007
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$158.40 |
| Max. Negotiated Rate |
$506.88 |
| Rate for Payer: Aetna Commercial |
$406.56
|
| Rate for Payer: Anthem Medicaid |
$181.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$411.84
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Cigna Commercial |
$438.24
|
| Rate for Payer: First Health Commercial |
$501.60
|
| Rate for Payer: Humana Commercial |
$448.80
|
| Rate for Payer: Humana KY Medicaid |
$181.58
|
| Rate for Payer: Kentucky WC Medicaid |
$183.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$432.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$389.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$158.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$185.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$464.64
|
| Rate for Payer: Ohio Health Group HMO |
$396.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$422.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$459.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$364.32
|
| Rate for Payer: PHCS Commercial |
$506.88
|
| Rate for Payer: United Healthcare All Payer |
$464.64
|
|
|
UNILAT RT FOLLOWUP PROC W/CAD
|
Facility
|
IP
|
$753.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
40100008
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$225.90 |
| Max. Negotiated Rate |
$722.88 |
| Rate for Payer: Aetna Commercial |
$579.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$587.34
|
| Rate for Payer: Cash Price |
$376.50
|
| Rate for Payer: Cigna Commercial |
$624.99
|
| Rate for Payer: First Health Commercial |
$715.35
|
| Rate for Payer: Humana Commercial |
$640.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$617.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$555.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$225.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$662.64
|
| Rate for Payer: Ohio Health Group HMO |
$564.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$602.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$655.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$519.57
|
| Rate for Payer: PHCS Commercial |
$722.88
|
| Rate for Payer: United Healthcare All Payer |
$662.64
|
|
