|
INJECTION FOR WRIST X-RAY
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 25246
|
| Hospital Charge Code |
76100594
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$47.09 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Aetna Commercial |
$119.02
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$47.09
|
| Rate for Payer: Anthem Medicaid |
$57.17
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,500.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$293.25
|
| Rate for Payer: Healthspan PPO |
$221.73
|
| Rate for Payer: Humana Medicaid |
$57.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$94.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$58.31
|
| Rate for Payer: Molina Healthcare Passport |
$57.17
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,050.00
|
| Rate for Payer: UHCCP Medicaid |
$49.44
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$57.74
|
|
|
INJECTION FOR WRIST X-RAY(P
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 25246
|
| Hospital Charge Code |
761P0594
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$47.09 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial |
$119.02
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$47.09
|
| Rate for Payer: Anthem Medicaid |
$57.17
|
| Rate for Payer: Buckeye Medicare Advantage |
$600.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$293.25
|
| Rate for Payer: Healthspan PPO |
$221.73
|
| Rate for Payer: Humana Medicaid |
$57.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$94.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$58.31
|
| Rate for Payer: Molina Healthcare Passport |
$57.17
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$49.44
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$57.74
|
|
|
INJECTION FOR WRIST X-RAY(T
|
Facility
|
IP
|
$900.00
|
|
|
Service Code
|
HCPCS 25246
|
| Hospital Charge Code |
761T0594
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$117.00 |
| Max. Negotiated Rate |
$864.00 |
| Rate for Payer: Aetna Commercial |
$693.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$702.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$747.00
|
| Rate for Payer: First Health Commercial |
$855.00
|
| Rate for Payer: Humana Commercial |
$765.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$738.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$664.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$270.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$792.00
|
| Rate for Payer: Ohio Health Group HMO |
$675.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$180.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$279.00
|
| Rate for Payer: PHCS Commercial |
$864.00
|
| Rate for Payer: United Healthcare All Payer |
$792.00
|
|
|
INJECTION FOR WRIST X-RAY(T
|
Facility
|
OP
|
$900.00
|
|
|
Service Code
|
HCPCS 25246
|
| Hospital Charge Code |
761T0594
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$117.00 |
| Max. Negotiated Rate |
$864.00 |
| Rate for Payer: Aetna Commercial |
$693.00
|
| Rate for Payer: Anthem Medicaid |
$309.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$702.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$747.00
|
| Rate for Payer: First Health Commercial |
$855.00
|
| Rate for Payer: Humana Commercial |
$765.00
|
| Rate for Payer: Humana KY Medicaid |
$309.51
|
| Rate for Payer: Kentucky WC Medicaid |
$312.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$738.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$664.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$270.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$315.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$792.00
|
| Rate for Payer: Ohio Health Group HMO |
$675.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$180.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$279.00
|
| Rate for Payer: PHCS Commercial |
$864.00
|
| Rate for Payer: United Healthcare All Payer |
$792.00
|
|
|
INJECTION HIP ARTHROGRAPHY
|
Facility
|
IP
|
$2,170.00
|
|
|
Service Code
|
HCPCS 27093
|
| Hospital Charge Code |
76100776
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$282.10 |
| Max. Negotiated Rate |
$2,083.20 |
| Rate for Payer: Aetna Commercial |
$1,670.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,692.60
|
| Rate for Payer: Cash Price |
$1,085.00
|
| Rate for Payer: Cigna Commercial |
$1,801.10
|
| Rate for Payer: First Health Commercial |
$2,061.50
|
| Rate for Payer: Humana Commercial |
$1,844.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,779.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,601.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,909.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,627.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$434.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$282.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$672.70
|
| Rate for Payer: PHCS Commercial |
$2,083.20
|
| Rate for Payer: United Healthcare All Payer |
$1,909.60
|
|
|
INJECTION HIP ARTHROGRAPHY
|
Professional
|
Both
|
$2,170.00
|
|
|
Service Code
|
HCPCS 27093
|
| Hospital Charge Code |
76100776
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$51.22 |
| Max. Negotiated Rate |
$2,170.00 |
| Rate for Payer: Aetna Commercial |
$111.06
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$51.22
|
| Rate for Payer: Anthem Medicaid |
$62.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,170.00
|
| Rate for Payer: Cash Price |
$1,085.00
|
| Rate for Payer: Cash Price |
$1,085.00
|
| Rate for Payer: Cigna Commercial |
$115.72
|
| Rate for Payer: Healthspan PPO |
$244.59
|
| Rate for Payer: Humana Medicaid |
$62.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$88.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$64.07
|
| Rate for Payer: Molina Healthcare Passport |
$62.81
|
| Rate for Payer: Multiplan PHCS |
$1,302.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,519.00
|
| Rate for Payer: UHCCP Medicaid |
$53.78
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$63.44
|
|
|
INJECTION HIP ARTHROGRAPHY
|
Facility
|
OP
|
$2,170.00
|
|
|
Service Code
|
HCPCS 27093
|
| Hospital Charge Code |
76100776
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$282.10 |
| Max. Negotiated Rate |
$2,083.20 |
| Rate for Payer: Aetna Commercial |
$1,670.90
|
| Rate for Payer: Anthem Medicaid |
$746.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,692.60
|
| Rate for Payer: Cash Price |
$1,085.00
|
| Rate for Payer: Cigna Commercial |
$1,801.10
|
| Rate for Payer: First Health Commercial |
$2,061.50
|
| Rate for Payer: Humana Commercial |
$1,844.50
|
| Rate for Payer: Humana KY Medicaid |
$746.26
|
| Rate for Payer: Kentucky WC Medicaid |
$753.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,779.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,601.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$761.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,909.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,627.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$434.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$282.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$672.70
|
| Rate for Payer: PHCS Commercial |
$2,083.20
|
| Rate for Payer: United Healthcare All Payer |
$1,909.60
|
|
|
INJECTION HIP ARTHROGRAPHY(P
|
Professional
|
Both
|
$970.00
|
|
|
Service Code
|
HCPCS 27093
|
| Hospital Charge Code |
761P0776
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$51.22 |
| Max. Negotiated Rate |
$970.00 |
| Rate for Payer: Aetna Commercial |
$111.06
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$51.22
|
| Rate for Payer: Anthem Medicaid |
$62.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$970.00
|
| Rate for Payer: Cash Price |
$485.00
|
| Rate for Payer: Cash Price |
$485.00
|
| Rate for Payer: Cigna Commercial |
$115.72
|
| Rate for Payer: Healthspan PPO |
$244.59
|
| Rate for Payer: Humana Medicaid |
$62.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$88.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$64.07
|
| Rate for Payer: Molina Healthcare Passport |
$62.81
|
| Rate for Payer: Multiplan PHCS |
$582.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$679.00
|
| Rate for Payer: UHCCP Medicaid |
$53.78
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$63.44
|
|
|
INJECTION HIP ARTHROGRAPHY(T
|
Facility
|
OP
|
$1,200.00
|
|
|
Service Code
|
HCPCS 27093
|
| Hospital Charge Code |
761T0776
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$156.00 |
| Max. Negotiated Rate |
$1,152.00 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem Medicaid |
$412.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Humana KY Medicaid |
$412.68
|
| Rate for Payer: Kentucky WC Medicaid |
$416.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$420.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$156.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$372.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
INJECTION HIP ARTHROGRAPHY(T
|
Facility
|
IP
|
$1,200.00
|
|
|
Service Code
|
HCPCS 27093
|
| Hospital Charge Code |
761T0776
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$156.00 |
| Max. Negotiated Rate |
$1,152.00 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$156.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$372.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
INJECTION KNEE ARTHROGRAPHY
|
Facility
|
OP
|
$240.00
|
|
|
Service Code
|
HCPCS 27369
|
| Hospital Charge Code |
76100827
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$230.40 |
| Rate for Payer: Aetna Commercial |
$184.80
|
| Rate for Payer: Anthem Medicaid |
$82.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$187.20
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$199.20
|
| Rate for Payer: First Health Commercial |
$228.00
|
| Rate for Payer: Humana Commercial |
$204.00
|
| Rate for Payer: Humana KY Medicaid |
$82.54
|
| Rate for Payer: Kentucky WC Medicaid |
$83.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$196.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$177.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$72.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$84.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$211.20
|
| Rate for Payer: Ohio Health Group HMO |
$180.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$74.40
|
| Rate for Payer: PHCS Commercial |
$230.40
|
| Rate for Payer: United Healthcare All Payer |
$211.20
|
|
|
INJECTION KNEE ARTHROGRAPHY
|
Facility
|
IP
|
$240.00
|
|
|
Service Code
|
HCPCS 27369
|
| Hospital Charge Code |
76100827
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$230.40 |
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Aetna Commercial |
$184.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$187.20
|
| Rate for Payer: Cigna Commercial |
$199.20
|
| Rate for Payer: First Health Commercial |
$228.00
|
| Rate for Payer: Humana Commercial |
$204.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$196.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$177.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$72.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$211.20
|
| Rate for Payer: Ohio Health Group HMO |
$180.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$74.40
|
| Rate for Payer: PHCS Commercial |
$230.40
|
| Rate for Payer: United Healthcare All Payer |
$211.20
|
|
|
INJECTION KNEE ARTHROGRAPHY
|
Professional
|
Both
|
$240.00
|
|
|
Service Code
|
HCPCS 27369
|
| Hospital Charge Code |
76100827
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$257.44 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$33.00
|
| Rate for Payer: Anthem Medicaid |
$33.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$240.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$257.44
|
| Rate for Payer: Humana Medicaid |
$33.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$54.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$33.79
|
| Rate for Payer: Molina Healthcare Passport |
$33.13
|
| Rate for Payer: Multiplan PHCS |
$144.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$168.00
|
| Rate for Payer: UHCCP Medicaid |
$34.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$33.46
|
|
|
INJECTION KNEE ARTHROGRAPHY(P
|
Professional
|
Both
|
$240.00
|
|
|
Service Code
|
HCPCS 27369
|
| Hospital Charge Code |
761P0827
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$257.44 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$33.00
|
| Rate for Payer: Anthem Medicaid |
$33.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$240.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$257.44
|
| Rate for Payer: Humana Medicaid |
$33.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$54.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$33.79
|
| Rate for Payer: Molina Healthcare Passport |
$33.13
|
| Rate for Payer: Multiplan PHCS |
$144.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$168.00
|
| Rate for Payer: UHCCP Medicaid |
$34.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$33.46
|
|
|
INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR OTHER THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHY
|
Facility
|
OP
|
$837.23
|
|
|
Service Code
|
CPT G0260
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$598.02 |
| Max. Negotiated Rate |
$837.23 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
|
|
INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED
|
Facility
|
OP
|
$1,103.49
|
|
|
Service Code
|
CPT 64417
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$788.21 |
| Max. Negotiated Rate |
$1,103.49 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$788.21
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,103.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,064.08
|
| Rate for Payer: Humana Medicare Advantage |
$788.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$945.85
|
|
|
INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; BRACHIAL PLEXUS, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED
|
Facility
|
OP
|
$1,103.49
|
|
|
Service Code
|
CPT 64415
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$788.21 |
| Max. Negotiated Rate |
$1,103.49 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$788.21
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,103.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,064.08
|
| Rate for Payer: Humana Medicare Advantage |
$788.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$945.85
|
|
|
INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; FEMORAL NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED
|
Facility
|
OP
|
$837.23
|
|
|
Service Code
|
CPT 64447
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$598.02 |
| Max. Negotiated Rate |
$837.23 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
|
|
INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GENICULAR NERVE BRANCHES, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED
|
Facility
|
OP
|
$837.23
|
|
|
Service Code
|
CPT 64454
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$598.02 |
| Max. Negotiated Rate |
$837.23 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
|
|
INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; GREATER OCCIPITAL NERVE
|
Facility
|
OP
|
$358.57
|
|
|
Service Code
|
CPT 64405
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$256.12 |
| Max. Negotiated Rate |
$358.57 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$256.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$358.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$345.76
|
| Rate for Payer: Humana Medicare Advantage |
$256.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$307.34
|
|
|
INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$1,103.49
|
|
|
Service Code
|
CPT 64421
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$788.21 |
| Max. Negotiated Rate |
$1,103.49 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$788.21
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,103.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,064.08
|
| Rate for Payer: Humana Medicare Advantage |
$788.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$945.85
|
|
|
INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; INTERCOSTAL NERVE, SINGLE LEVEL
|
Facility
|
OP
|
$837.23
|
|
|
Service Code
|
CPT 64420
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$598.02 |
| Max. Negotiated Rate |
$837.23 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
|
|
INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH
|
Facility
|
OP
|
$837.23
|
|
|
Service Code
|
CPT 64450
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$598.02 |
| Max. Negotiated Rate |
$837.23 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
|
|
INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; SUPRASCAPULAR NERVE
|
Facility
|
OP
|
$837.23
|
|
|
Service Code
|
CPT 64418
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$598.02 |
| Max. Negotiated Rate |
$837.23 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
|
|
INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC, SINGLE LEVEL
|
Facility
|
OP
|
$1,103.49
|
|
|
Service Code
|
CPT 64479
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$788.21 |
| Max. Negotiated Rate |
$1,103.49 |
| Rate for Payer: CareSource Just4Me Medicare |
$1,064.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$788.21
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,103.49
|
| Rate for Payer: Humana Medicare Advantage |
$788.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$945.85
|
|
