|
INJECT SKIN LESIONS </W 7(T
|
Facility
|
IP
|
$261.00
|
|
|
Service Code
|
HCPCS 11900
|
| Hospital Charge Code |
761T0107
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$33.93 |
| Max. Negotiated Rate |
$250.56 |
| Rate for Payer: Aetna Commercial |
$200.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$203.58
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cigna Commercial |
$216.63
|
| Rate for Payer: First Health Commercial |
$247.95
|
| Rate for Payer: Humana Commercial |
$221.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$214.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$192.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$229.68
|
| Rate for Payer: Ohio Health Group HMO |
$195.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.91
|
| Rate for Payer: PHCS Commercial |
$250.56
|
| Rate for Payer: United Healthcare All Payer |
$229.68
|
|
|
INJECT TRIGGER POINTS 3/>
|
Facility
|
IP
|
$735.00
|
|
|
Service Code
|
HCPCS 20553
|
| Hospital Charge Code |
76100340
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$95.55 |
| 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 |
$147.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$95.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$227.85
|
| Rate for Payer: PHCS Commercial |
$705.60
|
| Rate for Payer: United Healthcare All Payer |
$646.80
|
|
|
INJECT TRIGGER POINTS 3/>
|
Professional
|
Both
|
$735.00
|
|
|
Service Code
|
HCPCS 20553
|
| Hospital Charge Code |
76100340
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$33.88 |
| Max. Negotiated Rate |
$735.00 |
| Rate for Payer: Aetna Commercial |
$60.06
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$33.88
|
| Rate for Payer: Anthem Medicaid |
$36.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$735.00
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cigna Commercial |
$95.90
|
| Rate for Payer: Healthspan PPO |
$75.26
|
| Rate for Payer: Humana Medicaid |
$36.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$51.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$37.05
|
| Rate for Payer: Molina Healthcare Passport |
$36.32
|
| Rate for Payer: Multiplan PHCS |
$441.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$514.50
|
| Rate for Payer: UHCCP Medicaid |
$35.57
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$36.68
|
|
|
INJECT TRIGGER POINTS 3/>
|
Facility
|
OP
|
$735.00
|
|
|
Service Code
|
HCPCS 20553
|
| Hospital Charge Code |
76100340
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$95.55 |
| Max. Negotiated Rate |
$705.60 |
| Rate for Payer: Aetna Commercial |
$565.95
|
| Rate for Payer: Anthem Medicaid |
$252.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$256.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$573.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$358.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$345.76
|
| Rate for Payer: Cash Price |
$367.50
|
| 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: Humana Medicare Advantage |
$256.12
|
| 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 |
$307.34
|
| 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 |
$147.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$95.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$227.85
|
| Rate for Payer: PHCS Commercial |
$705.60
|
| Rate for Payer: United Healthcare All Payer |
$646.80
|
|
|
INJECT TRIGGER POINTS 3/>(P
|
Professional
|
Both
|
$90.00
|
|
|
Service Code
|
HCPCS 20553
|
| Hospital Charge Code |
761P0340
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$33.88 |
| Max. Negotiated Rate |
$95.90 |
| Rate for Payer: Aetna Commercial |
$60.06
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$33.88
|
| Rate for Payer: Anthem Medicaid |
$36.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$90.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$95.90
|
| Rate for Payer: Healthspan PPO |
$75.26
|
| Rate for Payer: Humana Medicaid |
$36.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$51.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$37.05
|
| Rate for Payer: Molina Healthcare Passport |
$36.32
|
| Rate for Payer: Multiplan PHCS |
$54.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$63.00
|
| Rate for Payer: UHCCP Medicaid |
$35.57
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$36.68
|
|
|
INJECT TRIGGER POINTS 3/>(T
|
Facility
|
OP
|
$645.00
|
|
|
Service Code
|
HCPCS 20553
|
| Hospital Charge Code |
761T0340
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$83.85 |
| Max. Negotiated Rate |
$619.20 |
| Rate for Payer: Aetna Commercial |
$496.65
|
| Rate for Payer: Anthem Medicaid |
$221.82
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$256.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$503.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$358.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$345.76
|
| Rate for Payer: Cash Price |
$322.50
|
| Rate for Payer: Cash Price |
$322.50
|
| Rate for Payer: Cigna Commercial |
$535.35
|
| Rate for Payer: First Health Commercial |
$612.75
|
| Rate for Payer: Humana Commercial |
$548.25
|
| Rate for Payer: Humana KY Medicaid |
$221.82
|
| Rate for Payer: Humana Medicare Advantage |
$256.12
|
| Rate for Payer: Kentucky WC Medicaid |
$224.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$528.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$476.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$307.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$226.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$567.60
|
| Rate for Payer: Ohio Health Group HMO |
$483.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$129.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$83.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$199.95
|
| Rate for Payer: PHCS Commercial |
$619.20
|
| Rate for Payer: United Healthcare All Payer |
$567.60
|
|
|
INJECT TRIGGER POINTS 3/>(T
|
Facility
|
IP
|
$645.00
|
|
|
Service Code
|
HCPCS 20553
|
| Hospital Charge Code |
761T0340
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$83.85 |
| Max. Negotiated Rate |
$619.20 |
| Rate for Payer: Aetna Commercial |
$496.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$503.10
|
| Rate for Payer: Cash Price |
$322.50
|
| Rate for Payer: Cigna Commercial |
$535.35
|
| Rate for Payer: First Health Commercial |
$612.75
|
| Rate for Payer: Humana Commercial |
$548.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$528.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$476.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$193.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$567.60
|
| Rate for Payer: Ohio Health Group HMO |
$483.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$129.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$83.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$199.95
|
| Rate for Payer: PHCS Commercial |
$619.20
|
| Rate for Payer: United Healthcare All Payer |
$567.60
|
|
|
INJ FORAMEN EPIDURAL ADD-ON
|
Facility
|
OP
|
$1,511.01
|
|
|
Service Code
|
HCPCS 64484
|
| Hospital Charge Code |
76102324
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$196.43 |
| Max. Negotiated Rate |
$1,450.57 |
| Rate for Payer: Aetna Commercial |
$1,163.48
|
| Rate for Payer: Anthem Medicaid |
$519.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,178.59
|
| Rate for Payer: Cash Price |
$755.50
|
| Rate for Payer: Cigna Commercial |
$1,254.14
|
| Rate for Payer: First Health Commercial |
$1,435.46
|
| Rate for Payer: Humana Commercial |
$1,284.36
|
| Rate for Payer: Humana KY Medicaid |
$519.64
|
| Rate for Payer: Kentucky WC Medicaid |
$524.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,239.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,115.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$453.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$530.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,329.69
|
| Rate for Payer: Ohio Health Group HMO |
$1,133.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$302.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$196.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$468.41
|
| Rate for Payer: PHCS Commercial |
$1,450.57
|
| Rate for Payer: United Healthcare All Payer |
$1,329.69
|
|
|
INJ FORAMEN EPIDURAL ADD-ON
|
Facility
|
IP
|
$1,511.01
|
|
|
Service Code
|
HCPCS 64484
|
| Hospital Charge Code |
76102324
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$196.43 |
| Max. Negotiated Rate |
$1,450.57 |
| Rate for Payer: Aetna Commercial |
$1,163.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,178.59
|
| Rate for Payer: Cash Price |
$755.50
|
| Rate for Payer: Cigna Commercial |
$1,254.14
|
| Rate for Payer: First Health Commercial |
$1,435.46
|
| Rate for Payer: Humana Commercial |
$1,284.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,239.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,115.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$453.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,329.69
|
| Rate for Payer: Ohio Health Group HMO |
$1,133.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$302.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$196.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$468.41
|
| Rate for Payer: PHCS Commercial |
$1,450.57
|
| Rate for Payer: United Healthcare All Payer |
$1,329.69
|
|
|
INJ FORAMEN EPIDURAL ADD-ON
|
Professional
|
Both
|
$1,511.01
|
|
|
Service Code
|
HCPCS 64484
|
| Hospital Charge Code |
76102324
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$41.78 |
| Max. Negotiated Rate |
$1,511.01 |
| Rate for Payer: Aetna Commercial |
$109.90
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$41.78
|
| Rate for Payer: Anthem Medicaid |
$137.14
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,511.01
|
| Rate for Payer: Cash Price |
$755.50
|
| Rate for Payer: Cash Price |
$755.50
|
| Rate for Payer: Cigna Commercial |
$133.23
|
| Rate for Payer: Healthspan PPO |
$162.54
|
| Rate for Payer: Humana Medicaid |
$137.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$67.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$139.88
|
| Rate for Payer: Molina Healthcare Passport |
$137.14
|
| Rate for Payer: Multiplan PHCS |
$906.61
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,057.71
|
| Rate for Payer: UHCCP Medicaid |
$43.87
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$138.51
|
|
|
INJ FORAMEN EPIDURAL ADD-ON(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 64484
|
| Hospital Charge Code |
761P2324
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$41.78 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Aetna Commercial |
$109.90
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$41.78
|
| Rate for Payer: Anthem Medicaid |
$137.14
|
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$133.23
|
| Rate for Payer: Healthspan PPO |
$162.54
|
| Rate for Payer: Humana Medicaid |
$137.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$67.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$139.88
|
| Rate for Payer: Molina Healthcare Passport |
$137.14
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$43.87
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$138.51
|
|
|
INJ FORAMEN EPIDURAL ADD-ON(T
|
Facility
|
IP
|
$1,261.01
|
|
|
Service Code
|
HCPCS 64484
|
| Hospital Charge Code |
761T2324
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$163.93 |
| Max. Negotiated Rate |
$1,210.57 |
| Rate for Payer: Aetna Commercial |
$970.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$983.59
|
| Rate for Payer: Cash Price |
$630.50
|
| Rate for Payer: Cigna Commercial |
$1,046.64
|
| Rate for Payer: First Health Commercial |
$1,197.96
|
| Rate for Payer: Humana Commercial |
$1,071.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,034.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$930.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$378.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,109.69
|
| Rate for Payer: Ohio Health Group HMO |
$945.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$252.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$163.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$390.91
|
| Rate for Payer: PHCS Commercial |
$1,210.57
|
| Rate for Payer: United Healthcare All Payer |
$1,109.69
|
|
|
INJ FORAMEN EPIDURAL ADD-ON(T
|
Facility
|
OP
|
$1,261.01
|
|
|
Service Code
|
HCPCS 64484
|
| Hospital Charge Code |
761T2324
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$163.93 |
| Max. Negotiated Rate |
$1,210.57 |
| Rate for Payer: Aetna Commercial |
$970.98
|
| Rate for Payer: Anthem Medicaid |
$433.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$983.59
|
| Rate for Payer: Cash Price |
$630.50
|
| Rate for Payer: Cigna Commercial |
$1,046.64
|
| Rate for Payer: First Health Commercial |
$1,197.96
|
| Rate for Payer: Humana Commercial |
$1,071.86
|
| Rate for Payer: Humana KY Medicaid |
$433.66
|
| Rate for Payer: Kentucky WC Medicaid |
$438.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,034.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$930.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$378.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$442.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,109.69
|
| Rate for Payer: Ohio Health Group HMO |
$945.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$252.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$163.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$390.91
|
| Rate for Payer: PHCS Commercial |
$1,210.57
|
| Rate for Payer: United Healthcare All Payer |
$1,109.69
|
|
|
INJ FORAMEN EPIDURAL C/T
|
Facility
|
IP
|
$2,728.00
|
|
|
Service Code
|
HCPCS 64479
|
| Hospital Charge Code |
76102321
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$354.64 |
| Max. Negotiated Rate |
$2,618.88 |
| Rate for Payer: Aetna Commercial |
$2,100.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,127.84
|
| Rate for Payer: Cash Price |
$1,364.00
|
| Rate for Payer: Cigna Commercial |
$2,264.24
|
| Rate for Payer: First Health Commercial |
$2,591.60
|
| Rate for Payer: Humana Commercial |
$2,318.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,236.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,013.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$818.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,400.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,046.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$545.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$354.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$845.68
|
| Rate for Payer: PHCS Commercial |
$2,618.88
|
| Rate for Payer: United Healthcare All Payer |
$2,400.64
|
|
|
INJ FORAMEN EPIDURAL C/T
|
Professional
|
Both
|
$2,728.00
|
|
|
Service Code
|
HCPCS 64479
|
| Hospital Charge Code |
76102321
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$66.45 |
| Max. Negotiated Rate |
$2,728.00 |
| Rate for Payer: Aetna Commercial |
$196.13
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$66.45
|
| Rate for Payer: Anthem Medicaid |
$162.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,728.00
|
| Rate for Payer: Cash Price |
$1,364.00
|
| Rate for Payer: Cash Price |
$1,364.00
|
| Rate for Payer: Cigna Commercial |
$332.93
|
| Rate for Payer: Healthspan PPO |
$326.90
|
| Rate for Payer: Humana Medicaid |
$162.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$167.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$166.11
|
| Rate for Payer: Molina Healthcare Passport |
$162.85
|
| Rate for Payer: Multiplan PHCS |
$1,636.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,909.60
|
| Rate for Payer: UHCCP Medicaid |
$69.77
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$164.48
|
|
|
INJ FORAMEN EPIDURAL C/T
|
Facility
|
OP
|
$2,728.00
|
|
|
Service Code
|
HCPCS 64479
|
| Hospital Charge Code |
76102321
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$354.64 |
| Max. Negotiated Rate |
$2,618.88 |
| Rate for Payer: Aetna Commercial |
$2,100.56
|
| Rate for Payer: Anthem Medicaid |
$938.16
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$788.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,127.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,103.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,064.08
|
| Rate for Payer: Cash Price |
$1,364.00
|
| Rate for Payer: Cash Price |
$1,364.00
|
| Rate for Payer: Cigna Commercial |
$2,264.24
|
| Rate for Payer: First Health Commercial |
$2,591.60
|
| Rate for Payer: Humana Commercial |
$2,318.80
|
| Rate for Payer: Humana KY Medicaid |
$938.16
|
| Rate for Payer: Humana Medicare Advantage |
$788.21
|
| Rate for Payer: Kentucky WC Medicaid |
$947.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,236.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,013.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$945.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$956.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,400.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,046.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$545.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$354.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$845.68
|
| Rate for Payer: PHCS Commercial |
$2,618.88
|
| Rate for Payer: United Healthcare All Payer |
$2,400.64
|
|
|
INJ FORAMEN EPIDURAL C/T(P
|
Professional
|
Both
|
$720.00
|
|
|
Service Code
|
HCPCS 64479
|
| Hospital Charge Code |
761P2321
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$66.45 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Aetna Commercial |
$196.13
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$66.45
|
| Rate for Payer: Anthem Medicaid |
$162.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$720.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cigna Commercial |
$332.93
|
| Rate for Payer: Healthspan PPO |
$326.90
|
| Rate for Payer: Humana Medicaid |
$162.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$167.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$166.11
|
| Rate for Payer: Molina Healthcare Passport |
$162.85
|
| Rate for Payer: Multiplan PHCS |
$432.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$504.00
|
| Rate for Payer: UHCCP Medicaid |
$69.77
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$164.48
|
|
|
INJ FORAMEN EPIDURAL C/T(T
|
Facility
|
OP
|
$2,008.00
|
|
|
Service Code
|
HCPCS 64479
|
| Hospital Charge Code |
761T2321
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$261.04 |
| Max. Negotiated Rate |
$1,927.68 |
| Rate for Payer: Aetna Commercial |
$1,546.16
|
| Rate for Payer: Anthem Medicaid |
$690.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$788.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,566.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,103.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,064.08
|
| Rate for Payer: Cash Price |
$1,004.00
|
| Rate for Payer: Cash Price |
$1,004.00
|
| Rate for Payer: Cigna Commercial |
$1,666.64
|
| Rate for Payer: First Health Commercial |
$1,907.60
|
| Rate for Payer: Humana Commercial |
$1,706.80
|
| Rate for Payer: Humana KY Medicaid |
$690.55
|
| Rate for Payer: Humana Medicare Advantage |
$788.21
|
| Rate for Payer: Kentucky WC Medicaid |
$697.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,646.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,481.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$945.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$704.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,767.04
|
| Rate for Payer: Ohio Health Group HMO |
$1,506.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$401.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$622.48
|
| Rate for Payer: PHCS Commercial |
$1,927.68
|
| Rate for Payer: United Healthcare All Payer |
$1,767.04
|
|
|
INJ FORAMEN EPIDURAL C/T(T
|
Facility
|
IP
|
$2,008.00
|
|
|
Service Code
|
HCPCS 64479
|
| Hospital Charge Code |
761T2321
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$261.04 |
| Max. Negotiated Rate |
$1,927.68 |
| Rate for Payer: Aetna Commercial |
$1,546.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,566.24
|
| Rate for Payer: Cash Price |
$1,004.00
|
| Rate for Payer: Cigna Commercial |
$1,666.64
|
| Rate for Payer: First Health Commercial |
$1,907.60
|
| Rate for Payer: Humana Commercial |
$1,706.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,646.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,481.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$602.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,767.04
|
| Rate for Payer: Ohio Health Group HMO |
$1,506.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$401.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$622.48
|
| Rate for Payer: PHCS Commercial |
$1,927.68
|
| Rate for Payer: United Healthcare All Payer |
$1,767.04
|
|
|
INJ FORAMEN EPIDURAL L/S
|
Professional
|
Both
|
$2,652.00
|
|
|
Service Code
|
HCPCS 64483
|
| Hospital Charge Code |
76102323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$56.41 |
| Max. Negotiated Rate |
$2,652.00 |
| Rate for Payer: Aetna Commercial |
$172.61
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$56.41
|
| Rate for Payer: Anthem Medicaid |
$149.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,652.00
|
| Rate for Payer: Cash Price |
$1,326.00
|
| Rate for Payer: Cash Price |
$1,326.00
|
| Rate for Payer: Cigna Commercial |
$299.74
|
| Rate for Payer: Healthspan PPO |
$317.12
|
| Rate for Payer: Humana Medicaid |
$149.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$130.56
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$152.91
|
| Rate for Payer: Molina Healthcare Passport |
$149.91
|
| Rate for Payer: Multiplan PHCS |
$1,591.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,856.40
|
| Rate for Payer: UHCCP Medicaid |
$59.23
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$151.41
|
|
|
INJ FORAMEN EPIDURAL L/S
|
Facility
|
IP
|
$2,652.00
|
|
|
Service Code
|
HCPCS 64483
|
| Hospital Charge Code |
76102323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$344.76 |
| Max. Negotiated Rate |
$2,545.92 |
| Rate for Payer: Aetna Commercial |
$2,042.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,068.56
|
| Rate for Payer: Cash Price |
$1,326.00
|
| Rate for Payer: Cigna Commercial |
$2,201.16
|
| Rate for Payer: First Health Commercial |
$2,519.40
|
| Rate for Payer: Humana Commercial |
$2,254.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,174.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,957.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$795.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,333.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,989.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$530.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$344.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$822.12
|
| Rate for Payer: PHCS Commercial |
$2,545.92
|
| Rate for Payer: United Healthcare All Payer |
$2,333.76
|
|
|
INJ FORAMEN EPIDURAL L/S
|
Facility
|
OP
|
$2,652.00
|
|
|
Service Code
|
HCPCS 64483
|
| Hospital Charge Code |
76102323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$344.76 |
| Max. Negotiated Rate |
$2,545.92 |
| Rate for Payer: Aetna Commercial |
$2,042.04
|
| Rate for Payer: Anthem Medicaid |
$912.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$788.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,068.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,103.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,064.08
|
| Rate for Payer: Cash Price |
$1,326.00
|
| Rate for Payer: Cash Price |
$1,326.00
|
| Rate for Payer: Cigna Commercial |
$2,201.16
|
| Rate for Payer: First Health Commercial |
$2,519.40
|
| Rate for Payer: Humana Commercial |
$2,254.20
|
| Rate for Payer: Humana KY Medicaid |
$912.02
|
| Rate for Payer: Humana Medicare Advantage |
$788.21
|
| Rate for Payer: Kentucky WC Medicaid |
$921.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,174.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,957.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$945.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$930.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,333.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,989.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$530.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$344.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$822.12
|
| Rate for Payer: PHCS Commercial |
$2,545.92
|
| Rate for Payer: United Healthcare All Payer |
$2,333.76
|
|
|
INJ FORAMEN EPIDURAL L/S(P
|
Professional
|
Both
|
$535.00
|
|
|
Service Code
|
HCPCS 64483
|
| Hospital Charge Code |
761P2323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$56.41 |
| Max. Negotiated Rate |
$535.00 |
| Rate for Payer: Aetna Commercial |
$172.61
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$56.41
|
| Rate for Payer: Anthem Medicaid |
$149.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$535.00
|
| Rate for Payer: Cash Price |
$267.50
|
| Rate for Payer: Cash Price |
$267.50
|
| Rate for Payer: Cigna Commercial |
$299.74
|
| Rate for Payer: Healthspan PPO |
$317.12
|
| Rate for Payer: Humana Medicaid |
$149.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$130.56
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$152.91
|
| Rate for Payer: Molina Healthcare Passport |
$149.91
|
| Rate for Payer: Multiplan PHCS |
$321.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$374.50
|
| Rate for Payer: UHCCP Medicaid |
$59.23
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$151.41
|
|
|
INJ FORAMEN EPIDURAL L/S(T
|
Facility
|
IP
|
$2,117.00
|
|
|
Service Code
|
HCPCS 64483
|
| Hospital Charge Code |
761T2323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$275.21 |
| Max. Negotiated Rate |
$2,032.32 |
| Rate for Payer: Aetna Commercial |
$1,630.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,651.26
|
| Rate for Payer: Cash Price |
$1,058.50
|
| Rate for Payer: Cigna Commercial |
$1,757.11
|
| Rate for Payer: First Health Commercial |
$2,011.15
|
| Rate for Payer: Humana Commercial |
$1,799.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,735.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,562.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$635.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,862.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,587.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$423.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$275.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$656.27
|
| Rate for Payer: PHCS Commercial |
$2,032.32
|
| Rate for Payer: United Healthcare All Payer |
$1,862.96
|
|
|
INJ FORAMEN EPIDURAL L/S(T
|
Facility
|
OP
|
$2,117.00
|
|
|
Service Code
|
HCPCS 64483
|
| Hospital Charge Code |
761T2323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$275.21 |
| Max. Negotiated Rate |
$2,032.32 |
| Rate for Payer: Aetna Commercial |
$1,630.09
|
| Rate for Payer: Anthem Medicaid |
$728.04
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$788.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,651.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,103.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,064.08
|
| Rate for Payer: Cash Price |
$1,058.50
|
| Rate for Payer: Cash Price |
$1,058.50
|
| Rate for Payer: Cigna Commercial |
$1,757.11
|
| Rate for Payer: First Health Commercial |
$2,011.15
|
| Rate for Payer: Humana Commercial |
$1,799.45
|
| Rate for Payer: Humana KY Medicaid |
$728.04
|
| Rate for Payer: Humana Medicare Advantage |
$788.21
|
| Rate for Payer: Kentucky WC Medicaid |
$735.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,735.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,562.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$945.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$742.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,862.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,587.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$423.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$275.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$656.27
|
| Rate for Payer: PHCS Commercial |
$2,032.32
|
| Rate for Payer: United Healthcare All Payer |
$1,862.96
|
|
