|
INJ FOR HIP XRAY WANESTH
|
Facility
|
OP
|
$2,425.38
|
|
|
Service Code
|
HCPCS 27095
|
| Hospital Charge Code |
76100777
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$315.30 |
| Max. Negotiated Rate |
$2,328.36 |
| Rate for Payer: Aetna Commercial |
$1,867.54
|
| Rate for Payer: Anthem Medicaid |
$834.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,891.80
|
| Rate for Payer: Cash Price |
$1,212.69
|
| Rate for Payer: Cigna Commercial |
$2,013.07
|
| Rate for Payer: First Health Commercial |
$2,304.11
|
| Rate for Payer: Humana Commercial |
$2,061.57
|
| Rate for Payer: Humana KY Medicaid |
$834.09
|
| Rate for Payer: Kentucky WC Medicaid |
$842.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,988.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,789.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$727.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$850.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,134.33
|
| Rate for Payer: Ohio Health Group HMO |
$1,819.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$485.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$315.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$751.87
|
| Rate for Payer: PHCS Commercial |
$2,328.36
|
| Rate for Payer: United Healthcare All Payer |
$2,134.33
|
|
|
INJ FOR HIP XRAY WANESTH
|
Facility
|
IP
|
$2,425.38
|
|
|
Service Code
|
HCPCS 27095
|
| Hospital Charge Code |
76100777
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$315.30 |
| Max. Negotiated Rate |
$2,328.36 |
| Rate for Payer: Aetna Commercial |
$1,867.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,891.80
|
| Rate for Payer: Cash Price |
$1,212.69
|
| Rate for Payer: Cigna Commercial |
$2,013.07
|
| Rate for Payer: First Health Commercial |
$2,304.11
|
| Rate for Payer: Humana Commercial |
$2,061.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,988.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,789.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$727.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,134.33
|
| Rate for Payer: Ohio Health Group HMO |
$1,819.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$485.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$315.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$751.87
|
| Rate for Payer: PHCS Commercial |
$2,328.36
|
| Rate for Payer: United Healthcare All Payer |
$2,134.33
|
|
|
INJ FOR HIP XRAY WANESTH
|
Professional
|
Both
|
$2,425.38
|
|
|
Service Code
|
HCPCS 27095
|
| Hospital Charge Code |
76100777
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$57.45 |
| Max. Negotiated Rate |
$2,425.38 |
| Rate for Payer: Aetna Commercial |
$126.53
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$57.45
|
| Rate for Payer: Anthem Medicaid |
$72.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,425.38
|
| Rate for Payer: Cash Price |
$1,212.69
|
| Rate for Payer: Cash Price |
$1,212.69
|
| Rate for Payer: Cigna Commercial |
$130.87
|
| Rate for Payer: Healthspan PPO |
$294.47
|
| Rate for Payer: Humana Medicaid |
$72.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$102.73
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$73.56
|
| Rate for Payer: Molina Healthcare Passport |
$72.12
|
| Rate for Payer: Multiplan PHCS |
$1,455.23
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,697.77
|
| Rate for Payer: UHCCP Medicaid |
$60.32
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.84
|
|
|
INJ FOR HIP XRAY WANESTH(P
|
Professional
|
Both
|
$850.00
|
|
|
Service Code
|
HCPCS 27095
|
| Hospital Charge Code |
761P0777
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$57.45 |
| Max. Negotiated Rate |
$850.00 |
| Rate for Payer: Aetna Commercial |
$126.53
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$57.45
|
| Rate for Payer: Anthem Medicaid |
$72.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$850.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$130.87
|
| Rate for Payer: Healthspan PPO |
$294.47
|
| Rate for Payer: Humana Medicaid |
$72.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$102.73
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$73.56
|
| Rate for Payer: Molina Healthcare Passport |
$72.12
|
| Rate for Payer: Multiplan PHCS |
$510.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$595.00
|
| Rate for Payer: UHCCP Medicaid |
$60.32
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.84
|
|
|
INJ FOR HIP XRAY WANESTH(T
|
Facility
|
OP
|
$1,575.38
|
|
|
Service Code
|
HCPCS 27095
|
| Hospital Charge Code |
761T0777
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$204.80 |
| Max. Negotiated Rate |
$1,512.36 |
| Rate for Payer: Aetna Commercial |
$1,213.04
|
| Rate for Payer: Anthem Medicaid |
$541.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,228.80
|
| Rate for Payer: Cash Price |
$787.69
|
| Rate for Payer: Cigna Commercial |
$1,307.57
|
| Rate for Payer: First Health Commercial |
$1,496.61
|
| Rate for Payer: Humana Commercial |
$1,339.07
|
| Rate for Payer: Humana KY Medicaid |
$541.77
|
| Rate for Payer: Kentucky WC Medicaid |
$547.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,291.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,162.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$472.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$552.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,386.33
|
| Rate for Payer: Ohio Health Group HMO |
$1,181.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$315.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$204.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$488.37
|
| Rate for Payer: PHCS Commercial |
$1,512.36
|
| Rate for Payer: United Healthcare All Payer |
$1,386.33
|
|
|
INJ FOR HIP XRAY WANESTH(T
|
Facility
|
IP
|
$1,575.38
|
|
|
Service Code
|
HCPCS 27095
|
| Hospital Charge Code |
761T0777
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$204.80 |
| Max. Negotiated Rate |
$1,512.36 |
| Rate for Payer: Aetna Commercial |
$1,213.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,228.80
|
| Rate for Payer: Cash Price |
$787.69
|
| Rate for Payer: Cigna Commercial |
$1,307.57
|
| Rate for Payer: First Health Commercial |
$1,496.61
|
| Rate for Payer: Humana Commercial |
$1,339.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,291.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,162.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$472.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,386.33
|
| Rate for Payer: Ohio Health Group HMO |
$1,181.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$315.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$204.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$488.37
|
| Rate for Payer: PHCS Commercial |
$1,512.36
|
| Rate for Payer: United Healthcare All Payer |
$1,386.33
|
|
|
INJ MAMMARY DUCTOGRAM
|
Professional
|
Both
|
$1,262.00
|
|
|
Service Code
|
HCPCS 19030
|
| Hospital Charge Code |
76100277
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$38.07 |
| Max. Negotiated Rate |
$1,262.00 |
| Rate for Payer: Aetna Commercial |
$125.25
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$38.07
|
| Rate for Payer: Anthem Medicaid |
$59.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,262.00
|
| Rate for Payer: Cash Price |
$631.00
|
| Rate for Payer: Cash Price |
$631.00
|
| Rate for Payer: Cigna Commercial |
$113.06
|
| Rate for Payer: Healthspan PPO |
$193.01
|
| Rate for Payer: Humana Medicaid |
$59.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$100.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$60.19
|
| Rate for Payer: Molina Healthcare Passport |
$59.01
|
| Rate for Payer: Multiplan PHCS |
$757.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$883.40
|
| Rate for Payer: UHCCP Medicaid |
$39.97
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$59.60
|
|
|
INJ MAMMARY DUCTOGRAM
|
Facility
|
OP
|
$1,262.00
|
|
|
Service Code
|
HCPCS 19030
|
| Hospital Charge Code |
76100277
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$164.06 |
| Max. Negotiated Rate |
$1,211.52 |
| Rate for Payer: Aetna Commercial |
$971.74
|
| Rate for Payer: Anthem Medicaid |
$434.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$984.36
|
| Rate for Payer: Cash Price |
$631.00
|
| Rate for Payer: Cigna Commercial |
$1,047.46
|
| Rate for Payer: First Health Commercial |
$1,198.90
|
| Rate for Payer: Humana Commercial |
$1,072.70
|
| Rate for Payer: Humana KY Medicaid |
$434.00
|
| Rate for Payer: Kentucky WC Medicaid |
$438.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,034.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$931.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$378.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$442.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,110.56
|
| Rate for Payer: Ohio Health Group HMO |
$946.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$252.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$164.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$391.22
|
| Rate for Payer: PHCS Commercial |
$1,211.52
|
| Rate for Payer: United Healthcare All Payer |
$1,110.56
|
|
|
INJ MAMMARY DUCTOGRAM
|
Facility
|
IP
|
$1,262.00
|
|
|
Service Code
|
HCPCS 19030
|
| Hospital Charge Code |
76100277
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$164.06 |
| Max. Negotiated Rate |
$1,211.52 |
| Rate for Payer: Aetna Commercial |
$971.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$984.36
|
| Rate for Payer: Cash Price |
$631.00
|
| Rate for Payer: Cigna Commercial |
$1,047.46
|
| Rate for Payer: First Health Commercial |
$1,198.90
|
| Rate for Payer: Humana Commercial |
$1,072.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,034.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$931.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$378.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,110.56
|
| Rate for Payer: Ohio Health Group HMO |
$946.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$252.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$164.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$391.22
|
| Rate for Payer: PHCS Commercial |
$1,211.52
|
| Rate for Payer: United Healthcare All Payer |
$1,110.56
|
|
|
INJ MAMMARY DUCTOGRAM(P
|
Professional
|
Both
|
$650.00
|
|
|
Service Code
|
HCPCS 19030
|
| Hospital Charge Code |
761P0277
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$38.07 |
| Max. Negotiated Rate |
$650.00 |
| Rate for Payer: Aetna Commercial |
$125.25
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$38.07
|
| Rate for Payer: Anthem Medicaid |
$59.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$650.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$113.06
|
| Rate for Payer: Healthspan PPO |
$193.01
|
| Rate for Payer: Humana Medicaid |
$59.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$100.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$60.19
|
| Rate for Payer: Molina Healthcare Passport |
$59.01
|
| Rate for Payer: Multiplan PHCS |
$390.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$455.00
|
| Rate for Payer: UHCCP Medicaid |
$39.97
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$59.60
|
|
|
INJ MAMMARY DUCTOGRAM(T
|
Facility
|
OP
|
$612.00
|
|
|
Service Code
|
HCPCS 19030
|
| Hospital Charge Code |
761T0277
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$79.56 |
| Max. Negotiated Rate |
$587.52 |
| Rate for Payer: Aetna Commercial |
$471.24
|
| Rate for Payer: Anthem Medicaid |
$210.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$477.36
|
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: Cigna Commercial |
$507.96
|
| Rate for Payer: First Health Commercial |
$581.40
|
| Rate for Payer: Humana Commercial |
$520.20
|
| Rate for Payer: Humana KY Medicaid |
$210.47
|
| Rate for Payer: Kentucky WC Medicaid |
$212.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$501.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$451.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$183.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$214.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$538.56
|
| Rate for Payer: Ohio Health Group HMO |
$459.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$122.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$189.72
|
| Rate for Payer: PHCS Commercial |
$587.52
|
| Rate for Payer: United Healthcare All Payer |
$538.56
|
|
|
INJ MAMMARY DUCTOGRAM(T
|
Facility
|
IP
|
$612.00
|
|
|
Service Code
|
HCPCS 19030
|
| Hospital Charge Code |
761T0277
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$79.56 |
| Max. Negotiated Rate |
$587.52 |
| Rate for Payer: Aetna Commercial |
$471.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$477.36
|
| Rate for Payer: Cash Price |
$306.00
|
| Rate for Payer: Cigna Commercial |
$507.96
|
| Rate for Payer: First Health Commercial |
$581.40
|
| Rate for Payer: Humana Commercial |
$520.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$501.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$451.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$183.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$538.56
|
| Rate for Payer: Ohio Health Group HMO |
$459.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$122.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$189.72
|
| Rate for Payer: PHCS Commercial |
$587.52
|
| Rate for Payer: United Healthcare All Payer |
$538.56
|
|
|
INJ METHYLENE BLUE LUNG LESION
|
Facility
|
OP
|
$206.00
|
|
|
Service Code
|
HCPCS 96379
|
| Hospital Charge Code |
26000014
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$26.78 |
| Max. Negotiated Rate |
$197.76 |
| Rate for Payer: Aetna Commercial |
$158.62
|
| Rate for Payer: Anthem Medicaid |
$70.84
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$41.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$160.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$57.51
|
| Rate for Payer: CareSource Just4Me Medicare |
$55.46
|
| Rate for Payer: Cash Price |
$103.00
|
| Rate for Payer: Cash Price |
$103.00
|
| Rate for Payer: Cigna Commercial |
$170.98
|
| Rate for Payer: First Health Commercial |
$195.70
|
| Rate for Payer: Humana Commercial |
$175.10
|
| Rate for Payer: Humana KY Medicaid |
$70.84
|
| Rate for Payer: Humana Medicare Advantage |
$41.08
|
| Rate for Payer: Kentucky WC Medicaid |
$71.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$168.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$152.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$72.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$181.28
|
| Rate for Payer: Ohio Health Group HMO |
$154.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$41.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.86
|
| Rate for Payer: PHCS Commercial |
$197.76
|
| Rate for Payer: United Healthcare All Payer |
$181.28
|
|
|
INJ METHYLENE BLUE LUNG LESION
|
Facility
|
IP
|
$206.00
|
|
|
Service Code
|
HCPCS 96379
|
| Hospital Charge Code |
26000014
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$26.78 |
| Max. Negotiated Rate |
$197.76 |
| Rate for Payer: Aetna Commercial |
$158.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$160.68
|
| Rate for Payer: Cash Price |
$103.00
|
| Rate for Payer: Cigna Commercial |
$170.98
|
| Rate for Payer: First Health Commercial |
$195.70
|
| Rate for Payer: Humana Commercial |
$175.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$168.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$152.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$181.28
|
| Rate for Payer: Ohio Health Group HMO |
$154.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$41.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.86
|
| Rate for Payer: PHCS Commercial |
$197.76
|
| Rate for Payer: United Healthcare All Payer |
$181.28
|
|
|
INJ METHYLENE BLUE LUNG LESION
|
Professional
|
Both
|
$206.00
|
|
|
Service Code
|
HCPCS 96379
|
| Hospital Charge Code |
26000014
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$206.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$206.00
|
| Rate for Payer: Cash Price |
$103.00
|
| Rate for Payer: Cash Price |
$103.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$65.23
|
| Rate for Payer: Multiplan PHCS |
$123.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$144.20
|
| Rate for Payer: UHCCP Medicaid |
$72.10
|
|
|
INJ PARAVERT F JNT 1 LEVER
|
Facility
|
OP
|
$2,164.33
|
|
|
Service Code
|
HCPCS 64493
|
| Hospital Charge Code |
76102329
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$281.36 |
| Max. Negotiated Rate |
$2,077.76 |
| Rate for Payer: Aetna Commercial |
$1,666.53
|
| Rate for Payer: Anthem Medicaid |
$744.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$788.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,688.18
|
| 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 |
$1,082.16
|
| Rate for Payer: Cash Price |
$1,082.16
|
| Rate for Payer: Cigna Commercial |
$1,796.39
|
| Rate for Payer: First Health Commercial |
$2,056.11
|
| Rate for Payer: Humana Commercial |
$1,839.68
|
| Rate for Payer: Humana KY Medicaid |
$744.31
|
| Rate for Payer: Humana Medicare Advantage |
$788.21
|
| Rate for Payer: Kentucky WC Medicaid |
$751.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,774.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,597.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$945.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$759.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,904.61
|
| Rate for Payer: Ohio Health Group HMO |
$1,623.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$432.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$281.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$670.94
|
| Rate for Payer: PHCS Commercial |
$2,077.76
|
| Rate for Payer: United Healthcare All Payer |
$1,904.61
|
|
|
INJ PARAVERT F JNT 1 LEVER
|
Facility
|
IP
|
$2,164.33
|
|
|
Service Code
|
HCPCS 64493
|
| Hospital Charge Code |
76102329
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$281.36 |
| Max. Negotiated Rate |
$2,077.76 |
| Rate for Payer: Aetna Commercial |
$1,666.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,688.18
|
| Rate for Payer: Cash Price |
$1,082.16
|
| Rate for Payer: Cigna Commercial |
$1,796.39
|
| Rate for Payer: First Health Commercial |
$2,056.11
|
| Rate for Payer: Humana Commercial |
$1,839.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,774.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,597.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$649.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,904.61
|
| Rate for Payer: Ohio Health Group HMO |
$1,623.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$432.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$281.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$670.94
|
| Rate for Payer: PHCS Commercial |
$2,077.76
|
| Rate for Payer: United Healthcare All Payer |
$1,904.61
|
|
|
INJ PARAVERT F JNT 1 LEVER
|
Professional
|
Both
|
$2,164.33
|
|
|
Service Code
|
HCPCS 64493
|
| Hospital Charge Code |
76102329
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$45.51 |
| Max. Negotiated Rate |
$2,164.33 |
| Rate for Payer: Aetna Commercial |
$154.68
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$45.51
|
| Rate for Payer: Anthem Medicaid |
$68.79
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,164.33
|
| Rate for Payer: Cash Price |
$1,082.16
|
| Rate for Payer: Cash Price |
$1,082.16
|
| Rate for Payer: Cigna Commercial |
$265.87
|
| Rate for Payer: Healthspan PPO |
$150.80
|
| Rate for Payer: Humana Medicaid |
$68.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$119.20
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$70.17
|
| Rate for Payer: Molina Healthcare Passport |
$68.79
|
| Rate for Payer: Multiplan PHCS |
$1,298.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,515.03
|
| Rate for Payer: UHCCP Medicaid |
$47.79
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$69.48
|
|
|
INJ PARAVERT F JNT 1 LEVER(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 64493
|
| Hospital Charge Code |
761P2329
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$45.51 |
| Max. Negotiated Rate |
$265.87 |
| Rate for Payer: Aetna Commercial |
$154.68
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$45.51
|
| Rate for Payer: Anthem Medicaid |
$68.79
|
| 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 |
$265.87
|
| Rate for Payer: Healthspan PPO |
$150.80
|
| Rate for Payer: Humana Medicaid |
$68.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$119.20
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$70.17
|
| Rate for Payer: Molina Healthcare Passport |
$68.79
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$47.79
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$69.48
|
|
|
INJ PARAVERT F JNT 1 LEVER(T
|
Facility
|
IP
|
$1,914.33
|
|
|
Service Code
|
HCPCS 64493
|
| Hospital Charge Code |
761T2329
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$248.86 |
| Max. Negotiated Rate |
$1,837.76 |
| Rate for Payer: Aetna Commercial |
$1,474.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,493.18
|
| Rate for Payer: Cash Price |
$957.16
|
| Rate for Payer: Cigna Commercial |
$1,588.89
|
| Rate for Payer: First Health Commercial |
$1,818.61
|
| Rate for Payer: Humana Commercial |
$1,627.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,569.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,412.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$574.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,684.61
|
| Rate for Payer: Ohio Health Group HMO |
$1,435.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$382.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$248.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$593.44
|
| Rate for Payer: PHCS Commercial |
$1,837.76
|
| Rate for Payer: United Healthcare All Payer |
$1,684.61
|
|
|
INJ PARAVERT F JNT 1 LEVER(T
|
Facility
|
OP
|
$1,914.33
|
|
|
Service Code
|
HCPCS 64493
|
| Hospital Charge Code |
761T2329
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$248.86 |
| Max. Negotiated Rate |
$1,837.76 |
| Rate for Payer: Aetna Commercial |
$1,474.03
|
| Rate for Payer: Anthem Medicaid |
$658.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$788.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,493.18
|
| 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 |
$957.16
|
| Rate for Payer: Cash Price |
$957.16
|
| Rate for Payer: Cigna Commercial |
$1,588.89
|
| Rate for Payer: First Health Commercial |
$1,818.61
|
| Rate for Payer: Humana Commercial |
$1,627.18
|
| Rate for Payer: Humana KY Medicaid |
$658.34
|
| Rate for Payer: Humana Medicare Advantage |
$788.21
|
| Rate for Payer: Kentucky WC Medicaid |
$665.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,569.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,412.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$945.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$671.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,684.61
|
| Rate for Payer: Ohio Health Group HMO |
$1,435.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$382.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$248.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$593.44
|
| Rate for Payer: PHCS Commercial |
$1,837.76
|
| Rate for Payer: United Healthcare All Payer |
$1,684.61
|
|
|
INJ PARAVERT F JNT 2 LEVER
|
Facility
|
OP
|
$1,202.00
|
|
|
Service Code
|
HCPCS 64494
|
| Hospital Charge Code |
76102330
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$156.26 |
| Max. Negotiated Rate |
$1,153.92 |
| Rate for Payer: Aetna Commercial |
$925.54
|
| Rate for Payer: Anthem Medicaid |
$413.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$937.56
|
| Rate for Payer: Cash Price |
$601.00
|
| Rate for Payer: Cigna Commercial |
$997.66
|
| Rate for Payer: First Health Commercial |
$1,141.90
|
| Rate for Payer: Humana Commercial |
$1,021.70
|
| Rate for Payer: Humana KY Medicaid |
$413.37
|
| Rate for Payer: Kentucky WC Medicaid |
$417.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$985.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$887.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$421.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,057.76
|
| Rate for Payer: Ohio Health Group HMO |
$901.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$240.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$156.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$372.62
|
| Rate for Payer: PHCS Commercial |
$1,153.92
|
| Rate for Payer: United Healthcare All Payer |
$1,057.76
|
|
|
INJ PARAVERT F JNT 2 LEVER
|
Facility
|
IP
|
$1,202.00
|
|
|
Service Code
|
HCPCS 64494
|
| Hospital Charge Code |
76102330
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$156.26 |
| Max. Negotiated Rate |
$1,153.92 |
| Rate for Payer: Aetna Commercial |
$925.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$937.56
|
| Rate for Payer: Cash Price |
$601.00
|
| Rate for Payer: Cigna Commercial |
$997.66
|
| Rate for Payer: First Health Commercial |
$1,141.90
|
| Rate for Payer: Humana Commercial |
$1,021.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$985.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$887.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,057.76
|
| Rate for Payer: Ohio Health Group HMO |
$901.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$240.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$156.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$372.62
|
| Rate for Payer: PHCS Commercial |
$1,153.92
|
| Rate for Payer: United Healthcare All Payer |
$1,057.76
|
|
|
INJ PARAVERT F JNT 2 LEVER
|
Professional
|
Both
|
$1,202.00
|
|
|
Service Code
|
HCPCS 64494
|
| Hospital Charge Code |
76102330
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$25.96 |
| Max. Negotiated Rate |
$1,202.00 |
| Rate for Payer: Aetna Commercial |
$89.89
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$25.96
|
| Rate for Payer: Anthem Medicaid |
$40.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,202.00
|
| Rate for Payer: Cash Price |
$601.00
|
| Rate for Payer: Cash Price |
$601.00
|
| Rate for Payer: Cigna Commercial |
$137.08
|
| Rate for Payer: Healthspan PPO |
$74.40
|
| Rate for Payer: Humana Medicaid |
$40.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$68.04
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$40.86
|
| Rate for Payer: Molina Healthcare Passport |
$40.06
|
| Rate for Payer: Multiplan PHCS |
$721.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$841.40
|
| Rate for Payer: UHCCP Medicaid |
$27.26
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$40.46
|
|
|
INJ PARAVERT F JNT 2 LEVER(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 64494
|
| Hospital Charge Code |
761P2330
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$25.96 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Aetna Commercial |
$89.89
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$25.96
|
| Rate for Payer: Anthem Medicaid |
$40.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$150.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$137.08
|
| Rate for Payer: Healthspan PPO |
$74.40
|
| Rate for Payer: Humana Medicaid |
$40.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$68.04
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$40.86
|
| Rate for Payer: Molina Healthcare Passport |
$40.06
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$27.26
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$40.46
|
|
