|
INJ 1 TENDON SHEATH LIGAMENT(T
|
Facility
|
IP
|
$371.00
|
|
|
Service Code
|
HCPCS 20550
|
| Hospital Charge Code |
761T0337
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$111.30 |
| Max. Negotiated Rate |
$356.16 |
| Rate for Payer: Aetna Commercial |
$285.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$289.38
|
| Rate for Payer: Cash Price |
$185.50
|
| Rate for Payer: Cigna Commercial |
$307.93
|
| Rate for Payer: First Health Commercial |
$352.45
|
| Rate for Payer: Humana Commercial |
$315.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$304.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$273.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$111.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$326.48
|
| Rate for Payer: Ohio Health Group HMO |
$278.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$296.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$322.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$255.99
|
| Rate for Payer: PHCS Commercial |
$356.16
|
| Rate for Payer: United Healthcare All Payer |
$326.48
|
|
|
INJ 1 TENDON SHEATH LIGAMENT(T
|
Facility
|
OP
|
$349.00
|
|
|
Service Code
|
HCPCS 20550
|
| Hospital Charge Code |
761T2847
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$120.02 |
| Max. Negotiated Rate |
$381.85 |
| Rate for Payer: Aetna Commercial |
$268.73
|
| Rate for Payer: Anthem Medicaid |
$120.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$272.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$272.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$381.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$368.21
|
| Rate for Payer: Cash Price |
$174.50
|
| Rate for Payer: Cash Price |
$174.50
|
| Rate for Payer: Cigna Commercial |
$289.67
|
| Rate for Payer: First Health Commercial |
$331.55
|
| Rate for Payer: Humana Commercial |
$296.65
|
| Rate for Payer: Humana KY Medicaid |
$120.02
|
| Rate for Payer: Humana Medicare Advantage |
$272.75
|
| Rate for Payer: Kentucky WC Medicaid |
$121.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$286.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$257.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$327.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$122.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$307.12
|
| Rate for Payer: Ohio Health Group HMO |
$261.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$279.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$303.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$240.81
|
| Rate for Payer: PHCS Commercial |
$335.04
|
| Rate for Payer: United Healthcare All Payer |
$307.12
|
|
|
INJ 1 TENDON SHEATH LIGAMENT(T
|
Facility
|
IP
|
$349.00
|
|
|
Service Code
|
HCPCS 20550
|
| Hospital Charge Code |
761T2847
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$104.70 |
| Max. Negotiated Rate |
$335.04 |
| Rate for Payer: Aetna Commercial |
$268.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$272.22
|
| Rate for Payer: Cash Price |
$174.50
|
| Rate for Payer: Cigna Commercial |
$289.67
|
| Rate for Payer: First Health Commercial |
$331.55
|
| Rate for Payer: Humana Commercial |
$296.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$286.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$257.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$104.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$307.12
|
| Rate for Payer: Ohio Health Group HMO |
$261.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$279.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$303.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$240.81
|
| Rate for Payer: PHCS Commercial |
$335.04
|
| Rate for Payer: United Healthcare All Payer |
$307.12
|
|
|
INJ ANES LMBR/THRC PARAV SYM(P
|
Professional
|
Both
|
$465.00
|
|
|
Service Code
|
HCPCS 64520
|
| Hospital Charge Code |
761P2335
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$51.38 |
| Max. Negotiated Rate |
$279.00 |
| Rate for Payer: Aetna Commercial |
$122.12
|
| Rate for Payer: Ambetter Exchange |
$79.54
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$51.38
|
| Rate for Payer: Anthem Medicaid |
$63.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$79.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$79.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$95.45
|
| Rate for Payer: Cash Price |
$232.50
|
| Rate for Payer: Cash Price |
$232.50
|
| Rate for Payer: Cigna Commercial |
$238.06
|
| Rate for Payer: Healthspan PPO |
$218.12
|
| Rate for Payer: Humana Medicaid |
$63.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$99.41
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$79.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$79.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$64.32
|
| Rate for Payer: Molina Healthcare Passport |
$63.06
|
| Rate for Payer: Multiplan PHCS |
$279.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$103.40
|
| Rate for Payer: UHCCP Medicaid |
$53.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$63.69
|
| Rate for Payer: Wellcare Medicare Advantage |
$79.54
|
|
|
INJ ANES LMBR/THRC PARAV SYMP
|
Professional
|
Both
|
$2,517.50
|
|
|
Service Code
|
HCPCS 64520
|
| Hospital Charge Code |
76102335
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$51.38 |
| Max. Negotiated Rate |
$1,510.50 |
| Rate for Payer: Aetna Commercial |
$122.12
|
| Rate for Payer: Ambetter Exchange |
$79.54
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$51.38
|
| Rate for Payer: Anthem Medicaid |
$63.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$79.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$79.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$95.45
|
| Rate for Payer: Cash Price |
$1,258.75
|
| Rate for Payer: Cash Price |
$1,258.75
|
| Rate for Payer: Cigna Commercial |
$238.06
|
| Rate for Payer: Healthspan PPO |
$218.12
|
| Rate for Payer: Humana Medicaid |
$63.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$99.41
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$79.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$79.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$64.32
|
| Rate for Payer: Molina Healthcare Passport |
$63.06
|
| Rate for Payer: Multiplan PHCS |
$1,510.50
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$103.40
|
| Rate for Payer: UHCCP Medicaid |
$53.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$63.69
|
| Rate for Payer: Wellcare Medicare Advantage |
$79.54
|
|
|
INJ ANES LMBR/THRC PARAV SYMP
|
Facility
|
IP
|
$2,517.50
|
|
|
Service Code
|
HCPCS 64520
|
| Hospital Charge Code |
76102335
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$755.25 |
| Max. Negotiated Rate |
$2,416.80 |
| Rate for Payer: Aetna Commercial |
$1,938.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,963.65
|
| Rate for Payer: Cash Price |
$1,258.75
|
| Rate for Payer: Cigna Commercial |
$2,089.53
|
| Rate for Payer: First Health Commercial |
$2,391.62
|
| Rate for Payer: Humana Commercial |
$2,139.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,064.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,857.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$755.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,215.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,888.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,014.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,190.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,737.08
|
| Rate for Payer: PHCS Commercial |
$2,416.80
|
| Rate for Payer: United Healthcare All Payer |
$2,215.40
|
|
|
INJ ANES LMBR/THRC PARAV SYMP
|
Facility
|
OP
|
$2,517.50
|
|
|
Service Code
|
HCPCS 64520
|
| Hospital Charge Code |
76102335
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$822.61 |
| Max. Negotiated Rate |
$2,416.80 |
| Rate for Payer: Aetna Commercial |
$1,938.47
|
| Rate for Payer: Anthem Medicaid |
$865.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$822.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,963.65
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,151.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,110.52
|
| Rate for Payer: Cash Price |
$1,258.75
|
| Rate for Payer: Cash Price |
$1,258.75
|
| Rate for Payer: Cigna Commercial |
$2,089.53
|
| Rate for Payer: First Health Commercial |
$2,391.62
|
| Rate for Payer: Humana Commercial |
$2,139.88
|
| Rate for Payer: Humana KY Medicaid |
$865.77
|
| Rate for Payer: Humana Medicare Advantage |
$822.61
|
| Rate for Payer: Kentucky WC Medicaid |
$874.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,064.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,857.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$987.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$883.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,215.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,888.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,014.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,190.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,737.08
|
| Rate for Payer: PHCS Commercial |
$2,416.80
|
| Rate for Payer: United Healthcare All Payer |
$2,215.40
|
|
|
INJ ANES LMBR/THRC PARAV SYM(T
|
Facility
|
OP
|
$2,052.50
|
|
|
Service Code
|
HCPCS 64520
|
| Hospital Charge Code |
761T2335
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$705.85 |
| Max. Negotiated Rate |
$1,970.40 |
| Rate for Payer: Aetna Commercial |
$1,580.42
|
| Rate for Payer: Anthem Medicaid |
$705.85
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$822.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,600.95
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,151.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,110.52
|
| Rate for Payer: Cash Price |
$1,026.25
|
| Rate for Payer: Cash Price |
$1,026.25
|
| Rate for Payer: Cigna Commercial |
$1,703.58
|
| Rate for Payer: First Health Commercial |
$1,949.88
|
| Rate for Payer: Humana Commercial |
$1,744.62
|
| Rate for Payer: Humana KY Medicaid |
$705.85
|
| Rate for Payer: Humana Medicare Advantage |
$822.61
|
| Rate for Payer: Kentucky WC Medicaid |
$713.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,683.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,514.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$987.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$720.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,806.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,539.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,642.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,785.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,416.22
|
| Rate for Payer: PHCS Commercial |
$1,970.40
|
| Rate for Payer: United Healthcare All Payer |
$1,806.20
|
|
|
INJ ANES LMBR/THRC PARAV SYM(T
|
Facility
|
IP
|
$2,052.50
|
|
|
Service Code
|
HCPCS 64520
|
| Hospital Charge Code |
761T2335
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$615.75 |
| Max. Negotiated Rate |
$1,970.40 |
| Rate for Payer: Aetna Commercial |
$1,580.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,600.95
|
| Rate for Payer: Cash Price |
$1,026.25
|
| Rate for Payer: Cigna Commercial |
$1,703.58
|
| Rate for Payer: First Health Commercial |
$1,949.88
|
| Rate for Payer: Humana Commercial |
$1,744.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,683.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,514.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,806.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,539.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,642.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,785.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,416.22
|
| Rate for Payer: PHCS Commercial |
$1,970.40
|
| Rate for Payer: United Healthcare All Payer |
$1,806.20
|
|
|
INJ ANES PERIPHER NERVE BRANCH
|
Facility
|
OP
|
$1,060.00
|
|
|
Service Code
|
HCPCS 64450
|
| Hospital Charge Code |
45000296
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$364.53 |
| Max. Negotiated Rate |
$1,017.60 |
| Rate for Payer: Aetna Commercial |
$816.20
|
| Rate for Payer: Anthem Medicaid |
$364.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$639.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$826.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$895.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$863.82
|
| Rate for Payer: Cash Price |
$530.00
|
| Rate for Payer: Cash Price |
$530.00
|
| Rate for Payer: Cigna Commercial |
$879.80
|
| Rate for Payer: First Health Commercial |
$1,007.00
|
| Rate for Payer: Humana Commercial |
$901.00
|
| Rate for Payer: Humana KY Medicaid |
$364.53
|
| Rate for Payer: Humana Medicare Advantage |
$639.87
|
| Rate for Payer: Kentucky WC Medicaid |
$368.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$869.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$782.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$767.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$371.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$932.80
|
| Rate for Payer: Ohio Health Group HMO |
$795.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$848.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$922.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$731.40
|
| Rate for Payer: PHCS Commercial |
$1,017.60
|
| Rate for Payer: United Healthcare All Payer |
$932.80
|
|
|
INJ ANES PERIPHER NERVE BRANCH
|
Facility
|
OP
|
$1,060.00
|
|
|
Service Code
|
HCPCS 64450
|
| Hospital Charge Code |
761T2319
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$364.53 |
| Max. Negotiated Rate |
$1,017.60 |
| Rate for Payer: Aetna Commercial |
$816.20
|
| Rate for Payer: Anthem Medicaid |
$364.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$639.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$826.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$895.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$863.82
|
| Rate for Payer: Cash Price |
$530.00
|
| Rate for Payer: Cash Price |
$530.00
|
| Rate for Payer: Cigna Commercial |
$879.80
|
| Rate for Payer: First Health Commercial |
$1,007.00
|
| Rate for Payer: Humana Commercial |
$901.00
|
| Rate for Payer: Humana KY Medicaid |
$364.53
|
| Rate for Payer: Humana Medicare Advantage |
$639.87
|
| Rate for Payer: Kentucky WC Medicaid |
$368.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$869.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$782.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$767.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$371.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$932.80
|
| Rate for Payer: Ohio Health Group HMO |
$795.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$848.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$922.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$731.40
|
| Rate for Payer: PHCS Commercial |
$1,017.60
|
| Rate for Payer: United Healthcare All Payer |
$932.80
|
|
|
INJ ANES PERIPHER NERVE BRANCH
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 64450
|
| Hospital Charge Code |
761P2319
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$26.61 |
| Max. Negotiated Rate |
$270.00 |
| Rate for Payer: Aetna Commercial |
$117.51
|
| Rate for Payer: Ambetter Exchange |
$38.98
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$26.61
|
| Rate for Payer: Anthem Medicaid |
$58.88
|
| Rate for Payer: Buckeye Individual/Medicaid |
$38.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$38.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$46.78
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$149.84
|
| Rate for Payer: Healthspan PPO |
$126.05
|
| Rate for Payer: Humana Medicaid |
$58.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$87.60
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$38.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$60.06
|
| Rate for Payer: Molina Healthcare Passport |
$58.88
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$50.67
|
| Rate for Payer: UHCCP Medicaid |
$27.94
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$59.47
|
| Rate for Payer: Wellcare Medicare Advantage |
$38.98
|
|
|
INJ ANES PERIPHER NERVE BRANCH
|
Facility
|
IP
|
$1,060.00
|
|
|
Service Code
|
HCPCS 64450
|
| Hospital Charge Code |
761T2319
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$318.00 |
| Max. Negotiated Rate |
$1,017.60 |
| Rate for Payer: Aetna Commercial |
$816.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$826.80
|
| Rate for Payer: Cash Price |
$530.00
|
| Rate for Payer: Cigna Commercial |
$879.80
|
| Rate for Payer: First Health Commercial |
$1,007.00
|
| Rate for Payer: Humana Commercial |
$901.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$869.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$782.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$318.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$932.80
|
| Rate for Payer: Ohio Health Group HMO |
$795.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$848.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$922.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$731.40
|
| Rate for Payer: PHCS Commercial |
$1,017.60
|
| Rate for Payer: United Healthcare All Payer |
$932.80
|
|
|
INJ ANES PERIPHER NERVE BRANCH
|
Professional
|
Both
|
$1,510.00
|
|
|
Service Code
|
HCPCS 64450
|
| Hospital Charge Code |
76102319
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$26.61 |
| Max. Negotiated Rate |
$906.00 |
| Rate for Payer: Aetna Commercial |
$117.51
|
| Rate for Payer: Ambetter Exchange |
$38.98
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$26.61
|
| Rate for Payer: Anthem Medicaid |
$58.88
|
| Rate for Payer: Buckeye Individual/Medicaid |
$38.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$38.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$46.78
|
| Rate for Payer: Cash Price |
$755.00
|
| Rate for Payer: Cash Price |
$755.00
|
| Rate for Payer: Cigna Commercial |
$149.84
|
| Rate for Payer: Healthspan PPO |
$126.05
|
| Rate for Payer: Humana Medicaid |
$58.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$87.60
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$38.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$60.06
|
| Rate for Payer: Molina Healthcare Passport |
$58.88
|
| Rate for Payer: Multiplan PHCS |
$906.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$50.67
|
| Rate for Payer: UHCCP Medicaid |
$27.94
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$59.47
|
| Rate for Payer: Wellcare Medicare Advantage |
$38.98
|
|
|
INJ ANES PERIPHER NERVE BRANCH
|
Facility
|
OP
|
$1,510.00
|
|
|
Service Code
|
HCPCS 64450
|
| Hospital Charge Code |
76102319
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$519.29 |
| Max. Negotiated Rate |
$1,449.60 |
| Rate for Payer: Aetna Commercial |
$1,162.70
|
| Rate for Payer: Anthem Medicaid |
$519.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$639.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,177.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$895.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$863.82
|
| Rate for Payer: Cash Price |
$755.00
|
| Rate for Payer: Cash Price |
$755.00
|
| Rate for Payer: Cigna Commercial |
$1,253.30
|
| Rate for Payer: First Health Commercial |
$1,434.50
|
| Rate for Payer: Humana Commercial |
$1,283.50
|
| Rate for Payer: Humana KY Medicaid |
$519.29
|
| Rate for Payer: Humana Medicare Advantage |
$639.87
|
| Rate for Payer: Kentucky WC Medicaid |
$524.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,238.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,114.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$767.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$529.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,328.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,132.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,208.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,313.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,041.90
|
| Rate for Payer: PHCS Commercial |
$1,449.60
|
| Rate for Payer: United Healthcare All Payer |
$1,328.80
|
|
|
INJ ANES PERIPHER NERVE BRANCH
|
Facility
|
IP
|
$1,510.00
|
|
|
Service Code
|
HCPCS 64450
|
| Hospital Charge Code |
76102319
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$453.00 |
| Max. Negotiated Rate |
$1,449.60 |
| Rate for Payer: Aetna Commercial |
$1,162.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,177.80
|
| Rate for Payer: Cash Price |
$755.00
|
| Rate for Payer: Cigna Commercial |
$1,253.30
|
| Rate for Payer: First Health Commercial |
$1,434.50
|
| Rate for Payer: Humana Commercial |
$1,283.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,238.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,114.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$453.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,328.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,132.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,208.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,313.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,041.90
|
| Rate for Payer: PHCS Commercial |
$1,449.60
|
| Rate for Payer: United Healthcare All Payer |
$1,328.80
|
|
|
INJ ANES PERIPHER NERVE BRANCH
|
Facility
|
IP
|
$1,060.00
|
|
|
Service Code
|
HCPCS 64450
|
| Hospital Charge Code |
45000296
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$318.00 |
| Max. Negotiated Rate |
$1,017.60 |
| Rate for Payer: Aetna Commercial |
$816.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$826.80
|
| Rate for Payer: Cash Price |
$530.00
|
| Rate for Payer: Cigna Commercial |
$879.80
|
| Rate for Payer: First Health Commercial |
$1,007.00
|
| Rate for Payer: Humana Commercial |
$901.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$869.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$782.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$318.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$932.80
|
| Rate for Payer: Ohio Health Group HMO |
$795.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$848.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$922.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$731.40
|
| Rate for Payer: PHCS Commercial |
$1,017.60
|
| Rate for Payer: United Healthcare All Payer |
$932.80
|
|
|
INJ BUPIVICAINE HYDRO 30ML
|
Facility
|
OP
|
$0.76
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
63600119
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Aetna Commercial |
$0.59
|
| Rate for Payer: Anthem Medicaid |
$0.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.59
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna Commercial |
$0.63
|
| Rate for Payer: First Health Commercial |
$0.72
|
| Rate for Payer: Humana Commercial |
$0.65
|
| Rate for Payer: Humana KY Medicaid |
$0.26
|
| Rate for Payer: Kentucky WC Medicaid |
$0.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.67
|
| Rate for Payer: Ohio Health Group HMO |
$0.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.52
|
| Rate for Payer: PHCS Commercial |
$0.73
|
| Rate for Payer: United Healthcare All Payer |
$0.67
|
|
|
INJ BUPIVICAINE HYDRO 30ML
|
Facility
|
IP
|
$0.76
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
636T0119
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Aetna Commercial |
$0.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.59
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna Commercial |
$0.63
|
| Rate for Payer: First Health Commercial |
$0.72
|
| Rate for Payer: Humana Commercial |
$0.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.67
|
| Rate for Payer: Ohio Health Group HMO |
$0.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.52
|
| Rate for Payer: PHCS Commercial |
$0.73
|
| Rate for Payer: United Healthcare All Payer |
$0.67
|
|
|
INJ BUPIVICAINE HYDRO 30ML
|
Facility
|
IP
|
$0.76
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
63600119
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Aetna Commercial |
$0.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.59
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna Commercial |
$0.63
|
| Rate for Payer: First Health Commercial |
$0.72
|
| Rate for Payer: Humana Commercial |
$0.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.67
|
| Rate for Payer: Ohio Health Group HMO |
$0.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.52
|
| Rate for Payer: PHCS Commercial |
$0.73
|
| Rate for Payer: United Healthcare All Payer |
$0.67
|
|
|
INJ BUPIVICAINE HYDRO 30ML
|
Facility
|
OP
|
$0.76
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
636T0119
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Aetna Commercial |
$0.59
|
| Rate for Payer: Anthem Medicaid |
$0.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.59
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna Commercial |
$0.63
|
| Rate for Payer: First Health Commercial |
$0.72
|
| Rate for Payer: Humana Commercial |
$0.65
|
| Rate for Payer: Humana KY Medicaid |
$0.26
|
| Rate for Payer: Kentucky WC Medicaid |
$0.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.67
|
| Rate for Payer: Ohio Health Group HMO |
$0.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.52
|
| Rate for Payer: PHCS Commercial |
$0.73
|
| Rate for Payer: United Healthcare All Payer |
$0.67
|
|
|
INJ BUPIVICAINE HYDRO 30ML
|
Professional
|
Both
|
$0.76
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
63600119
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Ambetter Exchange |
$0.01
|
| Rate for Payer: Buckeye Individual/Medicaid |
$0.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$0.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.01
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$0.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Multiplan PHCS |
$0.46
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$0.01
|
| Rate for Payer: UHCCP Medicaid |
$0.27
|
| Rate for Payer: Wellcare Medicare Advantage |
$0.01
|
|
|
INJECTAFER 1MG [750MG/15ML VL]
|
Facility
|
OP
|
$3,222.59
|
|
|
Service Code
|
HCPCS J1439
|
| Hospital Charge Code |
25002057
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$3,093.69 |
| Rate for Payer: Aetna Commercial |
$2,481.39
|
| Rate for Payer: Anthem Medicaid |
$1,108.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,513.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$1.54
|
| Rate for Payer: Cash Price |
$1,611.30
|
| Rate for Payer: Cash Price |
$1,611.30
|
| Rate for Payer: Cigna Commercial |
$2,674.75
|
| Rate for Payer: First Health Commercial |
$3,061.46
|
| Rate for Payer: Humana Commercial |
$2,739.20
|
| Rate for Payer: Humana KY Medicaid |
$1,108.25
|
| Rate for Payer: Humana Medicare Advantage |
$1.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,119.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,642.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,378.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,130.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,835.88
|
| Rate for Payer: Ohio Health Group HMO |
$2,416.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,578.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,803.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,223.59
|
| Rate for Payer: PHCS Commercial |
$3,093.69
|
| Rate for Payer: United Healthcare All Payer |
$2,835.88
|
|
|
INJECTAFER 1MG [750MG/15ML VL]
|
Facility
|
IP
|
$3,222.59
|
|
|
Service Code
|
HCPCS J1439
|
| Hospital Charge Code |
25002057
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$966.78 |
| Max. Negotiated Rate |
$3,093.69 |
| Rate for Payer: Aetna Commercial |
$2,481.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,513.62
|
| Rate for Payer: Cash Price |
$1,611.30
|
| Rate for Payer: Cigna Commercial |
$2,674.75
|
| Rate for Payer: First Health Commercial |
$3,061.46
|
| Rate for Payer: Humana Commercial |
$2,739.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,642.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,378.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$966.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,835.88
|
| Rate for Payer: Ohio Health Group HMO |
$2,416.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,578.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,803.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,223.59
|
| Rate for Payer: PHCS Commercial |
$3,093.69
|
| Rate for Payer: United Healthcare All Payer |
$2,835.88
|
|
|
INJECT CONGENITAL CARD CATH
|
Facility
|
IP
|
$337.00
|
|
|
Service Code
|
HCPCS 93563
|
| Hospital Charge Code |
48100075
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$101.10 |
| Max. Negotiated Rate |
$323.52 |
| Rate for Payer: Aetna Commercial |
$259.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$262.86
|
| Rate for Payer: Cash Price |
$168.50
|
| Rate for Payer: Cigna Commercial |
$279.71
|
| Rate for Payer: First Health Commercial |
$320.15
|
| Rate for Payer: Humana Commercial |
$286.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$276.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$248.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$101.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$296.56
|
| Rate for Payer: Ohio Health Group HMO |
$252.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$269.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$293.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$232.53
|
| Rate for Payer: PHCS Commercial |
$323.52
|
| Rate for Payer: United Healthcare All Payer |
$296.56
|
|
