|
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: Ambetter Exchange |
$39.01
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$33.88
|
| Rate for Payer: Anthem Medicaid |
$46.38
|
| Rate for Payer: Buckeye Individual/Medicaid |
$39.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$39.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$46.81
|
| 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 |
$75.25
|
| Rate for Payer: Humana Medicaid |
$46.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$51.33
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$39.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$47.31
|
| Rate for Payer: Molina Healthcare Passport |
$46.38
|
| Rate for Payer: Multiplan PHCS |
$54.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$50.71
|
| Rate for Payer: UHCCP Medicaid |
$35.57
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$46.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$39.01
|
|
|
INJECT TRIGGER POINTS 3/>(T
|
Facility
|
OP
|
$687.00
|
|
|
Service Code
|
HCPCS 20553
|
| Hospital Charge Code |
761T0340
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$236.26 |
| Max. Negotiated Rate |
$659.52 |
| Rate for Payer: Aetna Commercial |
$528.99
|
| Rate for Payer: Anthem Medicaid |
$236.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$272.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$535.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$381.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$368.21
|
| Rate for Payer: Cash Price |
$343.50
|
| Rate for Payer: Cash Price |
$343.50
|
| Rate for Payer: Cigna Commercial |
$570.21
|
| Rate for Payer: First Health Commercial |
$652.65
|
| Rate for Payer: Humana Commercial |
$583.95
|
| Rate for Payer: Humana KY Medicaid |
$236.26
|
| Rate for Payer: Humana Medicare Advantage |
$272.75
|
| Rate for Payer: Kentucky WC Medicaid |
$238.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$563.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$507.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$327.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$241.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$604.56
|
| Rate for Payer: Ohio Health Group HMO |
$515.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$549.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$597.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$474.03
|
| Rate for Payer: PHCS Commercial |
$659.52
|
| Rate for Payer: United Healthcare All Payer |
$604.56
|
|
|
INJECT TRIGGER POINTS 3/>(T
|
Facility
|
IP
|
$687.00
|
|
|
Service Code
|
HCPCS 20553
|
| Hospital Charge Code |
761T0340
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$206.10 |
| Max. Negotiated Rate |
$659.52 |
| Rate for Payer: Aetna Commercial |
$528.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$535.86
|
| Rate for Payer: Cash Price |
$343.50
|
| Rate for Payer: Cigna Commercial |
$570.21
|
| Rate for Payer: First Health Commercial |
$652.65
|
| Rate for Payer: Humana Commercial |
$583.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$563.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$507.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$206.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$604.56
|
| Rate for Payer: Ohio Health Group HMO |
$515.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$549.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$597.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$474.03
|
| Rate for Payer: PHCS Commercial |
$659.52
|
| Rate for Payer: United Healthcare All Payer |
$604.56
|
|
|
INJ FORAMEN EPIDURAL ADD-ON
|
Facility
|
IP
|
$1,555.00
|
|
|
Service Code
|
HCPCS 64484
|
| Hospital Charge Code |
76102324
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$466.50 |
| Max. Negotiated Rate |
$1,492.80 |
| Rate for Payer: Aetna Commercial |
$1,197.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,212.90
|
| Rate for Payer: Cash Price |
$777.50
|
| Rate for Payer: Cigna Commercial |
$1,290.65
|
| Rate for Payer: First Health Commercial |
$1,477.25
|
| Rate for Payer: Humana Commercial |
$1,321.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,275.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,147.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$466.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,368.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,166.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,244.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,352.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,072.95
|
| Rate for Payer: PHCS Commercial |
$1,492.80
|
| Rate for Payer: United Healthcare All Payer |
$1,368.40
|
|
|
INJ FORAMEN EPIDURAL ADD-ON
|
Professional
|
Both
|
$1,555.00
|
|
|
Service Code
|
HCPCS 64484
|
| Hospital Charge Code |
76102324
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$41.78 |
| Max. Negotiated Rate |
$933.00 |
| Rate for Payer: Aetna Commercial |
$109.90
|
| Rate for Payer: Ambetter Exchange |
$47.69
|
| 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 Individual/Medicaid |
$47.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$47.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$57.23
|
| Rate for Payer: Cash Price |
$777.50
|
| Rate for Payer: Cash Price |
$777.50
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$47.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.69
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$139.88
|
| Rate for Payer: Molina Healthcare Passport |
$137.14
|
| Rate for Payer: Multiplan PHCS |
$933.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$62.00
|
| Rate for Payer: UHCCP Medicaid |
$43.87
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$138.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$47.69
|
|
|
INJ FORAMEN EPIDURAL ADD-ON
|
Facility
|
OP
|
$1,555.00
|
|
|
Service Code
|
HCPCS 64484
|
| Hospital Charge Code |
76102324
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$466.50 |
| Max. Negotiated Rate |
$1,492.80 |
| Rate for Payer: Aetna Commercial |
$1,197.35
|
| Rate for Payer: Anthem Medicaid |
$534.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,212.90
|
| Rate for Payer: Cash Price |
$777.50
|
| Rate for Payer: Cigna Commercial |
$1,290.65
|
| Rate for Payer: First Health Commercial |
$1,477.25
|
| Rate for Payer: Humana Commercial |
$1,321.75
|
| Rate for Payer: Humana KY Medicaid |
$534.76
|
| Rate for Payer: Kentucky WC Medicaid |
$540.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,275.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,147.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$466.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$545.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,368.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,166.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,244.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,352.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,072.95
|
| Rate for Payer: PHCS Commercial |
$1,492.80
|
| Rate for Payer: United Healthcare All Payer |
$1,368.40
|
|
|
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 |
$162.54 |
| Rate for Payer: Aetna Commercial |
$109.90
|
| Rate for Payer: Ambetter Exchange |
$47.69
|
| 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 Individual/Medicaid |
$47.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$47.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$57.23
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$47.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.69
|
| 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 |
$62.00
|
| Rate for Payer: UHCCP Medicaid |
$43.87
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$138.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$47.69
|
|
|
INJ FORAMEN EPIDURAL ADD-ON(T
|
Facility
|
IP
|
$1,305.00
|
|
|
Service Code
|
HCPCS 64484
|
| Hospital Charge Code |
761T2324
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$391.50 |
| Max. Negotiated Rate |
$1,252.80 |
| Rate for Payer: Aetna Commercial |
$1,004.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,017.90
|
| Rate for Payer: Cash Price |
$652.50
|
| Rate for Payer: Cigna Commercial |
$1,083.15
|
| Rate for Payer: First Health Commercial |
$1,239.75
|
| Rate for Payer: Humana Commercial |
$1,109.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,070.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$963.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$391.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,148.40
|
| Rate for Payer: Ohio Health Group HMO |
$978.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,044.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,135.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$900.45
|
| Rate for Payer: PHCS Commercial |
$1,252.80
|
| Rate for Payer: United Healthcare All Payer |
$1,148.40
|
|
|
INJ FORAMEN EPIDURAL ADD-ON(T
|
Facility
|
OP
|
$1,305.00
|
|
|
Service Code
|
HCPCS 64484
|
| Hospital Charge Code |
761T2324
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$391.50 |
| Max. Negotiated Rate |
$1,252.80 |
| Rate for Payer: Aetna Commercial |
$1,004.85
|
| Rate for Payer: Anthem Medicaid |
$448.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,017.90
|
| Rate for Payer: Cash Price |
$652.50
|
| Rate for Payer: Cigna Commercial |
$1,083.15
|
| Rate for Payer: First Health Commercial |
$1,239.75
|
| Rate for Payer: Humana Commercial |
$1,109.25
|
| Rate for Payer: Humana KY Medicaid |
$448.79
|
| Rate for Payer: Kentucky WC Medicaid |
$453.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,070.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$963.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$391.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$457.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,148.40
|
| Rate for Payer: Ohio Health Group HMO |
$978.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,044.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,135.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$900.45
|
| Rate for Payer: PHCS Commercial |
$1,252.80
|
| Rate for Payer: United Healthcare All Payer |
$1,148.40
|
|
|
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 |
$822.61 |
| 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 |
$822.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,127.84
|
| 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 |
$1,364.00
|
| 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 |
$822.61
|
| 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 |
$987.13
|
| 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 |
$2,182.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,373.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,882.32
|
| Rate for Payer: PHCS Commercial |
$2,618.88
|
| Rate for Payer: United Healthcare All Payer |
$2,400.64
|
|
|
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 |
$818.40 |
| 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 |
$2,182.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,373.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,882.32
|
| 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 |
$1,636.80 |
| Rate for Payer: Aetna Commercial |
$196.13
|
| Rate for Payer: Ambetter Exchange |
$122.93
|
| 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 Individual/Medicaid |
$122.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$122.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$147.52
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$122.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$122.93
|
| 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 |
$159.81
|
| Rate for Payer: UHCCP Medicaid |
$69.77
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$164.48
|
| Rate for Payer: Wellcare Medicare Advantage |
$122.93
|
|
|
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 |
$432.00 |
| Rate for Payer: Aetna Commercial |
$196.13
|
| Rate for Payer: Ambetter Exchange |
$122.93
|
| 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 Individual/Medicaid |
$122.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$122.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$147.52
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$122.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$122.93
|
| 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 |
$159.81
|
| Rate for Payer: UHCCP Medicaid |
$69.77
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$164.48
|
| Rate for Payer: Wellcare Medicare Advantage |
$122.93
|
|
|
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 |
$602.40 |
| 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 |
$1,606.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,746.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,385.52
|
| 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
|
OP
|
$2,008.00
|
|
|
Service Code
|
HCPCS 64479
|
| Hospital Charge Code |
761T2321
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$690.55 |
| 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 |
$822.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,566.24
|
| 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 |
$1,004.00
|
| 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 |
$822.61
|
| 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 |
$987.13
|
| 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 |
$1,606.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,746.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,385.52
|
| Rate for Payer: PHCS Commercial |
$1,927.68
|
| Rate for Payer: United Healthcare All Payer |
$1,767.04
|
|
|
INJ FORAMEN EPIDURAL L/S
|
Facility
|
OP
|
$2,726.00
|
|
|
Service Code
|
HCPCS 64483
|
| Hospital Charge Code |
76102323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$822.61 |
| Max. Negotiated Rate |
$2,616.96 |
| Rate for Payer: Aetna Commercial |
$2,099.02
|
| Rate for Payer: Anthem Medicaid |
$937.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$822.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,126.28
|
| 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 |
$1,363.00
|
| Rate for Payer: Cash Price |
$1,363.00
|
| Rate for Payer: Cigna Commercial |
$2,262.58
|
| Rate for Payer: First Health Commercial |
$2,589.70
|
| Rate for Payer: Humana Commercial |
$2,317.10
|
| Rate for Payer: Humana KY Medicaid |
$937.47
|
| Rate for Payer: Humana Medicare Advantage |
$822.61
|
| Rate for Payer: Kentucky WC Medicaid |
$947.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,235.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,011.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$987.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$956.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,398.88
|
| Rate for Payer: Ohio Health Group HMO |
$2,044.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,180.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,880.94
|
| Rate for Payer: PHCS Commercial |
$2,616.96
|
| Rate for Payer: United Healthcare All Payer |
$2,398.88
|
|
|
INJ FORAMEN EPIDURAL L/S
|
Professional
|
Both
|
$2,726.00
|
|
|
Service Code
|
HCPCS 64483
|
| Hospital Charge Code |
76102323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$56.41 |
| Max. Negotiated Rate |
$1,635.60 |
| Rate for Payer: Aetna Commercial |
$172.61
|
| Rate for Payer: Ambetter Exchange |
$104.23
|
| 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 Individual/Medicaid |
$104.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$104.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$125.08
|
| Rate for Payer: Cash Price |
$1,363.00
|
| Rate for Payer: Cash Price |
$1,363.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$104.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$104.23
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$152.91
|
| Rate for Payer: Molina Healthcare Passport |
$149.91
|
| Rate for Payer: Multiplan PHCS |
$1,635.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$135.50
|
| Rate for Payer: UHCCP Medicaid |
$59.23
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$151.41
|
| Rate for Payer: Wellcare Medicare Advantage |
$104.23
|
|
|
INJ FORAMEN EPIDURAL L/S
|
Facility
|
IP
|
$2,726.00
|
|
|
Service Code
|
HCPCS 64483
|
| Hospital Charge Code |
76102323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$817.80 |
| Max. Negotiated Rate |
$2,616.96 |
| Rate for Payer: Aetna Commercial |
$2,099.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,126.28
|
| Rate for Payer: Cash Price |
$1,363.00
|
| Rate for Payer: Cigna Commercial |
$2,262.58
|
| Rate for Payer: First Health Commercial |
$2,589.70
|
| Rate for Payer: Humana Commercial |
$2,317.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,235.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,011.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$817.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,398.88
|
| Rate for Payer: Ohio Health Group HMO |
$2,044.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,180.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,371.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,880.94
|
| Rate for Payer: PHCS Commercial |
$2,616.96
|
| Rate for Payer: United Healthcare All Payer |
$2,398.88
|
|
|
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 |
$321.00 |
| Rate for Payer: Aetna Commercial |
$172.61
|
| Rate for Payer: Ambetter Exchange |
$104.23
|
| 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 Individual/Medicaid |
$104.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$104.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$125.08
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$104.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$104.23
|
| 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 |
$135.50
|
| Rate for Payer: UHCCP Medicaid |
$59.23
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$151.41
|
| Rate for Payer: Wellcare Medicare Advantage |
$104.23
|
|
|
INJ FORAMEN EPIDURAL L/S(T
|
Facility
|
OP
|
$2,191.00
|
|
|
Service Code
|
HCPCS 64483
|
| Hospital Charge Code |
761T2323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$753.48 |
| Max. Negotiated Rate |
$2,103.36 |
| Rate for Payer: Aetna Commercial |
$1,687.07
|
| Rate for Payer: Anthem Medicaid |
$753.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$822.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,708.98
|
| 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 |
$1,095.50
|
| Rate for Payer: Cash Price |
$1,095.50
|
| Rate for Payer: Cigna Commercial |
$1,818.53
|
| Rate for Payer: First Health Commercial |
$2,081.45
|
| Rate for Payer: Humana Commercial |
$1,862.35
|
| Rate for Payer: Humana KY Medicaid |
$753.48
|
| Rate for Payer: Humana Medicare Advantage |
$822.61
|
| Rate for Payer: Kentucky WC Medicaid |
$761.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,796.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,616.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$987.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$768.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,928.08
|
| Rate for Payer: Ohio Health Group HMO |
$1,643.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,752.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,906.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,511.79
|
| Rate for Payer: PHCS Commercial |
$2,103.36
|
| Rate for Payer: United Healthcare All Payer |
$1,928.08
|
|
|
INJ FORAMEN EPIDURAL L/S(T
|
Facility
|
IP
|
$2,191.00
|
|
|
Service Code
|
HCPCS 64483
|
| Hospital Charge Code |
761T2323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$657.30 |
| Max. Negotiated Rate |
$2,103.36 |
| Rate for Payer: Aetna Commercial |
$1,687.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,708.98
|
| Rate for Payer: Cash Price |
$1,095.50
|
| Rate for Payer: Cigna Commercial |
$1,818.53
|
| Rate for Payer: First Health Commercial |
$2,081.45
|
| Rate for Payer: Humana Commercial |
$1,862.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,796.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,616.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$657.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,928.08
|
| Rate for Payer: Ohio Health Group HMO |
$1,643.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,752.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,906.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,511.79
|
| Rate for Payer: PHCS Commercial |
$2,103.36
|
| Rate for Payer: United Healthcare All Payer |
$1,928.08
|
|
|
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 |
$727.61 |
| 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 |
$1,940.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,110.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,673.51
|
| Rate for Payer: PHCS Commercial |
$2,328.36
|
| Rate for Payer: United Healthcare All Payer |
$2,134.33
|
|
|
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 |
$727.61 |
| 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 |
$1,940.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,110.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,673.51
|
| 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 |
$1,455.23 |
| Rate for Payer: Aetna Commercial |
$126.53
|
| Rate for Payer: Ambetter Exchange |
$77.09
|
| 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 Individual/Medicaid |
$77.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$77.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$92.51
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$77.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$77.09
|
| 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 |
$100.22
|
| Rate for Payer: UHCCP Medicaid |
$60.32
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$77.09
|
|
|
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 |
$510.00 |
| Rate for Payer: Aetna Commercial |
$126.53
|
| Rate for Payer: Ambetter Exchange |
$77.09
|
| 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 Individual/Medicaid |
$77.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$77.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$92.51
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$77.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$77.09
|
| 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 |
$100.22
|
| Rate for Payer: UHCCP Medicaid |
$60.32
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$77.09
|
|
