|
INJ PARAVERT F JNT 3 LEVER
|
Professional
|
Both
|
$1,154.82
|
|
|
Service Code
|
HCPCS 64495
|
| Hospital Charge Code |
76102331
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$26.30 |
| Max. Negotiated Rate |
$692.89 |
| Rate for Payer: Aetna Commercial |
$91.62
|
| Rate for Payer: Ambetter Exchange |
$48.28
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$26.30
|
| Rate for Payer: Anthem Medicaid |
$62.51
|
| Rate for Payer: Buckeye Individual/Medicaid |
$48.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$48.28
|
| Rate for Payer: CareSource Just4Me Medicare |
$57.94
|
| Rate for Payer: Cash Price |
$577.41
|
| Rate for Payer: Cash Price |
$577.41
|
| Rate for Payer: Cigna Commercial |
$138.84
|
| Rate for Payer: Healthspan PPO |
$75.47
|
| Rate for Payer: Humana Medicaid |
$62.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$68.88
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$48.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.28
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$63.76
|
| Rate for Payer: Molina Healthcare Passport |
$62.51
|
| Rate for Payer: Multiplan PHCS |
$692.89
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$62.76
|
| Rate for Payer: UHCCP Medicaid |
$27.61
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$63.14
|
| Rate for Payer: Wellcare Medicare Advantage |
$48.28
|
|
|
INJ PARAVERT F JNT 3 LEVER(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 64495
|
| Hospital Charge Code |
761P2331
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$26.30 |
| Max. Negotiated Rate |
$138.84 |
| Rate for Payer: Aetna Commercial |
$91.62
|
| Rate for Payer: Ambetter Exchange |
$48.28
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$26.30
|
| Rate for Payer: Anthem Medicaid |
$62.51
|
| Rate for Payer: Buckeye Individual/Medicaid |
$48.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$48.28
|
| Rate for Payer: CareSource Just4Me Medicare |
$57.94
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$138.84
|
| Rate for Payer: Healthspan PPO |
$75.47
|
| Rate for Payer: Humana Medicaid |
$62.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$68.88
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$48.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.28
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$63.76
|
| Rate for Payer: Molina Healthcare Passport |
$62.51
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$62.76
|
| Rate for Payer: UHCCP Medicaid |
$27.61
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$63.14
|
| Rate for Payer: Wellcare Medicare Advantage |
$48.28
|
|
|
INJ PARAVERT F JNT 3 LEVER(T
|
Facility
|
OP
|
$1,004.82
|
|
|
Service Code
|
HCPCS 64495
|
| Hospital Charge Code |
761T2331
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$301.45 |
| Max. Negotiated Rate |
$964.63 |
| Rate for Payer: Aetna Commercial |
$773.71
|
| Rate for Payer: Anthem Medicaid |
$345.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$783.76
|
| Rate for Payer: Cash Price |
$502.41
|
| Rate for Payer: Cigna Commercial |
$834.00
|
| Rate for Payer: First Health Commercial |
$954.58
|
| Rate for Payer: Humana Commercial |
$854.10
|
| Rate for Payer: Humana KY Medicaid |
$345.56
|
| Rate for Payer: Kentucky WC Medicaid |
$349.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$823.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$741.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$301.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$352.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$884.24
|
| Rate for Payer: Ohio Health Group HMO |
$753.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$803.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$874.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$693.33
|
| Rate for Payer: PHCS Commercial |
$964.63
|
| Rate for Payer: United Healthcare All Payer |
$884.24
|
|
|
INJ PARAVERT F JNT 3 LEVER(T
|
Facility
|
IP
|
$1,004.82
|
|
|
Service Code
|
HCPCS 64495
|
| Hospital Charge Code |
761T2331
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$301.45 |
| Max. Negotiated Rate |
$964.63 |
| Rate for Payer: Aetna Commercial |
$773.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$783.76
|
| Rate for Payer: Cash Price |
$502.41
|
| Rate for Payer: Cigna Commercial |
$834.00
|
| Rate for Payer: First Health Commercial |
$954.58
|
| Rate for Payer: Humana Commercial |
$854.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$823.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$741.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$301.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$884.24
|
| Rate for Payer: Ohio Health Group HMO |
$753.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$803.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$874.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$693.33
|
| Rate for Payer: PHCS Commercial |
$964.63
|
| Rate for Payer: United Healthcare All Payer |
$884.24
|
|
|
INJ PARAVERT F JNT C/T 1 LE(P
|
Professional
|
Both
|
$585.00
|
|
|
Service Code
|
HCPCS 64490
|
| Hospital Charge Code |
761P2326
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$53.64 |
| Max. Negotiated Rate |
$351.00 |
| Rate for Payer: Aetna Commercial |
$182.52
|
| Rate for Payer: Ambetter Exchange |
$99.03
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$53.64
|
| Rate for Payer: Anthem Medicaid |
$133.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$99.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$99.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$118.84
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Cigna Commercial |
$297.61
|
| Rate for Payer: Healthspan PPO |
$167.18
|
| Rate for Payer: Humana Medicaid |
$133.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$142.09
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$99.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$99.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$136.29
|
| Rate for Payer: Molina Healthcare Passport |
$133.62
|
| Rate for Payer: Multiplan PHCS |
$351.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$128.74
|
| Rate for Payer: UHCCP Medicaid |
$56.32
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$134.96
|
| Rate for Payer: Wellcare Medicare Advantage |
$99.03
|
|
|
INJ PARAVERT F JNT C/T 1 LE(T
|
Facility
|
IP
|
$1,908.55
|
|
|
Service Code
|
HCPCS 64490
|
| Hospital Charge Code |
761T2326
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$572.57 |
| Max. Negotiated Rate |
$1,832.21 |
| Rate for Payer: Aetna Commercial |
$1,469.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,488.67
|
| Rate for Payer: Cash Price |
$954.28
|
| Rate for Payer: Cigna Commercial |
$1,584.10
|
| Rate for Payer: First Health Commercial |
$1,813.12
|
| Rate for Payer: Humana Commercial |
$1,622.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,565.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,408.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$572.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,679.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,431.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,526.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,660.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,316.90
|
| Rate for Payer: PHCS Commercial |
$1,832.21
|
| Rate for Payer: United Healthcare All Payer |
$1,679.52
|
|
|
INJ PARAVERT F JNT C/T 1 LE(T
|
Facility
|
OP
|
$1,908.55
|
|
|
Service Code
|
HCPCS 64490
|
| Hospital Charge Code |
761T2326
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$656.35 |
| Max. Negotiated Rate |
$1,832.21 |
| Rate for Payer: Aetna Commercial |
$1,469.58
|
| Rate for Payer: Anthem Medicaid |
$656.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$822.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,488.67
|
| 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 |
$954.28
|
| Rate for Payer: Cash Price |
$954.28
|
| Rate for Payer: Cigna Commercial |
$1,584.10
|
| Rate for Payer: First Health Commercial |
$1,813.12
|
| Rate for Payer: Humana Commercial |
$1,622.27
|
| Rate for Payer: Humana KY Medicaid |
$656.35
|
| Rate for Payer: Humana Medicare Advantage |
$822.61
|
| Rate for Payer: Kentucky WC Medicaid |
$663.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,565.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,408.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$987.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$669.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,679.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,431.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,526.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,660.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,316.90
|
| Rate for Payer: PHCS Commercial |
$1,832.21
|
| Rate for Payer: United Healthcare All Payer |
$1,679.52
|
|
|
INJ PARAVERT F JNT C/T 1 LEV
|
Facility
|
IP
|
$2,493.55
|
|
|
Service Code
|
HCPCS 64490
|
| Hospital Charge Code |
76102326
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$748.07 |
| Max. Negotiated Rate |
$2,393.81 |
| Rate for Payer: Aetna Commercial |
$1,920.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,944.97
|
| Rate for Payer: Cash Price |
$1,246.78
|
| Rate for Payer: Cigna Commercial |
$2,069.65
|
| Rate for Payer: First Health Commercial |
$2,368.87
|
| Rate for Payer: Humana Commercial |
$2,119.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,044.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,840.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$748.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,194.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,870.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,994.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,169.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,720.55
|
| Rate for Payer: PHCS Commercial |
$2,393.81
|
| Rate for Payer: United Healthcare All Payer |
$2,194.32
|
|
|
INJ PARAVERT F JNT C/T 1 LEV
|
Professional
|
Both
|
$2,493.55
|
|
|
Service Code
|
HCPCS 64490
|
| Hospital Charge Code |
76102326
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$53.64 |
| Max. Negotiated Rate |
$1,496.13 |
| Rate for Payer: Aetna Commercial |
$182.52
|
| Rate for Payer: Ambetter Exchange |
$99.03
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$53.64
|
| Rate for Payer: Anthem Medicaid |
$133.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$99.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$99.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$118.84
|
| Rate for Payer: Cash Price |
$1,246.78
|
| Rate for Payer: Cash Price |
$1,246.78
|
| Rate for Payer: Cigna Commercial |
$297.61
|
| Rate for Payer: Healthspan PPO |
$167.18
|
| Rate for Payer: Humana Medicaid |
$133.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$142.09
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$99.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$99.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$136.29
|
| Rate for Payer: Molina Healthcare Passport |
$133.62
|
| Rate for Payer: Multiplan PHCS |
$1,496.13
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$128.74
|
| Rate for Payer: UHCCP Medicaid |
$56.32
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$134.96
|
| Rate for Payer: Wellcare Medicare Advantage |
$99.03
|
|
|
INJ PARAVERT F JNT C/T 1 LEV
|
Facility
|
OP
|
$2,493.55
|
|
|
Service Code
|
HCPCS 64490
|
| Hospital Charge Code |
76102326
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$822.61 |
| Max. Negotiated Rate |
$2,393.81 |
| Rate for Payer: Aetna Commercial |
$1,920.03
|
| Rate for Payer: Anthem Medicaid |
$857.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$822.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,944.97
|
| 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 |
$1,246.78
|
| Rate for Payer: Cash Price |
$1,246.78
|
| Rate for Payer: Cigna Commercial |
$2,069.65
|
| Rate for Payer: First Health Commercial |
$2,368.87
|
| Rate for Payer: Humana Commercial |
$2,119.52
|
| Rate for Payer: Humana KY Medicaid |
$857.53
|
| Rate for Payer: Humana Medicare Advantage |
$822.61
|
| Rate for Payer: Kentucky WC Medicaid |
$866.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,044.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,840.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$987.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$874.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,194.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,870.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,994.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,169.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,720.55
|
| Rate for Payer: PHCS Commercial |
$2,393.81
|
| Rate for Payer: United Healthcare All Payer |
$2,194.32
|
|
|
INJ PARAVERT F JNT C/T 2 LE(P
|
Professional
|
Both
|
$390.00
|
|
|
Service Code
|
HCPCS 64491
|
| Hospital Charge Code |
761P2327
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.11 |
| Max. Negotiated Rate |
$234.00 |
| Rate for Payer: Aetna Commercial |
$105.39
|
| Rate for Payer: Ambetter Exchange |
$56.30
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$30.11
|
| Rate for Payer: Anthem Medicaid |
$68.01
|
| Rate for Payer: Buckeye Individual/Medicaid |
$56.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$56.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$67.56
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cigna Commercial |
$151.02
|
| Rate for Payer: Healthspan PPO |
$83.21
|
| Rate for Payer: Humana Medicaid |
$68.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$80.33
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$56.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$69.37
|
| Rate for Payer: Molina Healthcare Passport |
$68.01
|
| Rate for Payer: Multiplan PHCS |
$234.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$73.19
|
| Rate for Payer: UHCCP Medicaid |
$31.62
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$68.69
|
| Rate for Payer: Wellcare Medicare Advantage |
$56.30
|
|
|
INJ PARAVERT F JNT C/T 2 LE(T
|
Facility
|
OP
|
$1,046.00
|
|
|
Service Code
|
HCPCS 64491
|
| Hospital Charge Code |
761T2327
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$313.80 |
| Max. Negotiated Rate |
$1,004.16 |
| Rate for Payer: Aetna Commercial |
$805.42
|
| Rate for Payer: Anthem Medicaid |
$359.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$815.88
|
| Rate for Payer: Cash Price |
$523.00
|
| Rate for Payer: Cigna Commercial |
$868.18
|
| Rate for Payer: First Health Commercial |
$993.70
|
| Rate for Payer: Humana Commercial |
$889.10
|
| Rate for Payer: Humana KY Medicaid |
$359.72
|
| Rate for Payer: Kentucky WC Medicaid |
$363.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$857.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$771.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$313.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$366.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$920.48
|
| Rate for Payer: Ohio Health Group HMO |
$784.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$836.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$910.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$721.74
|
| Rate for Payer: PHCS Commercial |
$1,004.16
|
| Rate for Payer: United Healthcare All Payer |
$920.48
|
|
|
INJ PARAVERT F JNT C/T 2 LE(T
|
Facility
|
IP
|
$1,046.00
|
|
|
Service Code
|
HCPCS 64491
|
| Hospital Charge Code |
761T2327
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$313.80 |
| Max. Negotiated Rate |
$1,004.16 |
| Rate for Payer: Aetna Commercial |
$805.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$815.88
|
| Rate for Payer: Cash Price |
$523.00
|
| Rate for Payer: Cigna Commercial |
$868.18
|
| Rate for Payer: First Health Commercial |
$993.70
|
| Rate for Payer: Humana Commercial |
$889.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$857.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$771.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$313.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$920.48
|
| Rate for Payer: Ohio Health Group HMO |
$784.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$836.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$910.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$721.74
|
| Rate for Payer: PHCS Commercial |
$1,004.16
|
| Rate for Payer: United Healthcare All Payer |
$920.48
|
|
|
INJ PARAVERT F JNT C/T 2 LEV
|
Facility
|
IP
|
$1,436.00
|
|
|
Service Code
|
HCPCS 64491
|
| Hospital Charge Code |
76102327
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$430.80 |
| Max. Negotiated Rate |
$1,378.56 |
| Rate for Payer: Aetna Commercial |
$1,105.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,120.08
|
| Rate for Payer: Cash Price |
$718.00
|
| Rate for Payer: Cigna Commercial |
$1,191.88
|
| Rate for Payer: First Health Commercial |
$1,364.20
|
| Rate for Payer: Humana Commercial |
$1,220.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,177.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,059.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$430.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,263.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,077.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,148.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,249.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$990.84
|
| Rate for Payer: PHCS Commercial |
$1,378.56
|
| Rate for Payer: United Healthcare All Payer |
$1,263.68
|
|
|
INJ PARAVERT F JNT C/T 2 LEV
|
Professional
|
Both
|
$1,436.00
|
|
|
Service Code
|
HCPCS 64491
|
| Hospital Charge Code |
76102327
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.11 |
| Max. Negotiated Rate |
$861.60 |
| Rate for Payer: Aetna Commercial |
$105.39
|
| Rate for Payer: Ambetter Exchange |
$56.30
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$30.11
|
| Rate for Payer: Anthem Medicaid |
$68.01
|
| Rate for Payer: Buckeye Individual/Medicaid |
$56.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$56.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$67.56
|
| Rate for Payer: Cash Price |
$718.00
|
| Rate for Payer: Cash Price |
$718.00
|
| Rate for Payer: Cigna Commercial |
$151.02
|
| Rate for Payer: Healthspan PPO |
$83.21
|
| Rate for Payer: Humana Medicaid |
$68.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$80.33
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$56.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$69.37
|
| Rate for Payer: Molina Healthcare Passport |
$68.01
|
| Rate for Payer: Multiplan PHCS |
$861.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$73.19
|
| Rate for Payer: UHCCP Medicaid |
$31.62
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$68.69
|
| Rate for Payer: Wellcare Medicare Advantage |
$56.30
|
|
|
INJ PARAVERT F JNT C/T 2 LEV
|
Facility
|
OP
|
$1,436.00
|
|
|
Service Code
|
HCPCS 64491
|
| Hospital Charge Code |
76102327
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$430.80 |
| Max. Negotiated Rate |
$1,378.56 |
| Rate for Payer: Aetna Commercial |
$1,105.72
|
| Rate for Payer: Anthem Medicaid |
$493.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,120.08
|
| Rate for Payer: Cash Price |
$718.00
|
| Rate for Payer: Cigna Commercial |
$1,191.88
|
| Rate for Payer: First Health Commercial |
$1,364.20
|
| Rate for Payer: Humana Commercial |
$1,220.60
|
| Rate for Payer: Humana KY Medicaid |
$493.84
|
| Rate for Payer: Kentucky WC Medicaid |
$498.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,177.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,059.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$430.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$503.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,263.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,077.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,148.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,249.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$990.84
|
| Rate for Payer: PHCS Commercial |
$1,378.56
|
| Rate for Payer: United Healthcare All Payer |
$1,263.68
|
|
|
INJ PARAVERT F JNT C/T 3 LE(P
|
Professional
|
Both
|
$390.00
|
|
|
Service Code
|
HCPCS 64492
|
| Hospital Charge Code |
761P2328
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.46 |
| Max. Negotiated Rate |
$234.00 |
| Rate for Payer: Aetna Commercial |
$107.13
|
| Rate for Payer: Ambetter Exchange |
$56.56
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$30.46
|
| Rate for Payer: Anthem Medicaid |
$68.77
|
| Rate for Payer: Buckeye Individual/Medicaid |
$56.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$56.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$67.87
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cigna Commercial |
$152.75
|
| Rate for Payer: Healthspan PPO |
$84.28
|
| Rate for Payer: Humana Medicaid |
$68.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$81.58
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$56.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.56
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$70.15
|
| Rate for Payer: Molina Healthcare Passport |
$68.77
|
| Rate for Payer: Multiplan PHCS |
$234.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$73.53
|
| Rate for Payer: UHCCP Medicaid |
$31.98
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$69.46
|
| Rate for Payer: Wellcare Medicare Advantage |
$56.56
|
|
|
INJ PARAVERT F JNT C/T 3 LE(T
|
Facility
|
OP
|
$1,013.06
|
|
|
Service Code
|
HCPCS 64492
|
| Hospital Charge Code |
761T2328
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$303.92 |
| Max. Negotiated Rate |
$972.54 |
| Rate for Payer: Aetna Commercial |
$780.06
|
| Rate for Payer: Anthem Medicaid |
$348.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$790.19
|
| Rate for Payer: Cash Price |
$506.53
|
| Rate for Payer: Cigna Commercial |
$840.84
|
| Rate for Payer: First Health Commercial |
$962.41
|
| Rate for Payer: Humana Commercial |
$861.10
|
| Rate for Payer: Humana KY Medicaid |
$348.39
|
| Rate for Payer: Kentucky WC Medicaid |
$351.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$830.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$747.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$303.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$355.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$891.49
|
| Rate for Payer: Ohio Health Group HMO |
$759.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$810.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$881.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$699.01
|
| Rate for Payer: PHCS Commercial |
$972.54
|
| Rate for Payer: United Healthcare All Payer |
$891.49
|
|
|
INJ PARAVERT F JNT C/T 3 LE(T
|
Facility
|
IP
|
$1,013.06
|
|
|
Service Code
|
HCPCS 64492
|
| Hospital Charge Code |
761T2328
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$303.92 |
| Max. Negotiated Rate |
$972.54 |
| Rate for Payer: Aetna Commercial |
$780.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$790.19
|
| Rate for Payer: Cash Price |
$506.53
|
| Rate for Payer: Cigna Commercial |
$840.84
|
| Rate for Payer: First Health Commercial |
$962.41
|
| Rate for Payer: Humana Commercial |
$861.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$830.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$747.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$303.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$891.49
|
| Rate for Payer: Ohio Health Group HMO |
$759.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$810.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$881.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$699.01
|
| Rate for Payer: PHCS Commercial |
$972.54
|
| Rate for Payer: United Healthcare All Payer |
$891.49
|
|
|
INJ PARAVERT F JNT C/T 3 LEV
|
Facility
|
OP
|
$1,403.06
|
|
|
Service Code
|
HCPCS 64492
|
| Hospital Charge Code |
76102328
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$420.92 |
| Max. Negotiated Rate |
$1,346.94 |
| Rate for Payer: Aetna Commercial |
$1,080.36
|
| Rate for Payer: Anthem Medicaid |
$482.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,094.39
|
| Rate for Payer: Cash Price |
$701.53
|
| Rate for Payer: Cigna Commercial |
$1,164.54
|
| Rate for Payer: First Health Commercial |
$1,332.91
|
| Rate for Payer: Humana Commercial |
$1,192.60
|
| Rate for Payer: Humana KY Medicaid |
$482.51
|
| Rate for Payer: Kentucky WC Medicaid |
$487.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,150.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,035.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$420.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$492.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,234.69
|
| Rate for Payer: Ohio Health Group HMO |
$1,052.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,122.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,220.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$968.11
|
| Rate for Payer: PHCS Commercial |
$1,346.94
|
| Rate for Payer: United Healthcare All Payer |
$1,234.69
|
|
|
INJ PARAVERT F JNT C/T 3 LEV
|
Professional
|
Both
|
$1,403.06
|
|
|
Service Code
|
HCPCS 64492
|
| Hospital Charge Code |
76102328
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.46 |
| Max. Negotiated Rate |
$841.84 |
| Rate for Payer: Aetna Commercial |
$107.13
|
| Rate for Payer: Ambetter Exchange |
$56.56
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$30.46
|
| Rate for Payer: Anthem Medicaid |
$68.77
|
| Rate for Payer: Buckeye Individual/Medicaid |
$56.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$56.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$67.87
|
| Rate for Payer: Cash Price |
$701.53
|
| Rate for Payer: Cash Price |
$701.53
|
| Rate for Payer: Cigna Commercial |
$152.75
|
| Rate for Payer: Healthspan PPO |
$84.28
|
| Rate for Payer: Humana Medicaid |
$68.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$81.58
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$56.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.56
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$70.15
|
| Rate for Payer: Molina Healthcare Passport |
$68.77
|
| Rate for Payer: Multiplan PHCS |
$841.84
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$73.53
|
| Rate for Payer: UHCCP Medicaid |
$31.98
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$69.46
|
| Rate for Payer: Wellcare Medicare Advantage |
$56.56
|
|
|
INJ PARAVERT F JNT C/T 3 LEV
|
Facility
|
IP
|
$1,403.06
|
|
|
Service Code
|
HCPCS 64492
|
| Hospital Charge Code |
76102328
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$420.92 |
| Max. Negotiated Rate |
$1,346.94 |
| Rate for Payer: Aetna Commercial |
$1,080.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,094.39
|
| Rate for Payer: Cash Price |
$701.53
|
| Rate for Payer: Cigna Commercial |
$1,164.54
|
| Rate for Payer: First Health Commercial |
$1,332.91
|
| Rate for Payer: Humana Commercial |
$1,192.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,150.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,035.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$420.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,234.69
|
| Rate for Payer: Ohio Health Group HMO |
$1,052.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,122.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,220.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$968.11
|
| Rate for Payer: PHCS Commercial |
$1,346.94
|
| Rate for Payer: United Healthcare All Payer |
$1,234.69
|
|
|
INJ PERCTX EXTRM PSEUDANEURYSM
|
Facility
|
IP
|
$1,262.00
|
|
|
Service Code
|
HCPCS 36002
|
| Hospital Charge Code |
76101429
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$378.60 |
| 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 |
$1,009.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,097.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$870.78
|
| Rate for Payer: PHCS Commercial |
$1,211.52
|
| Rate for Payer: United Healthcare All Payer |
$1,110.56
|
|
|
INJ PERCTX EXTRM PSEUDANEURYSM
|
Facility
|
IP
|
$962.00
|
|
|
Service Code
|
HCPCS 36002
|
| Hospital Charge Code |
761T1429
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$288.60 |
| Max. Negotiated Rate |
$923.52 |
| Rate for Payer: Aetna Commercial |
$740.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$750.36
|
| Rate for Payer: Cash Price |
$481.00
|
| Rate for Payer: Cigna Commercial |
$798.46
|
| Rate for Payer: First Health Commercial |
$913.90
|
| Rate for Payer: Humana Commercial |
$817.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$788.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$709.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$288.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$846.56
|
| Rate for Payer: Ohio Health Group HMO |
$721.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$769.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$836.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$663.78
|
| Rate for Payer: PHCS Commercial |
$923.52
|
| Rate for Payer: United Healthcare All Payer |
$846.56
|
|
|
INJ PERCTX EXTRM PSEUDANEURYSM
|
Facility
|
OP
|
$1,262.00
|
|
|
Service Code
|
HCPCS 36002
|
| Hospital Charge Code |
76101429
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$434.00 |
| Max. Negotiated Rate |
$1,211.52 |
| Rate for Payer: Aetna Commercial |
$971.74
|
| Rate for Payer: Anthem Medicaid |
$434.00
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$571.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$984.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$799.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$771.20
|
| Rate for Payer: Cash Price |
$631.00
|
| 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: Humana Medicare Advantage |
$571.26
|
| 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 |
$685.51
|
| 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 |
$1,009.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,097.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$870.78
|
| Rate for Payer: PHCS Commercial |
$1,211.52
|
| Rate for Payer: United Healthcare All Payer |
$1,110.56
|
|
