|
INJ SUPRAVALVULAR AORTOGRAPHY
|
Facility
|
IP
|
$395.00
|
|
|
Service Code
|
HCPCS 93567
|
| Hospital Charge Code |
48100077
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$118.50 |
| Max. Negotiated Rate |
$379.20 |
| Rate for Payer: Aetna Commercial |
$304.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$308.10
|
| Rate for Payer: Cash Price |
$197.50
|
| Rate for Payer: Cigna Commercial |
$327.85
|
| Rate for Payer: First Health Commercial |
$375.25
|
| Rate for Payer: Humana Commercial |
$335.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$323.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$291.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$118.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$347.60
|
| Rate for Payer: Ohio Health Group HMO |
$296.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$316.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$343.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$272.55
|
| Rate for Payer: PHCS Commercial |
$379.20
|
| Rate for Payer: United Healthcare All Payer |
$347.60
|
|
|
INJ SUPRAVALVULAR AORTOGRAPHY
|
Facility
|
IP
|
$735.00
|
|
|
Service Code
|
HCPCS 93567
|
| Hospital Charge Code |
76102490
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$220.50 |
| Max. Negotiated Rate |
$705.60 |
| Rate for Payer: Aetna Commercial |
$565.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$573.30
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cigna Commercial |
$610.05
|
| Rate for Payer: First Health Commercial |
$698.25
|
| Rate for Payer: Humana Commercial |
$624.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$602.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$542.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$646.80
|
| Rate for Payer: Ohio Health Group HMO |
$551.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$588.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$639.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$507.15
|
| Rate for Payer: PHCS Commercial |
$705.60
|
| Rate for Payer: United Healthcare All Payer |
$646.80
|
|
|
INJ SUPRAVALVULAR AORTOGRAPHY
|
Facility
|
OP
|
$735.00
|
|
|
Service Code
|
HCPCS 93567
|
| Hospital Charge Code |
76102490
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$220.50 |
| Max. Negotiated Rate |
$705.60 |
| Rate for Payer: Aetna Commercial |
$565.95
|
| Rate for Payer: Anthem Medicaid |
$252.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$573.30
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cigna Commercial |
$610.05
|
| Rate for Payer: First Health Commercial |
$698.25
|
| Rate for Payer: Humana Commercial |
$624.75
|
| Rate for Payer: Humana KY Medicaid |
$252.77
|
| Rate for Payer: Kentucky WC Medicaid |
$255.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$602.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$542.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$257.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$646.80
|
| Rate for Payer: Ohio Health Group HMO |
$551.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$588.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$639.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$507.15
|
| Rate for Payer: PHCS Commercial |
$705.60
|
| Rate for Payer: United Healthcare All Payer |
$646.80
|
|
|
INJ SUPRAVALVULAR AORTOGRAPHY
|
Facility
|
OP
|
$395.00
|
|
|
Service Code
|
HCPCS 93567
|
| Hospital Charge Code |
48100077
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$118.50 |
| Max. Negotiated Rate |
$379.20 |
| Rate for Payer: Aetna Commercial |
$304.15
|
| Rate for Payer: Anthem Medicaid |
$135.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$308.10
|
| Rate for Payer: Cash Price |
$197.50
|
| Rate for Payer: Cigna Commercial |
$327.85
|
| Rate for Payer: First Health Commercial |
$375.25
|
| Rate for Payer: Humana Commercial |
$335.75
|
| Rate for Payer: Humana KY Medicaid |
$135.84
|
| Rate for Payer: Kentucky WC Medicaid |
$137.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$323.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$291.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$118.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$138.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$347.60
|
| Rate for Payer: Ohio Health Group HMO |
$296.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$316.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$343.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$272.55
|
| Rate for Payer: PHCS Commercial |
$379.20
|
| Rate for Payer: United Healthcare All Payer |
$347.60
|
|
|
INJ SUPRAVALVULAR AORTOGRAPHY
|
Professional
|
Both
|
$735.00
|
|
|
Service Code
|
HCPCS 93567
|
| Hospital Charge Code |
76102490
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$26.48 |
| Max. Negotiated Rate |
$441.00 |
| Rate for Payer: Aetna Commercial |
$77.98
|
| Rate for Payer: Ambetter Exchange |
$35.06
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$26.48
|
| Rate for Payer: Anthem Medicaid |
$121.94
|
| Rate for Payer: Buckeye Individual/Medicaid |
$35.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$35.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$42.07
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cigna Commercial |
$86.36
|
| Rate for Payer: Healthspan PPO |
$162.28
|
| Rate for Payer: Humana Medicaid |
$121.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$64.92
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$35.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$124.38
|
| Rate for Payer: Molina Healthcare Passport |
$121.94
|
| Rate for Payer: Multiplan PHCS |
$441.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$45.58
|
| Rate for Payer: UHCCP Medicaid |
$27.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$123.16
|
| Rate for Payer: Wellcare Medicare Advantage |
$35.06
|
|
|
INJ TENDON ORIGIN/INSERTION
|
Professional
|
Both
|
$571.00
|
|
|
Service Code
|
HCPCS 20551
|
| Hospital Charge Code |
76100338
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$33.71 |
| Max. Negotiated Rate |
$342.60 |
| Rate for Payer: Aetna Commercial |
$65.04
|
| Rate for Payer: Ambetter Exchange |
$36.36
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$33.71
|
| Rate for Payer: Anthem Medicaid |
$46.38
|
| Rate for Payer: Buckeye Individual/Medicaid |
$36.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$36.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$43.63
|
| Rate for Payer: Cash Price |
$285.50
|
| Rate for Payer: Cash Price |
$285.50
|
| Rate for Payer: Cigna Commercial |
$91.61
|
| Rate for Payer: Healthspan PPO |
$75.40
|
| Rate for Payer: Humana Medicaid |
$46.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$52.67
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$36.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.36
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$47.31
|
| Rate for Payer: Molina Healthcare Passport |
$46.38
|
| Rate for Payer: Multiplan PHCS |
$342.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$47.27
|
| Rate for Payer: UHCCP Medicaid |
$35.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$46.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$36.36
|
|
|
INJ TENDON ORIGIN/INSERTION
|
Facility
|
IP
|
$571.00
|
|
|
Service Code
|
HCPCS 20551
|
| Hospital Charge Code |
76100338
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$171.30 |
| Max. Negotiated Rate |
$548.16 |
| Rate for Payer: Aetna Commercial |
$439.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$445.38
|
| Rate for Payer: Cash Price |
$285.50
|
| Rate for Payer: Cigna Commercial |
$473.93
|
| Rate for Payer: First Health Commercial |
$542.45
|
| Rate for Payer: Humana Commercial |
$485.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$468.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$421.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$171.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$502.48
|
| Rate for Payer: Ohio Health Group HMO |
$428.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$456.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$496.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$393.99
|
| Rate for Payer: PHCS Commercial |
$548.16
|
| Rate for Payer: United Healthcare All Payer |
$502.48
|
|
|
INJ TENDON ORIGIN/INSERTION
|
Facility
|
OP
|
$571.00
|
|
|
Service Code
|
HCPCS 20551
|
| Hospital Charge Code |
76100338
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$196.37 |
| Max. Negotiated Rate |
$548.16 |
| Rate for Payer: Aetna Commercial |
$439.67
|
| Rate for Payer: Anthem Medicaid |
$196.37
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$272.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$445.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$381.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$368.21
|
| Rate for Payer: Cash Price |
$285.50
|
| Rate for Payer: Cash Price |
$285.50
|
| Rate for Payer: Cigna Commercial |
$473.93
|
| Rate for Payer: First Health Commercial |
$542.45
|
| Rate for Payer: Humana Commercial |
$485.35
|
| Rate for Payer: Humana KY Medicaid |
$196.37
|
| Rate for Payer: Humana Medicare Advantage |
$272.75
|
| Rate for Payer: Kentucky WC Medicaid |
$198.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$468.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$421.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$327.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$200.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$502.48
|
| Rate for Payer: Ohio Health Group HMO |
$428.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$456.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$496.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$393.99
|
| Rate for Payer: PHCS Commercial |
$548.16
|
| Rate for Payer: United Healthcare All Payer |
$502.48
|
|
|
INJ TENDON ORIGIN/INSERTION(P
|
Professional
|
Both
|
$90.00
|
|
|
Service Code
|
HCPCS 20551
|
| Hospital Charge Code |
761P0338
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$33.71 |
| Max. Negotiated Rate |
$91.61 |
| Rate for Payer: Aetna Commercial |
$65.04
|
| Rate for Payer: Ambetter Exchange |
$36.36
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$33.71
|
| Rate for Payer: Anthem Medicaid |
$46.38
|
| Rate for Payer: Buckeye Individual/Medicaid |
$36.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$36.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$43.63
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$91.61
|
| Rate for Payer: Healthspan PPO |
$75.40
|
| Rate for Payer: Humana Medicaid |
$46.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$52.67
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$36.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.36
|
| 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 |
$47.27
|
| Rate for Payer: UHCCP Medicaid |
$35.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$46.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$36.36
|
|
|
INJ TENDON ORIGIN/INSERTION(T
|
Facility
|
IP
|
$481.00
|
|
|
Service Code
|
HCPCS 20551
|
| Hospital Charge Code |
761T0338
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$144.30 |
| Max. Negotiated Rate |
$461.76 |
| Rate for Payer: Aetna Commercial |
$370.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$375.18
|
| Rate for Payer: Cash Price |
$240.50
|
| Rate for Payer: Cigna Commercial |
$399.23
|
| Rate for Payer: First Health Commercial |
$456.95
|
| Rate for Payer: Humana Commercial |
$408.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$394.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$354.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$144.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$423.28
|
| Rate for Payer: Ohio Health Group HMO |
$360.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$384.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$418.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$331.89
|
| Rate for Payer: PHCS Commercial |
$461.76
|
| Rate for Payer: United Healthcare All Payer |
$423.28
|
|
|
INJ TENDON ORIGIN/INSERTION(T
|
Facility
|
OP
|
$481.00
|
|
|
Service Code
|
HCPCS 20551
|
| Hospital Charge Code |
761T0338
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$165.42 |
| Max. Negotiated Rate |
$461.76 |
| Rate for Payer: Aetna Commercial |
$370.37
|
| Rate for Payer: Anthem Medicaid |
$165.42
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$272.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$375.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$381.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$368.21
|
| Rate for Payer: Cash Price |
$240.50
|
| Rate for Payer: Cash Price |
$240.50
|
| Rate for Payer: Cigna Commercial |
$399.23
|
| Rate for Payer: First Health Commercial |
$456.95
|
| Rate for Payer: Humana Commercial |
$408.85
|
| Rate for Payer: Humana KY Medicaid |
$165.42
|
| Rate for Payer: Humana Medicare Advantage |
$272.75
|
| Rate for Payer: Kentucky WC Medicaid |
$167.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$394.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$354.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$327.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$168.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$423.28
|
| Rate for Payer: Ohio Health Group HMO |
$360.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$384.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$418.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$331.89
|
| Rate for Payer: PHCS Commercial |
$461.76
|
| Rate for Payer: United Healthcare All Payer |
$423.28
|
|
|
INJ TRIGGER POINT 1/2 MUSCL
|
Facility
|
IP
|
$517.00
|
|
|
Service Code
|
HCPCS 20552
|
| Hospital Charge Code |
76100339
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$155.10 |
| Max. Negotiated Rate |
$496.32 |
| Rate for Payer: Aetna Commercial |
$398.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$403.26
|
| Rate for Payer: Cash Price |
$258.50
|
| Rate for Payer: Cigna Commercial |
$429.11
|
| Rate for Payer: First Health Commercial |
$491.15
|
| Rate for Payer: Humana Commercial |
$439.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$423.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$381.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$155.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$454.96
|
| Rate for Payer: Ohio Health Group HMO |
$387.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$413.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$449.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$356.73
|
| Rate for Payer: PHCS Commercial |
$496.32
|
| Rate for Payer: United Healthcare All Payer |
$454.96
|
|
|
INJ TRIGGER POINT 1/2 MUSCL
|
Facility
|
OP
|
$517.00
|
|
|
Service Code
|
HCPCS 20552
|
| Hospital Charge Code |
76100339
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$177.80 |
| Max. Negotiated Rate |
$496.32 |
| Rate for Payer: Aetna Commercial |
$398.09
|
| Rate for Payer: Anthem Medicaid |
$177.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$272.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$403.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$381.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$368.21
|
| Rate for Payer: Cash Price |
$258.50
|
| Rate for Payer: Cash Price |
$258.50
|
| Rate for Payer: Cigna Commercial |
$429.11
|
| Rate for Payer: First Health Commercial |
$491.15
|
| Rate for Payer: Humana Commercial |
$439.45
|
| Rate for Payer: Humana KY Medicaid |
$177.80
|
| Rate for Payer: Humana Medicare Advantage |
$272.75
|
| Rate for Payer: Kentucky WC Medicaid |
$179.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$423.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$381.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$327.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$181.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$454.96
|
| Rate for Payer: Ohio Health Group HMO |
$387.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$413.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$449.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$356.73
|
| Rate for Payer: PHCS Commercial |
$496.32
|
| Rate for Payer: United Healthcare All Payer |
$454.96
|
|
|
INJ TRIGGER POINT 1/2 MUSCL
|
Professional
|
Both
|
$517.00
|
|
|
Service Code
|
HCPCS 20552
|
| Hospital Charge Code |
76100339
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$28.11 |
| Max. Negotiated Rate |
$310.20 |
| Rate for Payer: Aetna Commercial |
$54.51
|
| Rate for Payer: Ambetter Exchange |
$34.30
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$28.11
|
| Rate for Payer: Anthem Medicaid |
$46.38
|
| Rate for Payer: Buckeye Individual/Medicaid |
$34.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$34.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$41.16
|
| Rate for Payer: Cash Price |
$258.50
|
| Rate for Payer: Cash Price |
$258.50
|
| Rate for Payer: Cigna Commercial |
$85.59
|
| Rate for Payer: Healthspan PPO |
$67.79
|
| Rate for Payer: Humana Medicaid |
$46.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$45.89
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$34.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$47.31
|
| Rate for Payer: Molina Healthcare Passport |
$46.38
|
| Rate for Payer: Multiplan PHCS |
$310.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$44.59
|
| Rate for Payer: UHCCP Medicaid |
$29.52
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$46.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$34.30
|
|
|
INJ TRIGGER POINT 1/2 MUSCL
|
Facility
|
OP
|
$417.00
|
|
|
Service Code
|
HCPCS 20552
|
| Hospital Charge Code |
45000088
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$143.41 |
| Max. Negotiated Rate |
$400.32 |
| Rate for Payer: Aetna Commercial |
$321.09
|
| Rate for Payer: Anthem Medicaid |
$143.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$272.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$325.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$381.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$368.21
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cigna Commercial |
$346.11
|
| Rate for Payer: First Health Commercial |
$396.15
|
| Rate for Payer: Humana Commercial |
$354.45
|
| Rate for Payer: Humana KY Medicaid |
$143.41
|
| Rate for Payer: Humana Medicare Advantage |
$272.75
|
| Rate for Payer: Kentucky WC Medicaid |
$144.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$341.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$307.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$327.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$146.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$366.96
|
| Rate for Payer: Ohio Health Group HMO |
$312.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$333.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$362.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$287.73
|
| Rate for Payer: PHCS Commercial |
$400.32
|
| Rate for Payer: United Healthcare All Payer |
$366.96
|
|
|
INJ TRIGGER POINT 1/2 MUSCL
|
Facility
|
IP
|
$417.00
|
|
|
Service Code
|
HCPCS 20552
|
| Hospital Charge Code |
45000088
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$125.10 |
| Max. Negotiated Rate |
$400.32 |
| Rate for Payer: Aetna Commercial |
$321.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$325.26
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cigna Commercial |
$346.11
|
| Rate for Payer: First Health Commercial |
$396.15
|
| Rate for Payer: Humana Commercial |
$354.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$341.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$307.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$125.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$366.96
|
| Rate for Payer: Ohio Health Group HMO |
$312.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$333.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$362.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$287.73
|
| Rate for Payer: PHCS Commercial |
$400.32
|
| Rate for Payer: United Healthcare All Payer |
$366.96
|
|
|
INJ TRIGGER POINT 1/2 MUSCL(P
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 20552
|
| Hospital Charge Code |
761P0339
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$28.11 |
| Max. Negotiated Rate |
$85.59 |
| Rate for Payer: Aetna Commercial |
$54.51
|
| Rate for Payer: Ambetter Exchange |
$34.30
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$28.11
|
| Rate for Payer: Anthem Medicaid |
$46.38
|
| Rate for Payer: Buckeye Individual/Medicaid |
$34.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$34.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$41.16
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$85.59
|
| Rate for Payer: Healthspan PPO |
$67.79
|
| Rate for Payer: Humana Medicaid |
$46.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$45.89
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$34.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$47.31
|
| Rate for Payer: Molina Healthcare Passport |
$46.38
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$44.59
|
| Rate for Payer: UHCCP Medicaid |
$29.52
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$46.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$34.30
|
|
|
INJ TRIGGER POINT 1/2 MUSCL(T
|
Facility
|
OP
|
$417.00
|
|
|
Service Code
|
HCPCS 20552
|
| Hospital Charge Code |
761T0339
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.41 |
| Max. Negotiated Rate |
$400.32 |
| Rate for Payer: Aetna Commercial |
$321.09
|
| Rate for Payer: Anthem Medicaid |
$143.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$272.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$325.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$381.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$368.21
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cigna Commercial |
$346.11
|
| Rate for Payer: First Health Commercial |
$396.15
|
| Rate for Payer: Humana Commercial |
$354.45
|
| Rate for Payer: Humana KY Medicaid |
$143.41
|
| Rate for Payer: Humana Medicare Advantage |
$272.75
|
| Rate for Payer: Kentucky WC Medicaid |
$144.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$341.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$307.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$327.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$146.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$366.96
|
| Rate for Payer: Ohio Health Group HMO |
$312.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$333.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$362.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$287.73
|
| Rate for Payer: PHCS Commercial |
$400.32
|
| Rate for Payer: United Healthcare All Payer |
$366.96
|
|
|
INJ TRIGGER POINT 1/2 MUSCL(T
|
Facility
|
IP
|
$417.00
|
|
|
Service Code
|
HCPCS 20552
|
| Hospital Charge Code |
761T0339
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$125.10 |
| Max. Negotiated Rate |
$400.32 |
| Rate for Payer: Aetna Commercial |
$321.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$325.26
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cigna Commercial |
$346.11
|
| Rate for Payer: First Health Commercial |
$396.15
|
| Rate for Payer: Humana Commercial |
$354.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$341.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$307.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$125.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$366.96
|
| Rate for Payer: Ohio Health Group HMO |
$312.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$333.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$362.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$287.73
|
| Rate for Payer: PHCS Commercial |
$400.32
|
| Rate for Payer: United Healthcare All Payer |
$366.96
|
|
|
INNOVA 5*100*130 STENT
|
Facility
|
IP
|
$4,287.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,286.25 |
| Max. Negotiated Rate |
$4,116.00 |
| Rate for Payer: Aetna Commercial |
$3,301.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,344.25
|
| Rate for Payer: Cash Price |
$2,143.75
|
| Rate for Payer: Cigna Commercial |
$3,558.62
|
| Rate for Payer: First Health Commercial |
$4,073.12
|
| Rate for Payer: Humana Commercial |
$3,644.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,515.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,164.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,286.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,773.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,215.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,430.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,730.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,958.38
|
| Rate for Payer: PHCS Commercial |
$4,116.00
|
| Rate for Payer: United Healthcare All Payer |
$3,773.00
|
|
|
INNOVA 5*100*130 STENT
|
Facility
|
OP
|
$4,287.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,286.25 |
| Max. Negotiated Rate |
$4,116.00 |
| Rate for Payer: Aetna Commercial |
$3,301.38
|
| Rate for Payer: Anthem Medicaid |
$1,474.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,344.25
|
| Rate for Payer: Cash Price |
$2,143.75
|
| Rate for Payer: Cigna Commercial |
$3,558.62
|
| Rate for Payer: First Health Commercial |
$4,073.12
|
| Rate for Payer: Humana Commercial |
$3,644.38
|
| Rate for Payer: Humana KY Medicaid |
$1,474.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1,489.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,515.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,164.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,286.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,504.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,773.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,215.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,430.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,730.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,958.38
|
| Rate for Payer: PHCS Commercial |
$4,116.00
|
| Rate for Payer: United Healthcare All Payer |
$3,773.00
|
|
|
INNOVA 5*120*130 STENT
|
Facility
|
OP
|
$4,287.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,286.25 |
| Max. Negotiated Rate |
$4,116.00 |
| Rate for Payer: Aetna Commercial |
$3,301.38
|
| Rate for Payer: Anthem Medicaid |
$1,474.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,344.25
|
| Rate for Payer: Cash Price |
$2,143.75
|
| Rate for Payer: Cigna Commercial |
$3,558.62
|
| Rate for Payer: First Health Commercial |
$4,073.12
|
| Rate for Payer: Humana Commercial |
$3,644.38
|
| Rate for Payer: Humana KY Medicaid |
$1,474.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1,489.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,515.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,164.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,286.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,504.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,773.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,215.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,430.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,730.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,958.38
|
| Rate for Payer: PHCS Commercial |
$4,116.00
|
| Rate for Payer: United Healthcare All Payer |
$3,773.00
|
|
|
INNOVA 5*120*130 STENT
|
Facility
|
IP
|
$4,287.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,286.25 |
| Max. Negotiated Rate |
$4,116.00 |
| Rate for Payer: Aetna Commercial |
$3,301.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,344.25
|
| Rate for Payer: Cash Price |
$2,143.75
|
| Rate for Payer: Cigna Commercial |
$3,558.62
|
| Rate for Payer: First Health Commercial |
$4,073.12
|
| Rate for Payer: Humana Commercial |
$3,644.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,515.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,164.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,286.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,773.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,215.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,430.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,730.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,958.38
|
| Rate for Payer: PHCS Commercial |
$4,116.00
|
| Rate for Payer: United Healthcare All Payer |
$3,773.00
|
|
|
INNOVA 5*150*130 STENT
|
Facility
|
OP
|
$10,950.10
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,285.03 |
| Max. Negotiated Rate |
$10,512.10 |
| Rate for Payer: Aetna Commercial |
$8,431.58
|
| Rate for Payer: Anthem Medicaid |
$3,765.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,541.08
|
| Rate for Payer: Cash Price |
$5,475.05
|
| Rate for Payer: Cigna Commercial |
$9,088.58
|
| Rate for Payer: First Health Commercial |
$10,402.59
|
| Rate for Payer: Humana Commercial |
$9,307.58
|
| Rate for Payer: Humana KY Medicaid |
$3,765.74
|
| Rate for Payer: Kentucky WC Medicaid |
$3,804.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,979.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,081.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,285.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,841.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,636.09
|
| Rate for Payer: Ohio Health Group HMO |
$8,212.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,760.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,526.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,555.57
|
| Rate for Payer: PHCS Commercial |
$10,512.10
|
| Rate for Payer: United Healthcare All Payer |
$9,636.09
|
|
|
INNOVA 5*150*130 STENT
|
Facility
|
IP
|
$10,950.10
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,285.03 |
| Max. Negotiated Rate |
$10,512.10 |
| Rate for Payer: Aetna Commercial |
$8,431.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,541.08
|
| Rate for Payer: Cash Price |
$5,475.05
|
| Rate for Payer: Cigna Commercial |
$9,088.58
|
| Rate for Payer: First Health Commercial |
$10,402.59
|
| Rate for Payer: Humana Commercial |
$9,307.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,979.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,081.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,285.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,636.09
|
| Rate for Payer: Ohio Health Group HMO |
$8,212.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,760.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,526.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,555.57
|
| Rate for Payer: PHCS Commercial |
$10,512.10
|
| Rate for Payer: United Healthcare All Payer |
$9,636.09
|
|
