|
INTERACTIVE COMPLEXITY ADDT
|
Facility
|
OP
|
$192.00
|
|
|
Service Code
|
HCPCS 90785
|
| Hospital Charge Code |
90000004
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$57.60 |
| Max. Negotiated Rate |
$184.32 |
| Rate for Payer: Aetna Commercial |
$147.84
|
| Rate for Payer: Anthem Medicaid |
$66.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$149.76
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cigna Commercial |
$159.36
|
| Rate for Payer: First Health Commercial |
$182.40
|
| Rate for Payer: Humana Commercial |
$163.20
|
| Rate for Payer: Humana KY Medicaid |
$66.03
|
| Rate for Payer: Kentucky WC Medicaid |
$66.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$157.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$141.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$67.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$168.96
|
| Rate for Payer: Ohio Health Group HMO |
$144.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$153.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$167.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$132.48
|
| Rate for Payer: PHCS Commercial |
$184.32
|
| Rate for Payer: United Healthcare All Payer |
$168.96
|
|
|
INTERACTIVE COMPLEXITY ADDT(P
|
Professional
|
Both
|
$192.00
|
|
|
Service Code
|
HCPCS 90785
|
| Hospital Charge Code |
900P0004
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$4.29 |
| Max. Negotiated Rate |
$115.20 |
| Rate for Payer: Aetna Commercial |
$8.13
|
| Rate for Payer: Ambetter Exchange |
$12.19
|
| Rate for Payer: Anthem Medicaid |
$10.48
|
| Rate for Payer: Buckeye Individual/Medicaid |
$12.19
|
| Rate for Payer: Buckeye Medicare Advantage |
$12.19
|
| Rate for Payer: CareSource Just4Me Medicare |
$14.63
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cigna Commercial |
$7.09
|
| Rate for Payer: Healthspan PPO |
$4.29
|
| Rate for Payer: Humana Medicaid |
$10.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$7.87
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$12.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.19
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$10.69
|
| Rate for Payer: Molina Healthcare Passport |
$10.48
|
| Rate for Payer: Multiplan PHCS |
$115.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$15.85
|
| Rate for Payer: UHCCP Medicaid |
$67.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$10.58
|
| Rate for Payer: Wellcare Medicare Advantage |
$12.19
|
|
|
INTERACTIVE COMPLEXITY ADDT TH
|
Professional
|
Both
|
$264.00
|
|
|
Service Code
|
HCPCS 90785
|
| Hospital Charge Code |
51000286
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$4.29 |
| Max. Negotiated Rate |
$158.40 |
| Rate for Payer: Aetna Commercial |
$8.13
|
| Rate for Payer: Ambetter Exchange |
$12.19
|
| Rate for Payer: Anthem Medicaid |
$10.48
|
| Rate for Payer: Buckeye Individual/Medicaid |
$12.19
|
| Rate for Payer: Buckeye Medicare Advantage |
$12.19
|
| Rate for Payer: CareSource Just4Me Medicare |
$14.63
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$7.09
|
| Rate for Payer: Healthspan PPO |
$4.29
|
| Rate for Payer: Humana Medicaid |
$10.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$7.87
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$12.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.19
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$10.69
|
| Rate for Payer: Molina Healthcare Passport |
$10.48
|
| Rate for Payer: Multiplan PHCS |
$158.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$15.85
|
| Rate for Payer: UHCCP Medicaid |
$92.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$10.58
|
| Rate for Payer: Wellcare Medicare Advantage |
$12.19
|
|
|
INTERCEED
|
Facility
|
IP
|
$416.93
|
|
| Hospital Charge Code |
27000092
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$125.08 |
| Max. Negotiated Rate |
$400.25 |
| Rate for Payer: Aetna Commercial |
$321.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$325.21
|
| Rate for Payer: Cash Price |
$208.46
|
| Rate for Payer: Cigna Commercial |
$346.05
|
| Rate for Payer: First Health Commercial |
$396.08
|
| Rate for Payer: Humana Commercial |
$354.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$341.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$307.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$125.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$366.90
|
| Rate for Payer: Ohio Health Group HMO |
$312.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$333.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$362.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$287.68
|
| Rate for Payer: PHCS Commercial |
$400.25
|
| Rate for Payer: United Healthcare All Payer |
$366.90
|
|
|
INTERCEED
|
Facility
|
OP
|
$416.93
|
|
| Hospital Charge Code |
27000092
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$125.08 |
| Max. Negotiated Rate |
$400.25 |
| Rate for Payer: Aetna Commercial |
$321.04
|
| Rate for Payer: Anthem Medicaid |
$143.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$325.21
|
| Rate for Payer: Cash Price |
$208.46
|
| Rate for Payer: Cigna Commercial |
$346.05
|
| Rate for Payer: First Health Commercial |
$396.08
|
| Rate for Payer: Humana Commercial |
$354.39
|
| Rate for Payer: Humana KY Medicaid |
$143.38
|
| Rate for Payer: Kentucky WC Medicaid |
$144.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$341.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$307.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$125.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$146.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$366.90
|
| Rate for Payer: Ohio Health Group HMO |
$312.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$333.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$362.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$287.68
|
| Rate for Payer: PHCS Commercial |
$400.25
|
| Rate for Payer: United Healthcare All Payer |
$366.90
|
|
|
INTERCOSTAL NERVE BLOCK
|
Professional
|
Both
|
$1,606.00
|
|
|
Service Code
|
HCPCS 64420
|
| Hospital Charge Code |
76102314
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$29.94 |
| Max. Negotiated Rate |
$963.60 |
| Rate for Payer: Aetna Commercial |
$105.75
|
| Rate for Payer: Ambetter Exchange |
$55.45
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$29.94
|
| Rate for Payer: Anthem Medicaid |
$77.31
|
| Rate for Payer: Buckeye Individual/Medicaid |
$55.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$55.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$66.54
|
| Rate for Payer: Cash Price |
$803.00
|
| Rate for Payer: Cash Price |
$803.00
|
| Rate for Payer: Cigna Commercial |
$271.42
|
| Rate for Payer: Healthspan PPO |
$188.64
|
| Rate for Payer: Humana Medicaid |
$77.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$85.07
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$55.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$78.86
|
| Rate for Payer: Molina Healthcare Passport |
$77.31
|
| Rate for Payer: Multiplan PHCS |
$963.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$72.08
|
| Rate for Payer: UHCCP Medicaid |
$31.44
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$78.08
|
| Rate for Payer: Wellcare Medicare Advantage |
$55.45
|
|
|
INTERCOSTAL NERVE BLOCK
|
Facility
|
IP
|
$1,606.00
|
|
|
Service Code
|
HCPCS 64420
|
| Hospital Charge Code |
76102314
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$481.80 |
| Max. Negotiated Rate |
$1,541.76 |
| Rate for Payer: Aetna Commercial |
$1,236.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,252.68
|
| Rate for Payer: Cash Price |
$803.00
|
| Rate for Payer: Cigna Commercial |
$1,332.98
|
| Rate for Payer: First Health Commercial |
$1,525.70
|
| Rate for Payer: Humana Commercial |
$1,365.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,316.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,185.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$481.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,413.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,204.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,284.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,397.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,108.14
|
| Rate for Payer: PHCS Commercial |
$1,541.76
|
| Rate for Payer: United Healthcare All Payer |
$1,413.28
|
|
|
INTERCOSTAL NERVE BLOCK
|
Facility
|
OP
|
$1,606.00
|
|
|
Service Code
|
HCPCS 64420
|
| Hospital Charge Code |
76102314
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$552.30 |
| Max. Negotiated Rate |
$1,541.76 |
| Rate for Payer: Aetna Commercial |
$1,236.62
|
| Rate for Payer: Anthem Medicaid |
$552.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$639.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,252.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$895.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$863.82
|
| Rate for Payer: Cash Price |
$803.00
|
| Rate for Payer: Cash Price |
$803.00
|
| Rate for Payer: Cigna Commercial |
$1,332.98
|
| Rate for Payer: First Health Commercial |
$1,525.70
|
| Rate for Payer: Humana Commercial |
$1,365.10
|
| Rate for Payer: Humana KY Medicaid |
$552.30
|
| Rate for Payer: Humana Medicare Advantage |
$639.87
|
| Rate for Payer: Kentucky WC Medicaid |
$557.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,316.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,185.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$767.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$563.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,413.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,204.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,284.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,397.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,108.14
|
| Rate for Payer: PHCS Commercial |
$1,541.76
|
| Rate for Payer: United Healthcare All Payer |
$1,413.28
|
|
|
INTERCOSTAL NERVE BLOCK DX MUL
|
Facility
|
OP
|
$2,380.00
|
|
|
Service Code
|
HCPCS 64421
|
| Hospital Charge Code |
76102315
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$818.48 |
| Max. Negotiated Rate |
$2,284.80 |
| Rate for Payer: Aetna Commercial |
$1,832.60
|
| Rate for Payer: Anthem Medicaid |
$818.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$822.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,856.40
|
| 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 |
$1,190.00
|
| Rate for Payer: Cash Price |
$1,190.00
|
| Rate for Payer: Cigna Commercial |
$1,975.40
|
| Rate for Payer: First Health Commercial |
$2,261.00
|
| Rate for Payer: Humana Commercial |
$2,023.00
|
| Rate for Payer: Humana KY Medicaid |
$818.48
|
| Rate for Payer: Humana Medicare Advantage |
$822.61
|
| Rate for Payer: Kentucky WC Medicaid |
$826.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,951.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,756.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$987.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$834.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,094.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,785.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,904.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,070.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,642.20
|
| Rate for Payer: PHCS Commercial |
$2,284.80
|
| Rate for Payer: United Healthcare All Payer |
$2,094.40
|
|
|
INTERCOSTAL NERVE BLOCK DX MUL
|
Professional
|
Both
|
$2,380.00
|
|
|
Service Code
|
HCPCS 64421
|
| Hospital Charge Code |
76102315
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$23.11 |
| Max. Negotiated Rate |
$1,428.00 |
| Rate for Payer: Aetna Commercial |
$145.02
|
| Rate for Payer: Ambetter Exchange |
$23.11
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$25.26
|
| Rate for Payer: Anthem Medicaid |
$26.73
|
| Rate for Payer: Buckeye Individual/Medicaid |
$23.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$23.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$27.73
|
| Rate for Payer: Cash Price |
$1,190.00
|
| Rate for Payer: Cash Price |
$1,190.00
|
| Rate for Payer: Cigna Commercial |
$411.97
|
| Rate for Payer: Healthspan PPO |
$277.96
|
| Rate for Payer: Humana Medicaid |
$26.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$117.67
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$23.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$27.26
|
| Rate for Payer: Molina Healthcare Passport |
$26.73
|
| Rate for Payer: Multiplan PHCS |
$1,428.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$30.04
|
| Rate for Payer: UHCCP Medicaid |
$26.52
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$27.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$23.11
|
|
|
INTERCOSTAL NERVE BLOCK DX MUL
|
Facility
|
IP
|
$1,955.00
|
|
|
Service Code
|
HCPCS 64421
|
| Hospital Charge Code |
761T2315
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$586.50 |
| Max. Negotiated Rate |
$1,876.80 |
| Rate for Payer: Aetna Commercial |
$1,505.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,524.90
|
| Rate for Payer: Cash Price |
$977.50
|
| Rate for Payer: Cigna Commercial |
$1,622.65
|
| Rate for Payer: First Health Commercial |
$1,857.25
|
| Rate for Payer: Humana Commercial |
$1,661.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,603.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,442.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$586.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,720.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,466.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,564.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,700.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,348.95
|
| Rate for Payer: PHCS Commercial |
$1,876.80
|
| Rate for Payer: United Healthcare All Payer |
$1,720.40
|
|
|
INTERCOSTAL NERVE BLOCK DX MUL
|
Facility
|
IP
|
$2,380.00
|
|
|
Service Code
|
HCPCS 64421
|
| Hospital Charge Code |
76102315
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$714.00 |
| Max. Negotiated Rate |
$2,284.80 |
| Rate for Payer: Aetna Commercial |
$1,832.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,856.40
|
| Rate for Payer: Cash Price |
$1,190.00
|
| Rate for Payer: Cigna Commercial |
$1,975.40
|
| Rate for Payer: First Health Commercial |
$2,261.00
|
| Rate for Payer: Humana Commercial |
$2,023.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,951.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,756.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$714.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,094.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,785.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,904.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,070.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,642.20
|
| Rate for Payer: PHCS Commercial |
$2,284.80
|
| Rate for Payer: United Healthcare All Payer |
$2,094.40
|
|
|
INTERCOSTAL NERVE BLOCK DX MUL
|
Professional
|
Both
|
$425.00
|
|
|
Service Code
|
HCPCS 64421
|
| Hospital Charge Code |
761P2315
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$23.11 |
| Max. Negotiated Rate |
$411.97 |
| Rate for Payer: Aetna Commercial |
$145.02
|
| Rate for Payer: Ambetter Exchange |
$23.11
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$25.26
|
| Rate for Payer: Anthem Medicaid |
$26.73
|
| Rate for Payer: Buckeye Individual/Medicaid |
$23.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$23.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$27.73
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cigna Commercial |
$411.97
|
| Rate for Payer: Healthspan PPO |
$277.96
|
| Rate for Payer: Humana Medicaid |
$26.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$117.67
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$23.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$27.26
|
| Rate for Payer: Molina Healthcare Passport |
$26.73
|
| Rate for Payer: Multiplan PHCS |
$255.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$30.04
|
| Rate for Payer: UHCCP Medicaid |
$26.52
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$27.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$23.11
|
|
|
INTERCOSTAL NERVE BLOCK DX MUL
|
Facility
|
OP
|
$1,955.00
|
|
|
Service Code
|
HCPCS 64421
|
| Hospital Charge Code |
761T2315
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$672.32 |
| Max. Negotiated Rate |
$1,876.80 |
| Rate for Payer: Aetna Commercial |
$1,505.35
|
| Rate for Payer: Anthem Medicaid |
$672.32
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$822.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,524.90
|
| 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 |
$977.50
|
| Rate for Payer: Cash Price |
$977.50
|
| Rate for Payer: Cigna Commercial |
$1,622.65
|
| Rate for Payer: First Health Commercial |
$1,857.25
|
| Rate for Payer: Humana Commercial |
$1,661.75
|
| Rate for Payer: Humana KY Medicaid |
$672.32
|
| Rate for Payer: Humana Medicare Advantage |
$822.61
|
| Rate for Payer: Kentucky WC Medicaid |
$679.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,603.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,442.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$987.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$685.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,720.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,466.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,564.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,700.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,348.95
|
| Rate for Payer: PHCS Commercial |
$1,876.80
|
| Rate for Payer: United Healthcare All Payer |
$1,720.40
|
|
|
INTERCOSTAL NERVE BLOCK(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 64420
|
| Hospital Charge Code |
761P2314
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$29.94 |
| Max. Negotiated Rate |
$271.42 |
| Rate for Payer: Aetna Commercial |
$105.75
|
| Rate for Payer: Ambetter Exchange |
$55.45
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$29.94
|
| Rate for Payer: Anthem Medicaid |
$77.31
|
| Rate for Payer: Buckeye Individual/Medicaid |
$55.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$55.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$66.54
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$271.42
|
| Rate for Payer: Healthspan PPO |
$188.64
|
| Rate for Payer: Humana Medicaid |
$77.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$85.07
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$55.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$78.86
|
| Rate for Payer: Molina Healthcare Passport |
$77.31
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$72.08
|
| Rate for Payer: UHCCP Medicaid |
$31.44
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$78.08
|
| Rate for Payer: Wellcare Medicare Advantage |
$55.45
|
|
|
INTERCOSTAL NERVE BLOCK(T
|
Facility
|
IP
|
$1,356.00
|
|
|
Service Code
|
HCPCS 64420
|
| Hospital Charge Code |
761T2314
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$406.80 |
| Max. Negotiated Rate |
$1,301.76 |
| Rate for Payer: Aetna Commercial |
$1,044.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,057.68
|
| Rate for Payer: Cash Price |
$678.00
|
| Rate for Payer: Cigna Commercial |
$1,125.48
|
| Rate for Payer: First Health Commercial |
$1,288.20
|
| Rate for Payer: Humana Commercial |
$1,152.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,111.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,000.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$406.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,193.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,017.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,084.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,179.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$935.64
|
| Rate for Payer: PHCS Commercial |
$1,301.76
|
| Rate for Payer: United Healthcare All Payer |
$1,193.28
|
|
|
INTERCOSTAL NERVE BLOCK(T
|
Facility
|
OP
|
$1,356.00
|
|
|
Service Code
|
HCPCS 64420
|
| Hospital Charge Code |
761T2314
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$466.33 |
| Max. Negotiated Rate |
$1,301.76 |
| Rate for Payer: Aetna Commercial |
$1,044.12
|
| Rate for Payer: Anthem Medicaid |
$466.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$639.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,057.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$895.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$863.82
|
| Rate for Payer: Cash Price |
$678.00
|
| Rate for Payer: Cash Price |
$678.00
|
| Rate for Payer: Cigna Commercial |
$1,125.48
|
| Rate for Payer: First Health Commercial |
$1,288.20
|
| Rate for Payer: Humana Commercial |
$1,152.60
|
| Rate for Payer: Humana KY Medicaid |
$466.33
|
| Rate for Payer: Humana Medicare Advantage |
$639.87
|
| Rate for Payer: Kentucky WC Medicaid |
$471.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,111.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,000.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$767.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$475.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,193.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,017.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,084.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,179.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$935.64
|
| Rate for Payer: PHCS Commercial |
$1,301.76
|
| Rate for Payer: United Healthcare All Payer |
$1,193.28
|
|
|
INTERNALBRACE AR-1789J-CP
|
Facility
|
OP
|
$8,456.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,537.03 |
| Max. Negotiated Rate |
$8,118.48 |
| Rate for Payer: Aetna Commercial |
$6,511.70
|
| Rate for Payer: Anthem Medicaid |
$2,908.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,596.27
|
| Rate for Payer: Cash Price |
$4,228.38
|
| Rate for Payer: Cigna Commercial |
$7,019.10
|
| Rate for Payer: First Health Commercial |
$8,033.91
|
| Rate for Payer: Humana Commercial |
$7,188.24
|
| Rate for Payer: Humana KY Medicaid |
$2,908.28
|
| Rate for Payer: Kentucky WC Medicaid |
$2,937.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,934.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,241.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,537.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,966.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,441.94
|
| Rate for Payer: Ohio Health Group HMO |
$6,342.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,765.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,357.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,835.16
|
| Rate for Payer: PHCS Commercial |
$8,118.48
|
| Rate for Payer: United Healthcare All Payer |
$7,441.94
|
|
|
INTERNALBRACE AR-1789J-CP
|
Facility
|
IP
|
$8,456.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,537.03 |
| Max. Negotiated Rate |
$8,118.48 |
| Rate for Payer: Aetna Commercial |
$6,511.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,596.27
|
| Rate for Payer: Cash Price |
$4,228.38
|
| Rate for Payer: Cigna Commercial |
$7,019.10
|
| Rate for Payer: First Health Commercial |
$8,033.91
|
| Rate for Payer: Humana Commercial |
$7,188.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,934.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,241.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,537.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,441.94
|
| Rate for Payer: Ohio Health Group HMO |
$6,342.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,765.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,357.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,835.16
|
| Rate for Payer: PHCS Commercial |
$8,118.48
|
| Rate for Payer: United Healthcare All Payer |
$7,441.94
|
|
|
INTERNALBRACE LGMT AUG RPR KIT
|
Facility
|
IP
|
$8,729.59
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,618.88 |
| Max. Negotiated Rate |
$8,380.41 |
| Rate for Payer: Aetna Commercial |
$6,721.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,809.08
|
| Rate for Payer: Cash Price |
$4,364.79
|
| Rate for Payer: Cigna Commercial |
$7,245.56
|
| Rate for Payer: First Health Commercial |
$8,293.11
|
| Rate for Payer: Humana Commercial |
$7,420.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,158.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,442.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,618.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,682.04
|
| Rate for Payer: Ohio Health Group HMO |
$6,547.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,983.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,594.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,023.42
|
| Rate for Payer: PHCS Commercial |
$8,380.41
|
| Rate for Payer: United Healthcare All Payer |
$7,682.04
|
|
|
INTERNALBRACE LGMT AUG RPR KIT
|
Facility
|
OP
|
$8,729.59
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,618.88 |
| Max. Negotiated Rate |
$8,380.41 |
| Rate for Payer: Aetna Commercial |
$6,721.78
|
| Rate for Payer: Anthem Medicaid |
$3,002.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,809.08
|
| Rate for Payer: Cash Price |
$4,364.79
|
| Rate for Payer: Cigna Commercial |
$7,245.56
|
| Rate for Payer: First Health Commercial |
$8,293.11
|
| Rate for Payer: Humana Commercial |
$7,420.15
|
| Rate for Payer: Humana KY Medicaid |
$3,002.11
|
| Rate for Payer: Kentucky WC Medicaid |
$3,032.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,158.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,442.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,618.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,062.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,682.04
|
| Rate for Payer: Ohio Health Group HMO |
$6,547.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,983.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,594.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,023.42
|
| Rate for Payer: PHCS Commercial |
$8,380.41
|
| Rate for Payer: United Healthcare All Payer |
$7,682.04
|
|
|
INTERNAL NERVE REVISION
|
Professional
|
Both
|
$850.00
|
|
|
Service Code
|
HCPCS 64727
|
| Hospital Charge Code |
76102366
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$167.13 |
| Max. Negotiated Rate |
$510.00 |
| Rate for Payer: Aetna Commercial |
$307.67
|
| Rate for Payer: Ambetter Exchange |
$167.13
|
| Rate for Payer: Anthem Medicaid |
$191.23
|
| Rate for Payer: Buckeye Individual/Medicaid |
$167.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$167.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$200.56
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$283.13
|
| Rate for Payer: Healthspan PPO |
$240.22
|
| Rate for Payer: Humana Medicaid |
$191.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$240.18
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$167.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$167.13
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$195.05
|
| Rate for Payer: Molina Healthcare Passport |
$191.23
|
| Rate for Payer: Multiplan PHCS |
$510.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$217.27
|
| Rate for Payer: UHCCP Medicaid |
$297.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$193.14
|
| Rate for Payer: Wellcare Medicare Advantage |
$167.13
|
|
|
INTERNAL NERVE REVISION
|
Facility
|
OP
|
$850.00
|
|
|
Service Code
|
HCPCS 64727
|
| Hospital Charge Code |
76102366
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$255.00 |
| Max. Negotiated Rate |
$816.00 |
| Rate for Payer: Aetna Commercial |
$654.50
|
| Rate for Payer: Anthem Medicaid |
$292.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$663.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$705.50
|
| Rate for Payer: First Health Commercial |
$807.50
|
| Rate for Payer: Humana Commercial |
$722.50
|
| Rate for Payer: Humana KY Medicaid |
$292.31
|
| Rate for Payer: Kentucky WC Medicaid |
$295.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$697.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$627.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$255.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$298.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$748.00
|
| Rate for Payer: Ohio Health Group HMO |
$637.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$680.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$739.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$586.50
|
| Rate for Payer: PHCS Commercial |
$816.00
|
| Rate for Payer: United Healthcare All Payer |
$748.00
|
|
|
INTERNAL NERVE REVISION
|
Facility
|
IP
|
$850.00
|
|
|
Service Code
|
HCPCS 64727
|
| Hospital Charge Code |
76102366
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$255.00 |
| Max. Negotiated Rate |
$816.00 |
| Rate for Payer: Aetna Commercial |
$654.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$663.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$705.50
|
| Rate for Payer: First Health Commercial |
$807.50
|
| Rate for Payer: Humana Commercial |
$722.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$697.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$627.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$255.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$748.00
|
| Rate for Payer: Ohio Health Group HMO |
$637.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$680.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$739.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$586.50
|
| Rate for Payer: PHCS Commercial |
$816.00
|
| Rate for Payer: United Healthcare All Payer |
$748.00
|
|
|
INTERNAL NERVE REVISION(P
|
Professional
|
Both
|
$850.00
|
|
|
Service Code
|
HCPCS 64727
|
| Hospital Charge Code |
761P2366
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$167.13 |
| Max. Negotiated Rate |
$510.00 |
| Rate for Payer: Aetna Commercial |
$307.67
|
| Rate for Payer: Ambetter Exchange |
$167.13
|
| Rate for Payer: Anthem Medicaid |
$191.23
|
| Rate for Payer: Buckeye Individual/Medicaid |
$167.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$167.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$200.56
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$283.13
|
| Rate for Payer: Healthspan PPO |
$240.22
|
| Rate for Payer: Humana Medicaid |
$191.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$240.18
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$167.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$167.13
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$195.05
|
| Rate for Payer: Molina Healthcare Passport |
$191.23
|
| Rate for Payer: Multiplan PHCS |
$510.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$217.27
|
| Rate for Payer: UHCCP Medicaid |
$297.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$193.14
|
| Rate for Payer: Wellcare Medicare Advantage |
$167.13
|
|
