|
NAVIG ACCESS SHEATH 12/14F*46C
|
Facility
|
OP
|
$1,783.72
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$231.88 |
| Max. Negotiated Rate |
$1,712.37 |
| Rate for Payer: Aetna Commercial |
$1,373.46
|
| Rate for Payer: Anthem Medicaid |
$613.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,391.30
|
| Rate for Payer: Cash Price |
$891.86
|
| Rate for Payer: Cigna Commercial |
$1,480.49
|
| Rate for Payer: First Health Commercial |
$1,694.53
|
| Rate for Payer: Humana Commercial |
$1,516.16
|
| Rate for Payer: Humana KY Medicaid |
$613.42
|
| Rate for Payer: Kentucky WC Medicaid |
$619.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,316.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$625.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.67
|
| Rate for Payer: Ohio Health Group HMO |
$1,337.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$552.95
|
| Rate for Payer: PHCS Commercial |
$1,712.37
|
| Rate for Payer: United Healthcare All Payer |
$1,569.67
|
|
|
NAVIG ACCESS SHEATH 12/14F*46C
|
Facility
|
IP
|
$1,783.72
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$231.88 |
| Max. Negotiated Rate |
$1,712.37 |
| Rate for Payer: Aetna Commercial |
$1,373.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,391.30
|
| Rate for Payer: Cash Price |
$891.86
|
| Rate for Payer: Cigna Commercial |
$1,480.49
|
| Rate for Payer: First Health Commercial |
$1,694.53
|
| Rate for Payer: Humana Commercial |
$1,516.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,316.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.67
|
| Rate for Payer: Ohio Health Group HMO |
$1,337.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$552.95
|
| Rate for Payer: PHCS Commercial |
$1,712.37
|
| Rate for Payer: United Healthcare All Payer |
$1,569.67
|
|
|
NAVIGATIONAL BRONCHOSCOPY
|
Professional
|
Both
|
$1,665.00
|
|
|
Service Code
|
HCPCS 31627
|
| Hospital Charge Code |
41000039
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$48.80 |
| Max. Negotiated Rate |
$1,665.00 |
| Rate for Payer: Aetna Commercial |
$174.58
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$48.80
|
| Rate for Payer: Anthem Medicaid |
$78.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,665.00
|
| Rate for Payer: Cash Price |
$832.50
|
| Rate for Payer: Cash Price |
$832.50
|
| Rate for Payer: Cigna Commercial |
$168.85
|
| Rate for Payer: Healthspan PPO |
$1,153.55
|
| Rate for Payer: Humana Medicaid |
$78.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$130.86
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$79.83
|
| Rate for Payer: Molina Healthcare Passport |
$78.26
|
| Rate for Payer: Multiplan PHCS |
$999.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,165.50
|
| Rate for Payer: UHCCP Medicaid |
$51.24
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$79.04
|
|
|
NAVIGATIONAL BRONCHOSCOPY(P
|
Professional
|
Both
|
$1,665.00
|
|
|
Service Code
|
HCPCS 31627
|
| Hospital Charge Code |
410P0039
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$48.80 |
| Max. Negotiated Rate |
$1,665.00 |
| Rate for Payer: Aetna Commercial |
$174.58
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$48.80
|
| Rate for Payer: Anthem Medicaid |
$78.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,665.00
|
| Rate for Payer: Cash Price |
$832.50
|
| Rate for Payer: Cash Price |
$832.50
|
| Rate for Payer: Cigna Commercial |
$168.85
|
| Rate for Payer: Healthspan PPO |
$1,153.55
|
| Rate for Payer: Humana Medicaid |
$78.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$130.86
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$79.83
|
| Rate for Payer: Molina Healthcare Passport |
$78.26
|
| Rate for Payer: Multiplan PHCS |
$999.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,165.50
|
| Rate for Payer: UHCCP Medicaid |
$51.24
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$79.04
|
|
|
N BLOCK INJ BRACHIAL PLEXUS
|
Professional
|
Both
|
$2,470.77
|
|
|
Service Code
|
HCPCS 64415
|
| Hospital Charge Code |
76102312
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$31.84 |
| Max. Negotiated Rate |
$2,470.77 |
| Rate for Payer: Aetna Commercial |
$119.44
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$31.84
|
| Rate for Payer: Anthem Medicaid |
$51.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,470.77
|
| Rate for Payer: Cash Price |
$1,235.38
|
| Rate for Payer: Cash Price |
$1,235.38
|
| Rate for Payer: Cigna Commercial |
$112.01
|
| Rate for Payer: Healthspan PPO |
$156.45
|
| Rate for Payer: Humana Medicaid |
$51.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$86.29
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$52.76
|
| Rate for Payer: Molina Healthcare Passport |
$51.73
|
| Rate for Payer: Multiplan PHCS |
$1,482.46
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,729.54
|
| Rate for Payer: UHCCP Medicaid |
$33.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$52.25
|
|
|
N BLOCK INJ BRACHIAL PLEXUS
|
Facility
|
OP
|
$2,470.77
|
|
|
Service Code
|
HCPCS 64415
|
| Hospital Charge Code |
76102312
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$321.20 |
| Max. Negotiated Rate |
$2,371.94 |
| Rate for Payer: Aetna Commercial |
$1,902.49
|
| Rate for Payer: Anthem Medicaid |
$849.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$788.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,927.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,103.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,064.08
|
| Rate for Payer: Cash Price |
$1,235.38
|
| Rate for Payer: Cash Price |
$1,235.38
|
| Rate for Payer: Cigna Commercial |
$2,050.74
|
| Rate for Payer: First Health Commercial |
$2,347.23
|
| Rate for Payer: Humana Commercial |
$2,100.15
|
| Rate for Payer: Humana KY Medicaid |
$849.70
|
| Rate for Payer: Humana Medicare Advantage |
$788.21
|
| Rate for Payer: Kentucky WC Medicaid |
$858.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,026.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,823.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$945.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$866.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,174.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,853.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$494.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$321.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$765.94
|
| Rate for Payer: PHCS Commercial |
$2,371.94
|
| Rate for Payer: United Healthcare All Payer |
$2,174.28
|
|
|
N BLOCK INJ BRACHIAL PLEXUS
|
Facility
|
IP
|
$2,470.77
|
|
|
Service Code
|
HCPCS 64415
|
| Hospital Charge Code |
76102312
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$321.20 |
| Max. Negotiated Rate |
$2,371.94 |
| Rate for Payer: Aetna Commercial |
$1,902.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,927.20
|
| Rate for Payer: Cash Price |
$1,235.38
|
| Rate for Payer: Cigna Commercial |
$2,050.74
|
| Rate for Payer: First Health Commercial |
$2,347.23
|
| Rate for Payer: Humana Commercial |
$2,100.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,026.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,823.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$741.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,174.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,853.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$494.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$321.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$765.94
|
| Rate for Payer: PHCS Commercial |
$2,371.94
|
| Rate for Payer: United Healthcare All Payer |
$2,174.28
|
|
|
N BLOCK INJ BRACHIAL PLEXUS(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 64415
|
| Hospital Charge Code |
761P2312
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$31.84 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Aetna Commercial |
$119.44
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$31.84
|
| Rate for Payer: Anthem Medicaid |
$51.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$112.01
|
| Rate for Payer: Healthspan PPO |
$156.45
|
| Rate for Payer: Humana Medicaid |
$51.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$86.29
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$52.76
|
| Rate for Payer: Molina Healthcare Passport |
$51.73
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$33.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$52.25
|
|
|
N BLOCK INJ BRACHIAL PLEXUS(T
|
Facility
|
OP
|
$2,220.77
|
|
|
Service Code
|
HCPCS 64415
|
| Hospital Charge Code |
761T2312
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$288.70 |
| Max. Negotiated Rate |
$2,131.94 |
| Rate for Payer: Aetna Commercial |
$1,709.99
|
| Rate for Payer: Anthem Medicaid |
$763.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$788.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,732.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,103.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,064.08
|
| Rate for Payer: Cash Price |
$1,110.38
|
| Rate for Payer: Cash Price |
$1,110.38
|
| Rate for Payer: Cigna Commercial |
$1,843.24
|
| Rate for Payer: First Health Commercial |
$2,109.73
|
| Rate for Payer: Humana Commercial |
$1,887.65
|
| Rate for Payer: Humana KY Medicaid |
$763.72
|
| Rate for Payer: Humana Medicare Advantage |
$788.21
|
| Rate for Payer: Kentucky WC Medicaid |
$771.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,821.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,638.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$945.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$779.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,954.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,665.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$444.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$288.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$688.44
|
| Rate for Payer: PHCS Commercial |
$2,131.94
|
| Rate for Payer: United Healthcare All Payer |
$1,954.28
|
|
|
N BLOCK INJ BRACHIAL PLEXUS(T
|
Facility
|
IP
|
$2,220.77
|
|
|
Service Code
|
HCPCS 64415
|
| Hospital Charge Code |
761T2312
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$288.70 |
| Max. Negotiated Rate |
$2,131.94 |
| Rate for Payer: Aetna Commercial |
$1,709.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,732.20
|
| Rate for Payer: Cash Price |
$1,110.38
|
| Rate for Payer: Cigna Commercial |
$1,843.24
|
| Rate for Payer: First Health Commercial |
$2,109.73
|
| Rate for Payer: Humana Commercial |
$1,887.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,821.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,638.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$666.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,954.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,665.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$444.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$288.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$688.44
|
| Rate for Payer: PHCS Commercial |
$2,131.94
|
| Rate for Payer: United Healthcare All Payer |
$1,954.28
|
|
|
N BLOCK INJ COMMON DIGIT
|
Professional
|
Both
|
$195.00
|
|
|
Service Code
|
HCPCS 64632
|
| Hospital Charge Code |
76102650
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$46.50 |
| Max. Negotiated Rate |
$195.00 |
| Rate for Payer: Aetna Commercial |
$115.09
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$46.50
|
| Rate for Payer: Anthem Medicaid |
$55.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$195.00
|
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: Cash Price |
$97.50
|
| Rate for Payer: Cigna Commercial |
$131.55
|
| Rate for Payer: Healthspan PPO |
$104.30
|
| Rate for Payer: Humana Medicaid |
$55.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$89.50
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$56.90
|
| Rate for Payer: Molina Healthcare Passport |
$55.78
|
| Rate for Payer: Multiplan PHCS |
$117.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$136.50
|
| Rate for Payer: UHCCP Medicaid |
$48.82
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$56.34
|
|
|
N BLOCK INJ HYPOGAS PLXS
|
Professional
|
Both
|
$2,454.00
|
|
|
Service Code
|
HCPCS 64517
|
| Hospital Charge Code |
76102334
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$64.02 |
| Max. Negotiated Rate |
$2,454.00 |
| Rate for Payer: Aetna Commercial |
$189.57
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$64.02
|
| Rate for Payer: Anthem Medicaid |
$89.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,454.00
|
| Rate for Payer: Cash Price |
$1,227.00
|
| Rate for Payer: Cash Price |
$1,227.00
|
| Rate for Payer: Cigna Commercial |
$175.10
|
| Rate for Payer: Healthspan PPO |
$204.44
|
| Rate for Payer: Humana Medicaid |
$89.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$152.50
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$91.06
|
| Rate for Payer: Molina Healthcare Passport |
$89.27
|
| Rate for Payer: Multiplan PHCS |
$1,472.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,717.80
|
| Rate for Payer: UHCCP Medicaid |
$67.22
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$90.16
|
|
|
N BLOCK INJ HYPOGAS PLXS
|
Facility
|
OP
|
$2,454.00
|
|
|
Service Code
|
HCPCS 64517
|
| Hospital Charge Code |
76102334
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$319.02 |
| Max. Negotiated Rate |
$2,355.84 |
| Rate for Payer: Aetna Commercial |
$1,889.58
|
| Rate for Payer: Anthem Medicaid |
$843.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$788.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,914.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,103.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,064.08
|
| Rate for Payer: Cash Price |
$1,227.00
|
| Rate for Payer: Cash Price |
$1,227.00
|
| Rate for Payer: Cigna Commercial |
$2,036.82
|
| Rate for Payer: First Health Commercial |
$2,331.30
|
| Rate for Payer: Humana Commercial |
$2,085.90
|
| Rate for Payer: Humana KY Medicaid |
$843.93
|
| Rate for Payer: Humana Medicare Advantage |
$788.21
|
| Rate for Payer: Kentucky WC Medicaid |
$852.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,012.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,811.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$945.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$860.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,159.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,840.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$490.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$319.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$760.74
|
| Rate for Payer: PHCS Commercial |
$2,355.84
|
| Rate for Payer: United Healthcare All Payer |
$2,159.52
|
|
|
N BLOCK INJ HYPOGAS PLXS
|
Facility
|
IP
|
$2,454.00
|
|
|
Service Code
|
HCPCS 64517
|
| Hospital Charge Code |
76102334
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$319.02 |
| Max. Negotiated Rate |
$2,355.84 |
| Rate for Payer: Aetna Commercial |
$1,889.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,914.12
|
| Rate for Payer: Cash Price |
$1,227.00
|
| Rate for Payer: Cigna Commercial |
$2,036.82
|
| Rate for Payer: First Health Commercial |
$2,331.30
|
| Rate for Payer: Humana Commercial |
$2,085.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,012.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,811.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$736.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,159.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,840.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$490.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$319.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$760.74
|
| Rate for Payer: PHCS Commercial |
$2,355.84
|
| Rate for Payer: United Healthcare All Payer |
$2,159.52
|
|
|
N BLOCK INJ HYPOGAS PLXS(P
|
Professional
|
Both
|
$550.00
|
|
|
Service Code
|
HCPCS 64517
|
| Hospital Charge Code |
761P2334
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$64.02 |
| Max. Negotiated Rate |
$550.00 |
| Rate for Payer: Aetna Commercial |
$189.57
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$64.02
|
| Rate for Payer: Anthem Medicaid |
$89.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$550.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$175.10
|
| Rate for Payer: Healthspan PPO |
$204.44
|
| Rate for Payer: Humana Medicaid |
$89.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$152.50
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$91.06
|
| Rate for Payer: Molina Healthcare Passport |
$89.27
|
| Rate for Payer: Multiplan PHCS |
$330.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$385.00
|
| Rate for Payer: UHCCP Medicaid |
$67.22
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$90.16
|
|
|
N BLOCK INJ HYPOGAS PLXS(T
|
Facility
|
IP
|
$1,904.00
|
|
|
Service Code
|
HCPCS 64517
|
| Hospital Charge Code |
761T2334
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$247.52 |
| Max. Negotiated Rate |
$1,827.84 |
| Rate for Payer: Aetna Commercial |
$1,466.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.12
|
| Rate for Payer: Cash Price |
$952.00
|
| Rate for Payer: Cigna Commercial |
$1,580.32
|
| Rate for Payer: First Health Commercial |
$1,808.80
|
| Rate for Payer: Humana Commercial |
$1,618.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,561.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,675.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$380.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$590.24
|
| Rate for Payer: PHCS Commercial |
$1,827.84
|
| Rate for Payer: United Healthcare All Payer |
$1,675.52
|
|
|
N BLOCK INJ HYPOGAS PLXS(T
|
Facility
|
OP
|
$1,904.00
|
|
|
Service Code
|
HCPCS 64517
|
| Hospital Charge Code |
761T2334
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$247.52 |
| Max. Negotiated Rate |
$1,827.84 |
| Rate for Payer: Aetna Commercial |
$1,466.08
|
| Rate for Payer: Anthem Medicaid |
$654.79
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$788.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,103.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,064.08
|
| Rate for Payer: Cash Price |
$952.00
|
| Rate for Payer: Cash Price |
$952.00
|
| Rate for Payer: Cigna Commercial |
$1,580.32
|
| Rate for Payer: First Health Commercial |
$1,808.80
|
| Rate for Payer: Humana Commercial |
$1,618.40
|
| Rate for Payer: Humana KY Medicaid |
$654.79
|
| Rate for Payer: Humana Medicare Advantage |
$788.21
|
| Rate for Payer: Kentucky WC Medicaid |
$661.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,561.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$945.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$667.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,675.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$380.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$590.24
|
| Rate for Payer: PHCS Commercial |
$1,827.84
|
| Rate for Payer: United Healthcare All Payer |
$1,675.52
|
|
|
N BLOCK INJ PLANTAR DIGIT
|
Facility
|
IP
|
$610.00
|
|
|
Service Code
|
HCPCS 64455
|
| Hospital Charge Code |
76102320
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$79.30 |
| Max. Negotiated Rate |
$585.60 |
| Rate for Payer: Aetna Commercial |
$469.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$475.80
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cigna Commercial |
$506.30
|
| Rate for Payer: First Health Commercial |
$579.50
|
| Rate for Payer: Humana Commercial |
$518.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$500.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$450.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$183.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$536.80
|
| Rate for Payer: Ohio Health Group HMO |
$457.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$122.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$189.10
|
| Rate for Payer: PHCS Commercial |
$585.60
|
| Rate for Payer: United Healthcare All Payer |
$536.80
|
|
|
N BLOCK INJ PLANTAR DIGIT
|
Professional
|
Both
|
$488.00
|
|
|
Service Code
|
HCPCS 64455
|
| Hospital Charge Code |
360P1278
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$25.87 |
| Max. Negotiated Rate |
$488.00 |
| Rate for Payer: Aetna Commercial |
$67.55
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$25.87
|
| Rate for Payer: Anthem Medicaid |
$40.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$488.00
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Cigna Commercial |
$81.44
|
| Rate for Payer: Healthspan PPO |
$65.38
|
| Rate for Payer: Humana Medicaid |
$40.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$41.16
|
| Rate for Payer: Molina Healthcare Passport |
$40.35
|
| Rate for Payer: Multiplan PHCS |
$292.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$341.60
|
| Rate for Payer: UHCCP Medicaid |
$27.16
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$40.75
|
|
|
N BLOCK INJ PLANTAR DIGIT
|
Facility
|
OP
|
$610.00
|
|
|
Service Code
|
HCPCS 64455
|
| Hospital Charge Code |
76102320
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$79.30 |
| Max. Negotiated Rate |
$585.60 |
| Rate for Payer: Aetna Commercial |
$469.70
|
| Rate for Payer: Anthem Medicaid |
$209.78
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$256.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$475.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$358.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$345.76
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cigna Commercial |
$506.30
|
| Rate for Payer: First Health Commercial |
$579.50
|
| Rate for Payer: Humana Commercial |
$518.50
|
| Rate for Payer: Humana KY Medicaid |
$209.78
|
| Rate for Payer: Humana Medicare Advantage |
$256.12
|
| Rate for Payer: Kentucky WC Medicaid |
$211.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$500.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$450.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$307.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$213.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$536.80
|
| Rate for Payer: Ohio Health Group HMO |
$457.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$122.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$189.10
|
| Rate for Payer: PHCS Commercial |
$585.60
|
| Rate for Payer: United Healthcare All Payer |
$536.80
|
|
|
N BLOCK INJ PLANTAR DIGIT
|
Professional
|
Both
|
$610.00
|
|
|
Service Code
|
HCPCS 64455
|
| Hospital Charge Code |
76102320
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$25.87 |
| Max. Negotiated Rate |
$610.00 |
| Rate for Payer: Aetna Commercial |
$67.55
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$25.87
|
| Rate for Payer: Anthem Medicaid |
$40.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$610.00
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cigna Commercial |
$81.44
|
| Rate for Payer: Healthspan PPO |
$65.38
|
| Rate for Payer: Humana Medicaid |
$40.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$41.16
|
| Rate for Payer: Molina Healthcare Passport |
$40.35
|
| Rate for Payer: Multiplan PHCS |
$366.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$427.00
|
| Rate for Payer: UHCCP Medicaid |
$27.16
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$40.75
|
|
|
N BLOCK INJ PLANTAR DIGIT
|
Professional
|
Both
|
$488.00
|
|
|
Service Code
|
HCPCS 64455
|
| Hospital Charge Code |
36001278
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$25.87 |
| Max. Negotiated Rate |
$488.00 |
| Rate for Payer: Aetna Commercial |
$67.55
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$25.87
|
| Rate for Payer: Anthem Medicaid |
$40.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$488.00
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Cigna Commercial |
$81.44
|
| Rate for Payer: Healthspan PPO |
$65.38
|
| Rate for Payer: Humana Medicaid |
$40.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$41.16
|
| Rate for Payer: Molina Healthcare Passport |
$40.35
|
| Rate for Payer: Multiplan PHCS |
$292.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$341.60
|
| Rate for Payer: UHCCP Medicaid |
$27.16
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$40.75
|
|
|
N BLOCK INJ PLANTAR DIGIT
|
Facility
|
IP
|
$488.00
|
|
|
Service Code
|
HCPCS 64455
|
| Hospital Charge Code |
36001278
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$63.44 |
| Max. Negotiated Rate |
$468.48 |
| Rate for Payer: Aetna Commercial |
$375.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$380.64
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Cigna Commercial |
$405.04
|
| Rate for Payer: First Health Commercial |
$463.60
|
| Rate for Payer: Humana Commercial |
$414.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$400.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$360.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$146.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$429.44
|
| Rate for Payer: Ohio Health Group HMO |
$366.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$97.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$151.28
|
| Rate for Payer: PHCS Commercial |
$468.48
|
| Rate for Payer: United Healthcare All Payer |
$429.44
|
|
|
N BLOCK INJ PLANTAR DIGIT
|
Facility
|
OP
|
$488.00
|
|
|
Service Code
|
HCPCS 64455
|
| Hospital Charge Code |
36001278
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$63.44 |
| Max. Negotiated Rate |
$468.48 |
| Rate for Payer: Aetna Commercial |
$375.76
|
| Rate for Payer: Anthem Medicaid |
$167.82
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$256.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$380.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$358.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$345.76
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Cigna Commercial |
$405.04
|
| Rate for Payer: First Health Commercial |
$463.60
|
| Rate for Payer: Humana Commercial |
$414.80
|
| Rate for Payer: Humana KY Medicaid |
$167.82
|
| Rate for Payer: Humana Medicare Advantage |
$256.12
|
| Rate for Payer: Kentucky WC Medicaid |
$169.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$400.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$360.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$307.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$171.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$429.44
|
| Rate for Payer: Ohio Health Group HMO |
$366.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$97.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$151.28
|
| Rate for Payer: PHCS Commercial |
$468.48
|
| Rate for Payer: United Healthcare All Payer |
$429.44
|
|
|
N BLOCK INJ PLANTAR DIGIT(P
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
HCPCS 64455
|
| Hospital Charge Code |
761P2320
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$25.87 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Aetna Commercial |
$67.55
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$25.87
|
| Rate for Payer: Anthem Medicaid |
$40.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$235.00
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$81.44
|
| Rate for Payer: Healthspan PPO |
$65.38
|
| Rate for Payer: Humana Medicaid |
$40.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$41.16
|
| Rate for Payer: Molina Healthcare Passport |
$40.35
|
| Rate for Payer: Multiplan PHCS |
$141.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$164.50
|
| Rate for Payer: UHCCP Medicaid |
$27.16
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$40.75
|
|
