|
N BLOCK INJ PLANTAR DIGIT(T
|
Facility
|
IP
|
$375.00
|
|
|
Service Code
|
HCPCS 64455
|
| Hospital Charge Code |
761T2320
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$48.75 |
| Max. Negotiated Rate |
$360.00 |
| Rate for Payer: Aetna Commercial |
$288.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$292.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cigna Commercial |
$311.25
|
| Rate for Payer: First Health Commercial |
$356.25
|
| Rate for Payer: Humana Commercial |
$318.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$307.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$276.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$112.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$330.00
|
| Rate for Payer: Ohio Health Group HMO |
$281.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$116.25
|
| Rate for Payer: PHCS Commercial |
$360.00
|
| Rate for Payer: United Healthcare All Payer |
$330.00
|
|
|
N BLOCK INJ PLANTAR DIGIT(T
|
Facility
|
OP
|
$375.00
|
|
|
Service Code
|
HCPCS 64455
|
| Hospital Charge Code |
761T2320
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$48.75 |
| Max. Negotiated Rate |
$360.00 |
| Rate for Payer: Aetna Commercial |
$288.75
|
| Rate for Payer: Anthem Medicaid |
$128.96
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$256.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$292.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$358.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$345.76
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cigna Commercial |
$311.25
|
| Rate for Payer: First Health Commercial |
$356.25
|
| Rate for Payer: Humana Commercial |
$318.75
|
| Rate for Payer: Humana KY Medicaid |
$128.96
|
| Rate for Payer: Humana Medicare Advantage |
$256.12
|
| Rate for Payer: Kentucky WC Medicaid |
$130.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$307.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$276.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$307.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$131.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$330.00
|
| Rate for Payer: Ohio Health Group HMO |
$281.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$75.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$116.25
|
| Rate for Payer: PHCS Commercial |
$360.00
|
| Rate for Payer: United Healthcare All Payer |
$330.00
|
|
|
N BLOCK INJ SCIATIC SNG
|
Professional
|
Both
|
$2,295.77
|
|
|
Service Code
|
HCPCS 64445
|
| Hospital Charge Code |
76102317
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.35 |
| Max. Negotiated Rate |
$2,295.77 |
| Rate for Payer: Aetna Commercial |
$129.45
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$30.35
|
| Rate for Payer: Anthem Medicaid |
$43.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,295.77
|
| Rate for Payer: Cash Price |
$1,147.88
|
| Rate for Payer: Cash Price |
$1,147.88
|
| Rate for Payer: Cigna Commercial |
$227.10
|
| Rate for Payer: Healthspan PPO |
$162.46
|
| Rate for Payer: Humana Medicaid |
$43.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$96.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$44.22
|
| Rate for Payer: Molina Healthcare Passport |
$43.35
|
| Rate for Payer: Multiplan PHCS |
$1,377.46
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,607.04
|
| Rate for Payer: UHCCP Medicaid |
$31.87
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$43.78
|
|
|
N BLOCK INJ SCIATIC SNG
|
Facility
|
IP
|
$2,295.77
|
|
|
Service Code
|
HCPCS 64445
|
| Hospital Charge Code |
76102317
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$298.45 |
| Max. Negotiated Rate |
$2,203.94 |
| Rate for Payer: Aetna Commercial |
$1,767.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,790.70
|
| Rate for Payer: Cash Price |
$1,147.88
|
| Rate for Payer: Cigna Commercial |
$1,905.49
|
| Rate for Payer: First Health Commercial |
$2,180.98
|
| Rate for Payer: Humana Commercial |
$1,951.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,882.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,694.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$688.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,020.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,721.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$459.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$298.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$711.69
|
| Rate for Payer: PHCS Commercial |
$2,203.94
|
| Rate for Payer: United Healthcare All Payer |
$2,020.28
|
|
|
N BLOCK INJ SCIATIC SNG
|
Facility
|
OP
|
$2,295.77
|
|
|
Service Code
|
HCPCS 64445
|
| Hospital Charge Code |
76102317
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$298.45 |
| Max. Negotiated Rate |
$2,203.94 |
| Rate for Payer: Aetna Commercial |
$1,767.74
|
| Rate for Payer: Anthem Medicaid |
$789.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,790.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Cash Price |
$1,147.88
|
| Rate for Payer: Cash Price |
$1,147.88
|
| Rate for Payer: Cigna Commercial |
$1,905.49
|
| Rate for Payer: First Health Commercial |
$2,180.98
|
| Rate for Payer: Humana Commercial |
$1,951.40
|
| Rate for Payer: Humana KY Medicaid |
$789.52
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Kentucky WC Medicaid |
$797.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,882.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,694.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$805.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,020.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,721.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$459.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$298.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$711.69
|
| Rate for Payer: PHCS Commercial |
$2,203.94
|
| Rate for Payer: United Healthcare All Payer |
$2,020.28
|
|
|
N BLOCK INJ SCIATIC SNG(P
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 64445
|
| Hospital Charge Code |
761P2317
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.35 |
| Max. Negotiated Rate |
$500.00 |
| Rate for Payer: Aetna Commercial |
$129.45
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$30.35
|
| Rate for Payer: Anthem Medicaid |
$43.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$500.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$227.10
|
| Rate for Payer: Healthspan PPO |
$162.46
|
| Rate for Payer: Humana Medicaid |
$43.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$96.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$44.22
|
| Rate for Payer: Molina Healthcare Passport |
$43.35
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$350.00
|
| Rate for Payer: UHCCP Medicaid |
$31.87
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$43.78
|
|
|
N BLOCK INJ SCIATIC SNG(T
|
Facility
|
OP
|
$1,795.77
|
|
|
Service Code
|
HCPCS 64445
|
| Hospital Charge Code |
761T2317
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$233.45 |
| Max. Negotiated Rate |
$1,723.94 |
| Rate for Payer: Aetna Commercial |
$1,382.74
|
| Rate for Payer: Anthem Medicaid |
$617.57
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,400.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Cash Price |
$897.88
|
| Rate for Payer: Cash Price |
$897.88
|
| Rate for Payer: Cigna Commercial |
$1,490.49
|
| Rate for Payer: First Health Commercial |
$1,705.98
|
| Rate for Payer: Humana Commercial |
$1,526.40
|
| Rate for Payer: Humana KY Medicaid |
$617.57
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Kentucky WC Medicaid |
$623.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,472.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,325.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$629.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,580.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,346.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$359.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$233.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$556.69
|
| Rate for Payer: PHCS Commercial |
$1,723.94
|
| Rate for Payer: United Healthcare All Payer |
$1,580.28
|
|
|
N BLOCK INJ SCIATIC SNG(T
|
Facility
|
IP
|
$1,795.77
|
|
|
Service Code
|
HCPCS 64445
|
| Hospital Charge Code |
761T2317
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$233.45 |
| Max. Negotiated Rate |
$1,723.94 |
| Rate for Payer: Aetna Commercial |
$1,382.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,400.70
|
| Rate for Payer: Cash Price |
$897.88
|
| Rate for Payer: Cigna Commercial |
$1,490.49
|
| Rate for Payer: First Health Commercial |
$1,705.98
|
| Rate for Payer: Humana Commercial |
$1,526.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,472.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,325.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$538.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,580.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,346.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$359.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$233.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$556.69
|
| Rate for Payer: PHCS Commercial |
$1,723.94
|
| Rate for Payer: United Healthcare All Payer |
$1,580.28
|
|
|
N BLOCK INJ TRIGEMINAL
|
Facility
|
OP
|
$1,238.00
|
|
|
Service Code
|
HCPCS 64400
|
| Hospital Charge Code |
76102310
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$160.94 |
| Max. Negotiated Rate |
$1,188.48 |
| Rate for Payer: Aetna Commercial |
$953.26
|
| Rate for Payer: Anthem Medicaid |
$425.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$256.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$965.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$358.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$345.76
|
| Rate for Payer: Cash Price |
$619.00
|
| Rate for Payer: Cash Price |
$619.00
|
| Rate for Payer: Cigna Commercial |
$1,027.54
|
| Rate for Payer: First Health Commercial |
$1,176.10
|
| Rate for Payer: Humana Commercial |
$1,052.30
|
| Rate for Payer: Humana KY Medicaid |
$425.75
|
| Rate for Payer: Humana Medicare Advantage |
$256.12
|
| Rate for Payer: Kentucky WC Medicaid |
$430.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,015.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$913.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$307.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$434.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,089.44
|
| Rate for Payer: Ohio Health Group HMO |
$928.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$247.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$160.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$383.78
|
| Rate for Payer: PHCS Commercial |
$1,188.48
|
| Rate for Payer: United Healthcare All Payer |
$1,089.44
|
|
|
N BLOCK INJ TRIGEMINAL
|
Facility
|
IP
|
$1,238.00
|
|
|
Service Code
|
HCPCS 64400
|
| Hospital Charge Code |
76102310
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$160.94 |
| Max. Negotiated Rate |
$1,188.48 |
| Rate for Payer: Aetna Commercial |
$953.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$965.64
|
| Rate for Payer: Cash Price |
$619.00
|
| Rate for Payer: Cigna Commercial |
$1,027.54
|
| Rate for Payer: First Health Commercial |
$1,176.10
|
| Rate for Payer: Humana Commercial |
$1,052.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,015.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$913.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$371.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,089.44
|
| Rate for Payer: Ohio Health Group HMO |
$928.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$247.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$160.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$383.78
|
| Rate for Payer: PHCS Commercial |
$1,188.48
|
| Rate for Payer: United Healthcare All Payer |
$1,089.44
|
|
|
N BLOCK INJ TRIGEMINAL
|
Professional
|
Both
|
$1,238.00
|
|
|
Service Code
|
HCPCS 64400
|
| Hospital Charge Code |
76102310
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$25.78 |
| Max. Negotiated Rate |
$1,238.00 |
| Rate for Payer: Aetna Commercial |
$100.61
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$25.78
|
| Rate for Payer: Anthem Medicaid |
$39.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,238.00
|
| Rate for Payer: Cash Price |
$619.00
|
| Rate for Payer: Cash Price |
$619.00
|
| Rate for Payer: Cigna Commercial |
$167.58
|
| Rate for Payer: Healthspan PPO |
$127.75
|
| Rate for Payer: Humana Medicaid |
$39.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$85.64
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$40.33
|
| Rate for Payer: Molina Healthcare Passport |
$39.54
|
| Rate for Payer: Multiplan PHCS |
$742.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$866.60
|
| Rate for Payer: UHCCP Medicaid |
$27.07
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$39.94
|
|
|
N BLOCK INJ TRIGEMINAL(P
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 64400
|
| Hospital Charge Code |
761P2310
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$25.78 |
| Max. Negotiated Rate |
$500.00 |
| Rate for Payer: Aetna Commercial |
$100.61
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$25.78
|
| Rate for Payer: Anthem Medicaid |
$39.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$500.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$167.58
|
| Rate for Payer: Healthspan PPO |
$127.75
|
| Rate for Payer: Humana Medicaid |
$39.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$85.64
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$40.33
|
| Rate for Payer: Molina Healthcare Passport |
$39.54
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$350.00
|
| Rate for Payer: UHCCP Medicaid |
$27.07
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$39.94
|
|
|
N BLOCK INJ TRIGEMINAL(T
|
Facility
|
IP
|
$738.00
|
|
|
Service Code
|
HCPCS 64400
|
| Hospital Charge Code |
761T2310
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$95.94 |
| Max. Negotiated Rate |
$708.48 |
| Rate for Payer: Aetna Commercial |
$568.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$575.64
|
| Rate for Payer: Cash Price |
$369.00
|
| Rate for Payer: Cigna Commercial |
$612.54
|
| Rate for Payer: First Health Commercial |
$701.10
|
| Rate for Payer: Humana Commercial |
$627.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$605.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$544.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$221.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$649.44
|
| Rate for Payer: Ohio Health Group HMO |
$553.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$95.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$228.78
|
| Rate for Payer: PHCS Commercial |
$708.48
|
| Rate for Payer: United Healthcare All Payer |
$649.44
|
|
|
N BLOCK INJ TRIGEMINAL(T
|
Facility
|
OP
|
$738.00
|
|
|
Service Code
|
HCPCS 64400
|
| Hospital Charge Code |
761T2310
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$95.94 |
| Max. Negotiated Rate |
$708.48 |
| Rate for Payer: Aetna Commercial |
$568.26
|
| Rate for Payer: Anthem Medicaid |
$253.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$256.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$575.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$358.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$345.76
|
| Rate for Payer: Cash Price |
$369.00
|
| Rate for Payer: Cash Price |
$369.00
|
| Rate for Payer: Cigna Commercial |
$612.54
|
| Rate for Payer: First Health Commercial |
$701.10
|
| Rate for Payer: Humana Commercial |
$627.30
|
| Rate for Payer: Humana KY Medicaid |
$253.80
|
| Rate for Payer: Humana Medicare Advantage |
$256.12
|
| Rate for Payer: Kentucky WC Medicaid |
$256.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$605.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$544.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$307.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$258.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$649.44
|
| Rate for Payer: Ohio Health Group HMO |
$553.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$95.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$228.78
|
| Rate for Payer: PHCS Commercial |
$708.48
|
| Rate for Payer: United Healthcare All Payer |
$649.44
|
|
|
N BLOCK SPENOPALATINE GANGL
|
Facility
|
OP
|
$1,030.00
|
|
|
Service Code
|
HCPCS 64505
|
| Hospital Charge Code |
76102332
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$133.90 |
| Max. Negotiated Rate |
$988.80 |
| Rate for Payer: Aetna Commercial |
$793.10
|
| Rate for Payer: Anthem Medicaid |
$354.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$256.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$803.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$358.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$345.76
|
| Rate for Payer: Cash Price |
$515.00
|
| Rate for Payer: Cash Price |
$515.00
|
| Rate for Payer: Cigna Commercial |
$854.90
|
| Rate for Payer: First Health Commercial |
$978.50
|
| Rate for Payer: Humana Commercial |
$875.50
|
| Rate for Payer: Humana KY Medicaid |
$354.22
|
| Rate for Payer: Humana Medicare Advantage |
$256.12
|
| Rate for Payer: Kentucky WC Medicaid |
$357.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$844.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$760.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$307.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$361.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$906.40
|
| Rate for Payer: Ohio Health Group HMO |
$772.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$206.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$133.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$319.30
|
| Rate for Payer: PHCS Commercial |
$988.80
|
| Rate for Payer: United Healthcare All Payer |
$906.40
|
|
|
N BLOCK SPENOPALATINE GANGL
|
Facility
|
IP
|
$1,030.00
|
|
|
Service Code
|
HCPCS 64505
|
| Hospital Charge Code |
76102332
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$133.90 |
| Max. Negotiated Rate |
$988.80 |
| Rate for Payer: Aetna Commercial |
$793.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$803.40
|
| Rate for Payer: Cash Price |
$515.00
|
| Rate for Payer: Cigna Commercial |
$854.90
|
| Rate for Payer: First Health Commercial |
$978.50
|
| Rate for Payer: Humana Commercial |
$875.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$844.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$760.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$309.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$906.40
|
| Rate for Payer: Ohio Health Group HMO |
$772.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$206.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$133.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$319.30
|
| Rate for Payer: PHCS Commercial |
$988.80
|
| Rate for Payer: United Healthcare All Payer |
$906.40
|
|
|
N BLOCK SPENOPALATINE GANGL
|
Professional
|
Both
|
$1,030.00
|
|
|
Service Code
|
HCPCS 64505
|
| Hospital Charge Code |
76102332
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$49.68 |
| Max. Negotiated Rate |
$1,030.00 |
| Rate for Payer: Aetna Commercial |
$134.12
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$52.95
|
| Rate for Payer: Anthem Medicaid |
$49.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,030.00
|
| Rate for Payer: Cash Price |
$515.00
|
| Rate for Payer: Cash Price |
$515.00
|
| Rate for Payer: Cigna Commercial |
$150.69
|
| Rate for Payer: Healthspan PPO |
$123.67
|
| Rate for Payer: Humana Medicaid |
$49.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$103.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$50.67
|
| Rate for Payer: Molina Healthcare Passport |
$49.68
|
| Rate for Payer: Multiplan PHCS |
$618.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$721.00
|
| Rate for Payer: UHCCP Medicaid |
$55.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$50.18
|
|
|
N BLOCK SPENOPALATINE GANGL(P
|
Professional
|
Both
|
$290.00
|
|
|
Service Code
|
HCPCS 64505
|
| Hospital Charge Code |
761P2332
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$49.68 |
| Max. Negotiated Rate |
$290.00 |
| Rate for Payer: Aetna Commercial |
$134.12
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$52.95
|
| Rate for Payer: Anthem Medicaid |
$49.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$290.00
|
| Rate for Payer: Cash Price |
$145.00
|
| Rate for Payer: Cash Price |
$145.00
|
| Rate for Payer: Cigna Commercial |
$150.69
|
| Rate for Payer: Healthspan PPO |
$123.67
|
| Rate for Payer: Humana Medicaid |
$49.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$103.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$50.67
|
| Rate for Payer: Molina Healthcare Passport |
$49.68
|
| Rate for Payer: Multiplan PHCS |
$174.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$203.00
|
| Rate for Payer: UHCCP Medicaid |
$55.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$50.18
|
|
|
N BLOCK SPENOPALATINE GANGL(T
|
Facility
|
IP
|
$740.00
|
|
|
Service Code
|
HCPCS 64505
|
| Hospital Charge Code |
761T2332
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$96.20 |
| Max. Negotiated Rate |
$710.40 |
| Rate for Payer: Aetna Commercial |
$569.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$577.20
|
| Rate for Payer: Cash Price |
$370.00
|
| Rate for Payer: Cigna Commercial |
$614.20
|
| Rate for Payer: First Health Commercial |
$703.00
|
| Rate for Payer: Humana Commercial |
$629.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$606.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$546.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$222.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$651.20
|
| Rate for Payer: Ohio Health Group HMO |
$555.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$148.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$96.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$229.40
|
| Rate for Payer: PHCS Commercial |
$710.40
|
| Rate for Payer: United Healthcare All Payer |
$651.20
|
|
|
N BLOCK SPENOPALATINE GANGL(T
|
Facility
|
OP
|
$740.00
|
|
|
Service Code
|
HCPCS 64505
|
| Hospital Charge Code |
761T2332
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$96.20 |
| Max. Negotiated Rate |
$710.40 |
| Rate for Payer: Aetna Commercial |
$569.80
|
| Rate for Payer: Anthem Medicaid |
$254.49
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$256.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$577.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$358.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$345.76
|
| Rate for Payer: Cash Price |
$370.00
|
| Rate for Payer: Cash Price |
$370.00
|
| Rate for Payer: Cigna Commercial |
$614.20
|
| Rate for Payer: First Health Commercial |
$703.00
|
| Rate for Payer: Humana Commercial |
$629.00
|
| Rate for Payer: Humana KY Medicaid |
$254.49
|
| Rate for Payer: Humana Medicare Advantage |
$256.12
|
| Rate for Payer: Kentucky WC Medicaid |
$257.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$606.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$546.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$307.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$259.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$651.20
|
| Rate for Payer: Ohio Health Group HMO |
$555.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$148.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$96.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$229.40
|
| Rate for Payer: PHCS Commercial |
$710.40
|
| Rate for Payer: United Healthcare All Payer |
$651.20
|
|
|
NB RESUSCITATION
|
Facility
|
OP
|
$1,301.00
|
|
|
Service Code
|
HCPCS 99465
|
| Hospital Charge Code |
51000121
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$169.13 |
| Max. Negotiated Rate |
$1,248.96 |
| Rate for Payer: Aetna Commercial |
$1,001.77
|
| Rate for Payer: Anthem Medicaid |
$447.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$562.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,014.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$787.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$759.78
|
| Rate for Payer: Cash Price |
$650.50
|
| Rate for Payer: Cash Price |
$650.50
|
| Rate for Payer: Cigna Commercial |
$1,079.83
|
| Rate for Payer: First Health Commercial |
$1,235.95
|
| Rate for Payer: Humana Commercial |
$1,105.85
|
| Rate for Payer: Humana KY Medicaid |
$447.41
|
| Rate for Payer: Humana Medicare Advantage |
$562.80
|
| Rate for Payer: Kentucky WC Medicaid |
$451.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,066.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$960.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$675.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$456.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,144.88
|
| Rate for Payer: Ohio Health Group HMO |
$975.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$260.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$169.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$403.31
|
| Rate for Payer: PHCS Commercial |
$1,248.96
|
| Rate for Payer: United Healthcare All Payer |
$1,144.88
|
|
|
NB RESUSCITATION
|
Facility
|
IP
|
$1,301.00
|
|
|
Service Code
|
HCPCS 99465
|
| Hospital Charge Code |
51000121
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$169.13 |
| Max. Negotiated Rate |
$1,248.96 |
| Rate for Payer: Aetna Commercial |
$1,001.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,014.78
|
| Rate for Payer: Cash Price |
$650.50
|
| Rate for Payer: Cigna Commercial |
$1,079.83
|
| Rate for Payer: First Health Commercial |
$1,235.95
|
| Rate for Payer: Humana Commercial |
$1,105.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,066.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$960.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$390.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,144.88
|
| Rate for Payer: Ohio Health Group HMO |
$975.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$260.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$169.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$403.31
|
| Rate for Payer: PHCS Commercial |
$1,248.96
|
| Rate for Payer: United Healthcare All Payer |
$1,144.88
|
|
|
NB RESUSCITATION
|
Professional
|
Both
|
$1,301.00
|
|
|
Service Code
|
HCPCS 99465
|
| Hospital Charge Code |
51000121
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$119.57 |
| Max. Negotiated Rate |
$1,301.00 |
| Rate for Payer: Aetna Commercial |
$229.62
|
| Rate for Payer: Anthem Medicaid |
$119.57
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,301.00
|
| Rate for Payer: Cash Price |
$650.50
|
| Rate for Payer: Cash Price |
$650.50
|
| Rate for Payer: Cigna Commercial |
$233.27
|
| Rate for Payer: Healthspan PPO |
$170.69
|
| Rate for Payer: Humana Medicaid |
$119.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$190.56
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$121.96
|
| Rate for Payer: Molina Healthcare Passport |
$119.57
|
| Rate for Payer: Multiplan PHCS |
$780.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$910.70
|
| Rate for Payer: UHCCP Medicaid |
$455.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$120.77
|
|
|
NB RESUSCITATION(P
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 99465
|
| Hospital Charge Code |
510P0121
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$119.57 |
| Max. Negotiated Rate |
$500.00 |
| Rate for Payer: Aetna Commercial |
$229.62
|
| Rate for Payer: Anthem Medicaid |
$119.57
|
| Rate for Payer: Buckeye Medicare Advantage |
$500.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$233.27
|
| Rate for Payer: Healthspan PPO |
$170.69
|
| Rate for Payer: Humana Medicaid |
$119.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$190.56
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$121.96
|
| Rate for Payer: Molina Healthcare Passport |
$119.57
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$350.00
|
| Rate for Payer: UHCCP Medicaid |
$175.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$120.77
|
|
|
NB RESUSCITATION(T
|
Facility
|
OP
|
$801.00
|
|
|
Service Code
|
HCPCS 99465
|
| Hospital Charge Code |
510T0121
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$104.13 |
| Max. Negotiated Rate |
$787.92 |
| Rate for Payer: Aetna Commercial |
$616.77
|
| Rate for Payer: Anthem Medicaid |
$275.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$562.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$787.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$759.78
|
| Rate for Payer: Cash Price |
$400.50
|
| Rate for Payer: Cash Price |
$400.50
|
| Rate for Payer: Cigna Commercial |
$664.83
|
| Rate for Payer: First Health Commercial |
$760.95
|
| Rate for Payer: Humana Commercial |
$680.85
|
| Rate for Payer: Humana KY Medicaid |
$275.46
|
| Rate for Payer: Humana Medicare Advantage |
$562.80
|
| Rate for Payer: Kentucky WC Medicaid |
$278.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$591.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$675.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$280.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.88
|
| Rate for Payer: Ohio Health Group HMO |
$600.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.31
|
| Rate for Payer: PHCS Commercial |
$768.96
|
| Rate for Payer: United Healthcare All Payer |
$704.88
|
|
