|
NEUPRO 3MG PATCH (24HR)
|
Facility
|
IP
|
$66.10
|
|
|
Service Code
|
NDC 50474080303
|
| Hospital Charge Code |
25003264
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.59 |
| Max. Negotiated Rate |
$63.46 |
| Rate for Payer: Aetna Commercial |
$50.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.56
|
| Rate for Payer: Cash Price |
$33.05
|
| Rate for Payer: Cigna Commercial |
$54.86
|
| Rate for Payer: First Health Commercial |
$62.80
|
| Rate for Payer: Humana Commercial |
$56.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.17
|
| Rate for Payer: Ohio Health Group HMO |
$49.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.49
|
| Rate for Payer: PHCS Commercial |
$63.46
|
| Rate for Payer: United Healthcare All Payer |
$58.17
|
|
|
NEUPRO 3MG PATCH (24HR)
|
Facility
|
OP
|
$66.10
|
|
|
Service Code
|
NDC 50474080303
|
| Hospital Charge Code |
25003264
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.59 |
| Max. Negotiated Rate |
$63.46 |
| Rate for Payer: Aetna Commercial |
$50.90
|
| Rate for Payer: Anthem Medicaid |
$22.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.56
|
| Rate for Payer: Cash Price |
$33.05
|
| Rate for Payer: Cigna Commercial |
$54.86
|
| Rate for Payer: First Health Commercial |
$62.80
|
| Rate for Payer: Humana Commercial |
$56.18
|
| Rate for Payer: Humana KY Medicaid |
$22.73
|
| Rate for Payer: Kentucky WC Medicaid |
$22.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.17
|
| Rate for Payer: Ohio Health Group HMO |
$49.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.49
|
| Rate for Payer: PHCS Commercial |
$63.46
|
| Rate for Payer: United Healthcare All Payer |
$58.17
|
|
|
NEUPRO 4MG PATCH (24HR)
|
Facility
|
OP
|
$66.10
|
|
|
Service Code
|
NDC 50474080403
|
| Hospital Charge Code |
25003265
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.59 |
| Max. Negotiated Rate |
$63.46 |
| Rate for Payer: Aetna Commercial |
$50.90
|
| Rate for Payer: Anthem Medicaid |
$22.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.56
|
| Rate for Payer: Cash Price |
$33.05
|
| Rate for Payer: Cigna Commercial |
$54.86
|
| Rate for Payer: First Health Commercial |
$62.80
|
| Rate for Payer: Humana Commercial |
$56.18
|
| Rate for Payer: Humana KY Medicaid |
$22.73
|
| Rate for Payer: Kentucky WC Medicaid |
$22.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.17
|
| Rate for Payer: Ohio Health Group HMO |
$49.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.49
|
| Rate for Payer: PHCS Commercial |
$63.46
|
| Rate for Payer: United Healthcare All Payer |
$58.17
|
|
|
NEUPRO 4MG PATCH (24HR)
|
Facility
|
IP
|
$66.10
|
|
|
Service Code
|
NDC 50474080403
|
| Hospital Charge Code |
25003265
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.59 |
| Max. Negotiated Rate |
$63.46 |
| Rate for Payer: Aetna Commercial |
$50.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.56
|
| Rate for Payer: Cash Price |
$33.05
|
| Rate for Payer: Cigna Commercial |
$54.86
|
| Rate for Payer: First Health Commercial |
$62.80
|
| Rate for Payer: Humana Commercial |
$56.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.17
|
| Rate for Payer: Ohio Health Group HMO |
$49.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.49
|
| Rate for Payer: PHCS Commercial |
$63.46
|
| Rate for Payer: United Healthcare All Payer |
$58.17
|
|
|
NEUPRO 6MG PATCH (24HR)
|
Facility
|
IP
|
$66.10
|
|
|
Service Code
|
NDC 50474080503
|
| Hospital Charge Code |
25003266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.59 |
| Max. Negotiated Rate |
$63.46 |
| Rate for Payer: Aetna Commercial |
$50.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.56
|
| Rate for Payer: Cash Price |
$33.05
|
| Rate for Payer: Cigna Commercial |
$54.86
|
| Rate for Payer: First Health Commercial |
$62.80
|
| Rate for Payer: Humana Commercial |
$56.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.17
|
| Rate for Payer: Ohio Health Group HMO |
$49.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.49
|
| Rate for Payer: PHCS Commercial |
$63.46
|
| Rate for Payer: United Healthcare All Payer |
$58.17
|
|
|
NEUPRO 6MG PATCH (24HR)
|
Facility
|
OP
|
$66.10
|
|
|
Service Code
|
NDC 50474080503
|
| Hospital Charge Code |
25003266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.59 |
| Max. Negotiated Rate |
$63.46 |
| Rate for Payer: Aetna Commercial |
$50.90
|
| Rate for Payer: Anthem Medicaid |
$22.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.56
|
| Rate for Payer: Cash Price |
$33.05
|
| Rate for Payer: Cigna Commercial |
$54.86
|
| Rate for Payer: First Health Commercial |
$62.80
|
| Rate for Payer: Humana Commercial |
$56.18
|
| Rate for Payer: Humana KY Medicaid |
$22.73
|
| Rate for Payer: Kentucky WC Medicaid |
$22.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.17
|
| Rate for Payer: Ohio Health Group HMO |
$49.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.49
|
| Rate for Payer: PHCS Commercial |
$63.46
|
| Rate for Payer: United Healthcare All Payer |
$58.17
|
|
|
NEUPRO 8MG PATCH (24HR)
|
Facility
|
IP
|
$66.10
|
|
|
Service Code
|
NDC 50474080603
|
| Hospital Charge Code |
25003267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.59 |
| Max. Negotiated Rate |
$63.46 |
| Rate for Payer: Aetna Commercial |
$50.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.56
|
| Rate for Payer: Cash Price |
$33.05
|
| Rate for Payer: Cigna Commercial |
$54.86
|
| Rate for Payer: First Health Commercial |
$62.80
|
| Rate for Payer: Humana Commercial |
$56.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.17
|
| Rate for Payer: Ohio Health Group HMO |
$49.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.49
|
| Rate for Payer: PHCS Commercial |
$63.46
|
| Rate for Payer: United Healthcare All Payer |
$58.17
|
|
|
NEUPRO 8MG PATCH (24HR)
|
Facility
|
OP
|
$66.10
|
|
|
Service Code
|
NDC 50474080603
|
| Hospital Charge Code |
25003267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.59 |
| Max. Negotiated Rate |
$63.46 |
| Rate for Payer: Anthem Medicaid |
$22.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.56
|
| Rate for Payer: Cash Price |
$33.05
|
| Rate for Payer: Cigna Commercial |
$54.86
|
| Rate for Payer: First Health Commercial |
$62.80
|
| Rate for Payer: Humana Commercial |
$56.18
|
| Rate for Payer: Humana KY Medicaid |
$22.73
|
| Rate for Payer: Kentucky WC Medicaid |
$22.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.17
|
| Rate for Payer: Ohio Health Group HMO |
$49.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.49
|
| Rate for Payer: PHCS Commercial |
$63.46
|
| Rate for Payer: United Healthcare All Payer |
$58.17
|
| Rate for Payer: Aetna Commercial |
$50.90
|
|
|
NEURECTOMY FOOT
|
Professional
|
Both
|
$405.00
|
|
|
Service Code
|
HCPCS 28055
|
| Hospital Charge Code |
76102745
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$141.75 |
| Max. Negotiated Rate |
$645.47 |
| Rate for Payer: Aetna Commercial |
$599.54
|
| Rate for Payer: Anthem Medicaid |
$289.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$405.00
|
| Rate for Payer: Cash Price |
$202.50
|
| Rate for Payer: Cash Price |
$202.50
|
| Rate for Payer: Cigna Commercial |
$645.47
|
| Rate for Payer: Healthspan PPO |
$543.05
|
| Rate for Payer: Humana Medicaid |
$289.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$471.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$294.91
|
| Rate for Payer: Molina Healthcare Passport |
$289.13
|
| Rate for Payer: Multiplan PHCS |
$243.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$283.50
|
| Rate for Payer: UHCCP Medicaid |
$141.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$292.02
|
|
|
NEUROBEHAVIORAL STATUS
|
Facility
|
OP
|
$565.00
|
|
|
Service Code
|
HCPCS 96116
|
| Hospital Charge Code |
51000047
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$73.45 |
| Max. Negotiated Rate |
$542.40 |
| Rate for Payer: Aetna Commercial |
$435.05
|
| Rate for Payer: Anthem Medicaid |
$194.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$271.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$440.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$380.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$366.43
|
| Rate for Payer: Cash Price |
$282.50
|
| Rate for Payer: Cash Price |
$282.50
|
| Rate for Payer: Cigna Commercial |
$468.95
|
| Rate for Payer: First Health Commercial |
$536.75
|
| Rate for Payer: Humana Commercial |
$480.25
|
| Rate for Payer: Humana KY Medicaid |
$194.30
|
| Rate for Payer: Humana Medicare Advantage |
$271.43
|
| Rate for Payer: Kentucky WC Medicaid |
$196.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$463.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$416.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$325.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$198.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$497.20
|
| Rate for Payer: Ohio Health Group HMO |
$423.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$113.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$175.15
|
| Rate for Payer: PHCS Commercial |
$542.40
|
| Rate for Payer: United Healthcare All Payer |
$497.20
|
|
|
NEUROBEHAVIORAL STATUS
|
Facility
|
IP
|
$565.00
|
|
|
Service Code
|
HCPCS 96116
|
| Hospital Charge Code |
51000047
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$73.45 |
| Max. Negotiated Rate |
$542.40 |
| Rate for Payer: Aetna Commercial |
$435.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$440.70
|
| Rate for Payer: Cash Price |
$282.50
|
| Rate for Payer: Cigna Commercial |
$468.95
|
| Rate for Payer: First Health Commercial |
$536.75
|
| Rate for Payer: Humana Commercial |
$480.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$463.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$416.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$169.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$497.20
|
| Rate for Payer: Ohio Health Group HMO |
$423.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$113.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$175.15
|
| Rate for Payer: PHCS Commercial |
$542.40
|
| Rate for Payer: United Healthcare All Payer |
$497.20
|
|
|
NEUROBEHAVIORAL STATUS
|
Professional
|
Both
|
$565.00
|
|
|
Service Code
|
HCPCS 96116
|
| Hospital Charge Code |
51000047
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$54.66 |
| Max. Negotiated Rate |
$565.00 |
| Rate for Payer: Aetna Commercial |
$145.35
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$54.66
|
| Rate for Payer: Anthem Medicaid |
$64.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$565.00
|
| Rate for Payer: Cash Price |
$282.50
|
| Rate for Payer: Cash Price |
$282.50
|
| Rate for Payer: Cigna Commercial |
$131.05
|
| Rate for Payer: Healthspan PPO |
$143.22
|
| Rate for Payer: Humana Medicaid |
$64.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$99.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.52
|
| Rate for Payer: Molina Healthcare Passport |
$64.24
|
| Rate for Payer: Multiplan PHCS |
$339.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$395.50
|
| Rate for Payer: UHCCP Medicaid |
$57.39
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$64.88
|
|
|
NEUROBEHAVIORAL STATUS(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 96116
|
| Hospital Charge Code |
510P0047
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$54.66 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Aetna Commercial |
$145.35
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$54.66
|
| Rate for Payer: Anthem Medicaid |
$64.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$150.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$131.05
|
| Rate for Payer: Healthspan PPO |
$143.22
|
| Rate for Payer: Humana Medicaid |
$64.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$99.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.52
|
| Rate for Payer: Molina Healthcare Passport |
$64.24
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$57.39
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$64.88
|
|
|
NEUROBEHAVIORAL STATUS(T
|
Facility
|
IP
|
$415.00
|
|
|
Service Code
|
HCPCS 96116
|
| Hospital Charge Code |
510T0047
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$53.95 |
| Max. Negotiated Rate |
$398.40 |
| Rate for Payer: Aetna Commercial |
$319.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$323.70
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cigna Commercial |
$344.45
|
| Rate for Payer: First Health Commercial |
$394.25
|
| Rate for Payer: Humana Commercial |
$352.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$340.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$306.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$124.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$365.20
|
| Rate for Payer: Ohio Health Group HMO |
$311.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$83.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$128.65
|
| Rate for Payer: PHCS Commercial |
$398.40
|
| Rate for Payer: United Healthcare All Payer |
$365.20
|
|
|
NEUROBEHAVIORAL STATUS(T
|
Facility
|
OP
|
$415.00
|
|
|
Service Code
|
HCPCS 96116
|
| Hospital Charge Code |
510T0047
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$53.95 |
| Max. Negotiated Rate |
$398.40 |
| Rate for Payer: Aetna Commercial |
$319.55
|
| Rate for Payer: Anthem Medicaid |
$142.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$271.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$323.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$380.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$366.43
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cigna Commercial |
$344.45
|
| Rate for Payer: First Health Commercial |
$394.25
|
| Rate for Payer: Humana Commercial |
$352.75
|
| Rate for Payer: Humana KY Medicaid |
$142.72
|
| Rate for Payer: Humana Medicare Advantage |
$271.43
|
| Rate for Payer: Kentucky WC Medicaid |
$144.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$340.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$306.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$325.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$145.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$365.20
|
| Rate for Payer: Ohio Health Group HMO |
$311.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$83.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$128.65
|
| Rate for Payer: PHCS Commercial |
$398.40
|
| Rate for Payer: United Healthcare All Payer |
$365.20
|
|
|
NEUROELTRD STIM POST TIBIAL
|
Facility
|
IP
|
$530.00
|
|
|
Service Code
|
HCPCS 64566
|
| Hospital Charge Code |
76102789
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$68.90 |
| Max. Negotiated Rate |
$508.80 |
| Rate for Payer: Aetna Commercial |
$408.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$413.40
|
| Rate for Payer: Cash Price |
$265.00
|
| Rate for Payer: Cigna Commercial |
$439.90
|
| Rate for Payer: First Health Commercial |
$503.50
|
| Rate for Payer: Humana Commercial |
$450.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$434.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$466.40
|
| Rate for Payer: Ohio Health Group HMO |
$397.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$106.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$164.30
|
| Rate for Payer: PHCS Commercial |
$508.80
|
| Rate for Payer: United Healthcare All Payer |
$466.40
|
|
|
NEUROELTRD STIM POST TIBIAL
|
Professional
|
Both
|
$530.00
|
|
|
Service Code
|
HCPCS 64566
|
| Hospital Charge Code |
76102789
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$15.58 |
| Max. Negotiated Rate |
$530.00 |
| Rate for Payer: Aetna Commercial |
$51.85
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$15.58
|
| Rate for Payer: Anthem Medicaid |
$24.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$530.00
|
| Rate for Payer: Cash Price |
$265.00
|
| Rate for Payer: Cash Price |
$265.00
|
| Rate for Payer: Cigna Commercial |
$221.18
|
| Rate for Payer: Healthspan PPO |
$127.67
|
| Rate for Payer: Humana Medicaid |
$24.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$38.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$25.39
|
| Rate for Payer: Molina Healthcare Passport |
$24.89
|
| Rate for Payer: Multiplan PHCS |
$318.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$371.00
|
| Rate for Payer: UHCCP Medicaid |
$16.36
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$25.14
|
|
|
NEUROELTRD STIM POST TIBIAL
|
Facility
|
OP
|
$530.00
|
|
|
Service Code
|
HCPCS 64566
|
| Hospital Charge Code |
76102789
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$68.90 |
| Max. Negotiated Rate |
$508.80 |
| Rate for Payer: Aetna Commercial |
$408.10
|
| Rate for Payer: Anthem Medicaid |
$182.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$256.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$413.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$358.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$345.76
|
| Rate for Payer: Cash Price |
$265.00
|
| Rate for Payer: Cash Price |
$265.00
|
| Rate for Payer: Cigna Commercial |
$439.90
|
| Rate for Payer: First Health Commercial |
$503.50
|
| Rate for Payer: Humana Commercial |
$450.50
|
| Rate for Payer: Humana KY Medicaid |
$182.27
|
| Rate for Payer: Humana Medicare Advantage |
$256.12
|
| Rate for Payer: Kentucky WC Medicaid |
$184.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$434.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$307.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$185.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$466.40
|
| Rate for Payer: Ohio Health Group HMO |
$397.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$106.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$164.30
|
| Rate for Payer: PHCS Commercial |
$508.80
|
| Rate for Payer: United Healthcare All Payer |
$466.40
|
|
|
NEUROELTRD STIM POST TIBIAL (P
|
Professional
|
Both
|
$140.00
|
|
|
Service Code
|
HCPCS 64566
|
| Hospital Charge Code |
761P2789
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$15.58 |
| Max. Negotiated Rate |
$221.18 |
| Rate for Payer: Aetna Commercial |
$51.85
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$15.58
|
| Rate for Payer: Anthem Medicaid |
$24.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$140.00
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Cigna Commercial |
$221.18
|
| Rate for Payer: Healthspan PPO |
$127.67
|
| Rate for Payer: Humana Medicaid |
$24.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$38.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$25.39
|
| Rate for Payer: Molina Healthcare Passport |
$24.89
|
| Rate for Payer: Multiplan PHCS |
$84.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$98.00
|
| Rate for Payer: UHCCP Medicaid |
$16.36
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$25.14
|
|
|
NEUROELTRD STIM POST TIBIAL (T
|
Facility
|
OP
|
$390.00
|
|
|
Service Code
|
HCPCS 64566
|
| Hospital Charge Code |
761T2789
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$50.70 |
| Max. Negotiated Rate |
$374.40 |
| Rate for Payer: Aetna Commercial |
$300.30
|
| Rate for Payer: Anthem Medicaid |
$134.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$256.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$304.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$358.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$345.76
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cigna Commercial |
$323.70
|
| Rate for Payer: First Health Commercial |
$370.50
|
| Rate for Payer: Humana Commercial |
$331.50
|
| Rate for Payer: Humana KY Medicaid |
$134.12
|
| Rate for Payer: Humana Medicare Advantage |
$256.12
|
| Rate for Payer: Kentucky WC Medicaid |
$135.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$319.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$287.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$307.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$136.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$343.20
|
| Rate for Payer: Ohio Health Group HMO |
$292.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$50.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$120.90
|
| Rate for Payer: PHCS Commercial |
$374.40
|
| Rate for Payer: United Healthcare All Payer |
$343.20
|
|
|
NEUROELTRD STIM POST TIBIAL (T
|
Facility
|
IP
|
$390.00
|
|
|
Service Code
|
HCPCS 64566
|
| Hospital Charge Code |
761T2789
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$50.70 |
| Max. Negotiated Rate |
$374.40 |
| Rate for Payer: Aetna Commercial |
$300.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$304.20
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cigna Commercial |
$323.70
|
| Rate for Payer: First Health Commercial |
$370.50
|
| Rate for Payer: Humana Commercial |
$331.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$319.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$287.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$343.20
|
| Rate for Payer: Ohio Health Group HMO |
$292.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$50.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$120.90
|
| Rate for Payer: PHCS Commercial |
$374.40
|
| Rate for Payer: United Healthcare All Payer |
$343.20
|
|
|
NEUROLOGICAL EYE DISORDERS
|
Facility
|
IP
|
$9,405.35
|
|
|
Service Code
|
MSDRG 123
|
| Min. Negotiated Rate |
$6,382.20 |
| Max. Negotiated Rate |
$9,405.35 |
| Rate for Payer: Anthem Medicaid |
$6,382.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,718.11
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9,405.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$9,069.45
|
| Rate for Payer: Humana KY Medicaid |
$6,382.20
|
| Rate for Payer: Humana Medicare Advantage |
$6,718.11
|
| Rate for Payer: Kentucky WC Medicaid |
$6,446.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,061.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,509.85
|
|
|
NEUROMEND 12MM*2.5CM
|
Facility
|
IP
|
$7,880.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,024.50 |
| Max. Negotiated Rate |
$7,565.57 |
| Rate for Payer: Aetna Commercial |
$6,068.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,147.02
|
| Rate for Payer: Cash Price |
$3,940.40
|
| Rate for Payer: Cigna Commercial |
$6,541.06
|
| Rate for Payer: First Health Commercial |
$7,486.76
|
| Rate for Payer: Humana Commercial |
$6,698.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,462.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,816.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,364.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,935.10
|
| Rate for Payer: Ohio Health Group HMO |
$5,910.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,576.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,024.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,443.05
|
| Rate for Payer: PHCS Commercial |
$7,565.57
|
| Rate for Payer: United Healthcare All Payer |
$6,935.10
|
|
|
NEUROMEND 12MM*2.5CM
|
Facility
|
OP
|
$7,880.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,024.50 |
| Max. Negotiated Rate |
$7,565.57 |
| Rate for Payer: Aetna Commercial |
$6,068.22
|
| Rate for Payer: Anthem Medicaid |
$2,710.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,147.02
|
| Rate for Payer: Cash Price |
$3,940.40
|
| Rate for Payer: Cigna Commercial |
$6,541.06
|
| Rate for Payer: First Health Commercial |
$7,486.76
|
| Rate for Payer: Humana Commercial |
$6,698.68
|
| Rate for Payer: Humana KY Medicaid |
$2,710.21
|
| Rate for Payer: Kentucky WC Medicaid |
$2,737.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,462.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,816.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,364.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,764.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,935.10
|
| Rate for Payer: Ohio Health Group HMO |
$5,910.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,576.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,024.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,443.05
|
| Rate for Payer: PHCS Commercial |
$7,565.57
|
| Rate for Payer: United Healthcare All Payer |
$6,935.10
|
|
|
NEUROMEND 12MM*5.0CM
|
Facility
|
IP
|
$8,318.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,081.44 |
| Max. Negotiated Rate |
$7,986.05 |
| Rate for Payer: Aetna Commercial |
$6,405.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,488.66
|
| Rate for Payer: Cash Price |
$4,159.40
|
| Rate for Payer: Cigna Commercial |
$6,904.60
|
| Rate for Payer: First Health Commercial |
$7,902.86
|
| Rate for Payer: Humana Commercial |
$7,070.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,821.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,139.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,495.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,320.54
|
| Rate for Payer: Ohio Health Group HMO |
$6,239.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,663.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,081.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,578.83
|
| Rate for Payer: PHCS Commercial |
$7,986.05
|
| Rate for Payer: United Healthcare All Payer |
$7,320.54
|
|
