|
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 |
$617.57 |
| 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 |
$639.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,400.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$895.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$863.82
|
| 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 |
$639.87
|
| 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 |
$767.84
|
| 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 |
$1,436.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,562.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,239.08
|
| 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 |
$538.73 |
| 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 |
$1,436.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,562.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,239.08
|
| Rate for Payer: PHCS Commercial |
$1,723.94
|
| Rate for Payer: United Healthcare All Payer |
$1,580.28
|
|
|
N BLOCK INJ TRIGEMINAL
|
Professional
|
Both
|
$1,286.00
|
|
|
Service Code
|
HCPCS 64400
|
| Hospital Charge Code |
76102310
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$25.78 |
| Max. Negotiated Rate |
$771.60 |
| Rate for Payer: Aetna Commercial |
$100.61
|
| Rate for Payer: Ambetter Exchange |
$49.25
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$25.78
|
| Rate for Payer: Anthem Medicaid |
$81.31
|
| Rate for Payer: Buckeye Individual/Medicaid |
$49.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$49.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$59.10
|
| Rate for Payer: Cash Price |
$643.00
|
| Rate for Payer: Cash Price |
$643.00
|
| Rate for Payer: Cigna Commercial |
$167.58
|
| Rate for Payer: Healthspan PPO |
$127.75
|
| Rate for Payer: Humana Medicaid |
$81.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$85.64
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$49.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.25
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$82.94
|
| Rate for Payer: Molina Healthcare Passport |
$81.31
|
| Rate for Payer: Multiplan PHCS |
$771.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$64.03
|
| Rate for Payer: UHCCP Medicaid |
$27.07
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$82.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$49.25
|
|
|
N BLOCK INJ TRIGEMINAL
|
Facility
|
IP
|
$1,286.00
|
|
|
Service Code
|
HCPCS 64400
|
| Hospital Charge Code |
76102310
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$385.80 |
| Max. Negotiated Rate |
$1,234.56 |
| Rate for Payer: Aetna Commercial |
$990.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,003.08
|
| Rate for Payer: Cash Price |
$643.00
|
| Rate for Payer: Cigna Commercial |
$1,067.38
|
| Rate for Payer: First Health Commercial |
$1,221.70
|
| Rate for Payer: Humana Commercial |
$1,093.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,054.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$949.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$385.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,131.68
|
| Rate for Payer: Ohio Health Group HMO |
$964.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,028.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,118.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$887.34
|
| Rate for Payer: PHCS Commercial |
$1,234.56
|
| Rate for Payer: United Healthcare All Payer |
$1,131.68
|
|
|
N BLOCK INJ TRIGEMINAL
|
Facility
|
OP
|
$1,286.00
|
|
|
Service Code
|
HCPCS 64400
|
| Hospital Charge Code |
76102310
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$272.75 |
| Max. Negotiated Rate |
$1,234.56 |
| Rate for Payer: Aetna Commercial |
$990.22
|
| Rate for Payer: Anthem Medicaid |
$442.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$272.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,003.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$381.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$368.21
|
| Rate for Payer: Cash Price |
$643.00
|
| Rate for Payer: Cash Price |
$643.00
|
| Rate for Payer: Cigna Commercial |
$1,067.38
|
| Rate for Payer: First Health Commercial |
$1,221.70
|
| Rate for Payer: Humana Commercial |
$1,093.10
|
| Rate for Payer: Humana KY Medicaid |
$442.26
|
| Rate for Payer: Humana Medicare Advantage |
$272.75
|
| Rate for Payer: Kentucky WC Medicaid |
$446.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,054.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$949.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$327.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$451.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,131.68
|
| Rate for Payer: Ohio Health Group HMO |
$964.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,028.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,118.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$887.34
|
| Rate for Payer: PHCS Commercial |
$1,234.56
|
| Rate for Payer: United Healthcare All Payer |
$1,131.68
|
|
|
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 |
$300.00 |
| Rate for Payer: Aetna Commercial |
$100.61
|
| Rate for Payer: Ambetter Exchange |
$49.25
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$25.78
|
| Rate for Payer: Anthem Medicaid |
$81.31
|
| Rate for Payer: Buckeye Individual/Medicaid |
$49.25
|
| Rate for Payer: Buckeye Medicare Advantage |
$49.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$59.10
|
| 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 |
$81.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$85.64
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$49.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.25
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$82.94
|
| Rate for Payer: Molina Healthcare Passport |
$81.31
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$64.03
|
| Rate for Payer: UHCCP Medicaid |
$27.07
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$82.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$49.25
|
|
|
N BLOCK INJ TRIGEMINAL(T
|
Facility
|
IP
|
$786.00
|
|
|
Service Code
|
HCPCS 64400
|
| Hospital Charge Code |
761T2310
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$235.80 |
| Max. Negotiated Rate |
$754.56 |
| Rate for Payer: Aetna Commercial |
$605.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$613.08
|
| Rate for Payer: Cash Price |
$393.00
|
| Rate for Payer: Cigna Commercial |
$652.38
|
| Rate for Payer: First Health Commercial |
$746.70
|
| Rate for Payer: Humana Commercial |
$668.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$644.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$580.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$235.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$691.68
|
| Rate for Payer: Ohio Health Group HMO |
$589.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$628.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$683.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$542.34
|
| Rate for Payer: PHCS Commercial |
$754.56
|
| Rate for Payer: United Healthcare All Payer |
$691.68
|
|
|
N BLOCK INJ TRIGEMINAL(T
|
Facility
|
OP
|
$786.00
|
|
|
Service Code
|
HCPCS 64400
|
| Hospital Charge Code |
761T2310
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$270.31 |
| Max. Negotiated Rate |
$754.56 |
| Rate for Payer: Aetna Commercial |
$605.22
|
| Rate for Payer: Anthem Medicaid |
$270.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$272.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$613.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$381.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$368.21
|
| Rate for Payer: Cash Price |
$393.00
|
| Rate for Payer: Cash Price |
$393.00
|
| Rate for Payer: Cigna Commercial |
$652.38
|
| Rate for Payer: First Health Commercial |
$746.70
|
| Rate for Payer: Humana Commercial |
$668.10
|
| Rate for Payer: Humana KY Medicaid |
$270.31
|
| Rate for Payer: Humana Medicare Advantage |
$272.75
|
| Rate for Payer: Kentucky WC Medicaid |
$273.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$644.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$580.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$327.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$275.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$691.68
|
| Rate for Payer: Ohio Health Group HMO |
$589.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$628.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$683.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$542.34
|
| Rate for Payer: PHCS Commercial |
$754.56
|
| Rate for Payer: United Healthcare All Payer |
$691.68
|
|
|
N BLOCK SPENOPALATINE GANGL
|
Facility
|
IP
|
$1,030.00
|
|
|
Service Code
|
HCPCS 64505
|
| Hospital Charge Code |
76102332
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$309.00 |
| 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 |
$824.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$896.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$710.70
|
| Rate for Payer: PHCS Commercial |
$988.80
|
| Rate for Payer: United Healthcare All Payer |
$906.40
|
|
|
N BLOCK SPENOPALATINE GANGL
|
Facility
|
OP
|
$1,030.00
|
|
|
Service Code
|
HCPCS 64505
|
| Hospital Charge Code |
76102332
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$272.75 |
| 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 |
$272.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$803.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$381.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$368.21
|
| 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 |
$272.75
|
| 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 |
$327.30
|
| 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 |
$824.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$896.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$710.70
|
| 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 |
$52.95 |
| Max. Negotiated Rate |
$618.00 |
| Rate for Payer: Aetna Commercial |
$134.12
|
| Rate for Payer: Ambetter Exchange |
$100.05
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$52.95
|
| Rate for Payer: Anthem Medicaid |
$57.99
|
| Rate for Payer: Buckeye Individual/Medicaid |
$100.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$100.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$120.06
|
| 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 |
$57.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$103.89
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$100.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$100.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$59.15
|
| Rate for Payer: Molina Healthcare Passport |
$57.99
|
| Rate for Payer: Multiplan PHCS |
$618.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$130.06
|
| Rate for Payer: UHCCP Medicaid |
$55.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$58.57
|
| Rate for Payer: Wellcare Medicare Advantage |
$100.05
|
|
|
N BLOCK SPENOPALATINE GANGL(P
|
Professional
|
Both
|
$290.00
|
|
|
Service Code
|
HCPCS 64505
|
| Hospital Charge Code |
761P2332
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$52.95 |
| Max. Negotiated Rate |
$174.00 |
| Rate for Payer: Aetna Commercial |
$134.12
|
| Rate for Payer: Ambetter Exchange |
$100.05
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$52.95
|
| Rate for Payer: Anthem Medicaid |
$57.99
|
| Rate for Payer: Buckeye Individual/Medicaid |
$100.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$100.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$120.06
|
| 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 |
$57.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$103.89
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$100.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$100.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$59.15
|
| Rate for Payer: Molina Healthcare Passport |
$57.99
|
| Rate for Payer: Multiplan PHCS |
$174.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$130.06
|
| Rate for Payer: UHCCP Medicaid |
$55.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$58.57
|
| Rate for Payer: Wellcare Medicare Advantage |
$100.05
|
|
|
N BLOCK SPENOPALATINE GANGL(T
|
Facility
|
IP
|
$740.00
|
|
|
Service Code
|
HCPCS 64505
|
| Hospital Charge Code |
761T2332
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$222.00 |
| 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 |
$592.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$643.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$510.60
|
| 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 |
$254.49 |
| 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 |
$272.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$577.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$381.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$368.21
|
| 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 |
$272.75
|
| 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 |
$327.30
|
| 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 |
$592.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$643.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$510.60
|
| Rate for Payer: PHCS Commercial |
$710.40
|
| Rate for Payer: United Healthcare All Payer |
$651.20
|
|
|
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 |
$780.60 |
| Rate for Payer: Aetna Commercial |
$229.62
|
| Rate for Payer: Ambetter Exchange |
$132.69
|
| Rate for Payer: Anthem Medicaid |
$119.57
|
| Rate for Payer: Buckeye Individual/Medicaid |
$132.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$132.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$159.23
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$132.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.69
|
| 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 |
$172.50
|
| Rate for Payer: UHCCP Medicaid |
$455.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$120.77
|
| Rate for Payer: Wellcare Medicare Advantage |
$132.69
|
|
|
NB RESUSCITATION
|
Facility
|
IP
|
$1,301.00
|
|
|
Service Code
|
HCPCS 99465
|
| Hospital Charge Code |
51000121
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$390.30 |
| 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 |
$1,040.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,131.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$897.69
|
| Rate for Payer: PHCS Commercial |
$1,248.96
|
| Rate for Payer: United Healthcare All Payer |
$1,144.88
|
|
|
NB RESUSCITATION
|
Facility
|
OP
|
$1,301.00
|
|
|
Service Code
|
HCPCS 99465
|
| Hospital Charge Code |
51000121
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$447.41 |
| 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 |
$604.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,014.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$846.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$816.25
|
| 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 |
$604.63
|
| 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 |
$725.56
|
| 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 |
$1,040.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,131.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$897.69
|
| Rate for Payer: PHCS Commercial |
$1,248.96
|
| Rate for Payer: United Healthcare All Payer |
$1,144.88
|
|
|
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 |
$300.00 |
| Rate for Payer: Aetna Commercial |
$229.62
|
| Rate for Payer: Ambetter Exchange |
$132.69
|
| Rate for Payer: Anthem Medicaid |
$119.57
|
| Rate for Payer: Buckeye Individual/Medicaid |
$132.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$132.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$159.23
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$132.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.69
|
| 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 |
$172.50
|
| Rate for Payer: UHCCP Medicaid |
$175.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$120.77
|
| Rate for Payer: Wellcare Medicare Advantage |
$132.69
|
|
|
NB RESUSCITATION(T
|
Facility
|
OP
|
$801.00
|
|
|
Service Code
|
HCPCS 99465
|
| Hospital Charge Code |
510T0121
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$275.46 |
| Max. Negotiated Rate |
$846.48 |
| Rate for Payer: Aetna Commercial |
$616.77
|
| Rate for Payer: Anthem Medicaid |
$275.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$604.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$846.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$816.25
|
| 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 |
$604.63
|
| 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 |
$725.56
|
| 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 |
$640.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$696.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$552.69
|
| Rate for Payer: PHCS Commercial |
$768.96
|
| Rate for Payer: United Healthcare All Payer |
$704.88
|
|
|
NB RESUSCITATION(T
|
Facility
|
IP
|
$801.00
|
|
|
Service Code
|
HCPCS 99465
|
| Hospital Charge Code |
510T0121
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$240.30 |
| Max. Negotiated Rate |
$768.96 |
| Rate for Payer: Aetna Commercial |
$616.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.78
|
| 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: 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 |
$240.30
|
| 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 |
$640.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$696.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$552.69
|
| Rate for Payer: PHCS Commercial |
$768.96
|
| Rate for Payer: United Healthcare All Payer |
$704.88
|
|
|
NBX INTRA PARAVERTEB DISC TISS
|
Facility
|
OP
|
$1,191.00
|
|
|
Service Code
|
HCPCS 62267
|
| Hospital Charge Code |
761T2290
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$409.58 |
| Max. Negotiated Rate |
$1,143.36 |
| Rate for Payer: Aetna Commercial |
$917.07
|
| Rate for Payer: Anthem Medicaid |
$409.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$650.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$928.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$910.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$877.63
|
| Rate for Payer: Cash Price |
$595.50
|
| Rate for Payer: Cash Price |
$595.50
|
| Rate for Payer: Cigna Commercial |
$988.53
|
| Rate for Payer: First Health Commercial |
$1,131.45
|
| Rate for Payer: Humana Commercial |
$1,012.35
|
| Rate for Payer: Humana KY Medicaid |
$409.58
|
| Rate for Payer: Humana Medicare Advantage |
$650.10
|
| Rate for Payer: Kentucky WC Medicaid |
$413.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$976.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$878.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$780.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$417.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,048.08
|
| Rate for Payer: Ohio Health Group HMO |
$893.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$952.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,036.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$821.79
|
| Rate for Payer: PHCS Commercial |
$1,143.36
|
| Rate for Payer: United Healthcare All Payer |
$1,048.08
|
|
|
NBX INTRA PARAVERTEB DISC TISS
|
Professional
|
Both
|
$1,891.00
|
|
|
Service Code
|
HCPCS 62267
|
| Hospital Charge Code |
76102290
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$107.57 |
| Max. Negotiated Rate |
$1,134.60 |
| Rate for Payer: Aetna Commercial |
$271.24
|
| Rate for Payer: Ambetter Exchange |
$144.74
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$107.57
|
| Rate for Payer: Anthem Medicaid |
$196.12
|
| Rate for Payer: Buckeye Individual/Medicaid |
$144.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$144.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$173.69
|
| Rate for Payer: Cash Price |
$945.50
|
| Rate for Payer: Cash Price |
$945.50
|
| Rate for Payer: Cigna Commercial |
$264.59
|
| Rate for Payer: Healthspan PPO |
$312.43
|
| Rate for Payer: Humana Medicaid |
$196.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$204.01
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$144.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$144.74
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$200.04
|
| Rate for Payer: Molina Healthcare Passport |
$196.12
|
| Rate for Payer: Multiplan PHCS |
$1,134.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$188.16
|
| Rate for Payer: UHCCP Medicaid |
$112.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$198.08
|
| Rate for Payer: Wellcare Medicare Advantage |
$144.74
|
|
|
NBX INTRA PARAVERTEB DISC TISS
|
Facility
|
IP
|
$1,191.00
|
|
|
Service Code
|
HCPCS 62267
|
| Hospital Charge Code |
761T2290
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$357.30 |
| Max. Negotiated Rate |
$1,143.36 |
| Rate for Payer: Aetna Commercial |
$917.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$928.98
|
| Rate for Payer: Cash Price |
$595.50
|
| Rate for Payer: Cigna Commercial |
$988.53
|
| Rate for Payer: First Health Commercial |
$1,131.45
|
| Rate for Payer: Humana Commercial |
$1,012.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$976.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$878.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$357.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,048.08
|
| Rate for Payer: Ohio Health Group HMO |
$893.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$952.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,036.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$821.79
|
| Rate for Payer: PHCS Commercial |
$1,143.36
|
| Rate for Payer: United Healthcare All Payer |
$1,048.08
|
|
|
NBX INTRA PARAVERTEB DISC TISS
|
Facility
|
IP
|
$1,891.00
|
|
|
Service Code
|
HCPCS 62267
|
| Hospital Charge Code |
76102290
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$567.30 |
| Max. Negotiated Rate |
$1,815.36 |
| Rate for Payer: Aetna Commercial |
$1,456.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,474.98
|
| Rate for Payer: Cash Price |
$945.50
|
| Rate for Payer: Cigna Commercial |
$1,569.53
|
| Rate for Payer: First Health Commercial |
$1,796.45
|
| Rate for Payer: Humana Commercial |
$1,607.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,550.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,395.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$567.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,664.08
|
| Rate for Payer: Ohio Health Group HMO |
$1,418.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,512.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,645.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,304.79
|
| Rate for Payer: PHCS Commercial |
$1,815.36
|
| Rate for Payer: United Healthcare All Payer |
$1,664.08
|
|
|
NBX INTRA PARAVERTEB DISC TISS
|
Facility
|
OP
|
$1,891.00
|
|
|
Service Code
|
HCPCS 62267
|
| Hospital Charge Code |
76102290
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$650.10 |
| Max. Negotiated Rate |
$1,815.36 |
| Rate for Payer: Aetna Commercial |
$1,456.07
|
| Rate for Payer: Anthem Medicaid |
$650.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$650.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,474.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$910.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$877.63
|
| Rate for Payer: Cash Price |
$945.50
|
| Rate for Payer: Cash Price |
$945.50
|
| Rate for Payer: Cigna Commercial |
$1,569.53
|
| Rate for Payer: First Health Commercial |
$1,796.45
|
| Rate for Payer: Humana Commercial |
$1,607.35
|
| Rate for Payer: Humana KY Medicaid |
$650.31
|
| Rate for Payer: Humana Medicare Advantage |
$650.10
|
| Rate for Payer: Kentucky WC Medicaid |
$656.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,550.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,395.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$780.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$663.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,664.08
|
| Rate for Payer: Ohio Health Group HMO |
$1,418.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,512.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,645.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,304.79
|
| Rate for Payer: PHCS Commercial |
$1,815.36
|
| Rate for Payer: United Healthcare All Payer |
$1,664.08
|
|
