|
RADIOELEMENT HANDLING
|
Professional
|
Both
|
$723.10
|
|
|
Service Code
|
HCPCS 77790
|
| Hospital Charge Code |
33300045
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$16.88 |
| Max. Negotiated Rate |
$433.86 |
| Rate for Payer: Aetna Commercial |
$135.17
|
| Rate for Payer: Ambetter Exchange |
$16.88
|
| Rate for Payer: Anthem Medicaid |
$58.45
|
| Rate for Payer: Buckeye Individual/Medicaid |
$16.88
|
| Rate for Payer: Buckeye Medicare Advantage |
$16.88
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.26
|
| Rate for Payer: Cash Price |
$361.55
|
| Rate for Payer: Cash Price |
$361.55
|
| Rate for Payer: Cigna Commercial |
$114.60
|
| Rate for Payer: Healthspan PPO |
$113.99
|
| Rate for Payer: Humana Medicaid |
$58.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$114.03
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$16.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.88
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$59.62
|
| Rate for Payer: Molina Healthcare Passport |
$58.45
|
| Rate for Payer: Multiplan PHCS |
$433.86
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$21.94
|
| Rate for Payer: UHCCP Medicaid |
$253.09
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$59.03
|
| Rate for Payer: Wellcare Medicare Advantage |
$16.88
|
|
|
RADIOELEMENT HANDLING
|
Facility
|
IP
|
$723.10
|
|
|
Service Code
|
HCPCS 77790
|
| Hospital Charge Code |
33300045
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$216.93 |
| Max. Negotiated Rate |
$694.18 |
| Rate for Payer: Aetna Commercial |
$556.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$564.02
|
| Rate for Payer: Cash Price |
$361.55
|
| Rate for Payer: Cigna Commercial |
$600.17
|
| Rate for Payer: First Health Commercial |
$686.95
|
| Rate for Payer: Humana Commercial |
$614.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$592.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$533.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$216.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$636.33
|
| Rate for Payer: Ohio Health Group HMO |
$542.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$578.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$629.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$498.94
|
| Rate for Payer: PHCS Commercial |
$694.18
|
| Rate for Payer: United Healthcare All Payer |
$636.33
|
|
|
RADIOELEMENT HANDLING
|
Facility
|
OP
|
$723.10
|
|
|
Service Code
|
HCPCS 77790
|
| Hospital Charge Code |
33300045
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$216.93 |
| Max. Negotiated Rate |
$694.18 |
| Rate for Payer: Aetna Commercial |
$556.79
|
| Rate for Payer: Anthem Medicaid |
$248.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$564.02
|
| Rate for Payer: Cash Price |
$361.55
|
| Rate for Payer: Cigna Commercial |
$600.17
|
| Rate for Payer: First Health Commercial |
$686.95
|
| Rate for Payer: Humana Commercial |
$614.63
|
| Rate for Payer: Humana KY Medicaid |
$248.67
|
| Rate for Payer: Kentucky WC Medicaid |
$251.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$592.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$533.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$216.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$253.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$636.33
|
| Rate for Payer: Ohio Health Group HMO |
$542.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$578.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$629.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$498.94
|
| Rate for Payer: PHCS Commercial |
$694.18
|
| Rate for Payer: United Healthcare All Payer |
$636.33
|
|
|
RADIOELEMENT HANDLING(T
|
Facility
|
IP
|
$723.10
|
|
|
Service Code
|
HCPCS 77790
|
| Hospital Charge Code |
333T0045
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$216.93 |
| Max. Negotiated Rate |
$694.18 |
| Rate for Payer: Aetna Commercial |
$556.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$564.02
|
| Rate for Payer: Cash Price |
$361.55
|
| Rate for Payer: Cigna Commercial |
$600.17
|
| Rate for Payer: First Health Commercial |
$686.95
|
| Rate for Payer: Humana Commercial |
$614.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$592.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$533.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$216.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$636.33
|
| Rate for Payer: Ohio Health Group HMO |
$542.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$578.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$629.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$498.94
|
| Rate for Payer: PHCS Commercial |
$694.18
|
| Rate for Payer: United Healthcare All Payer |
$636.33
|
|
|
RADIOELEMENT HANDLING(T
|
Facility
|
OP
|
$723.10
|
|
|
Service Code
|
HCPCS 77790
|
| Hospital Charge Code |
333T0045
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$216.93 |
| Max. Negotiated Rate |
$694.18 |
| Rate for Payer: Aetna Commercial |
$556.79
|
| Rate for Payer: Anthem Medicaid |
$248.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$564.02
|
| Rate for Payer: Cash Price |
$361.55
|
| Rate for Payer: Cigna Commercial |
$600.17
|
| Rate for Payer: First Health Commercial |
$686.95
|
| Rate for Payer: Humana Commercial |
$614.63
|
| Rate for Payer: Humana KY Medicaid |
$248.67
|
| Rate for Payer: Kentucky WC Medicaid |
$251.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$592.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$533.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$216.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$253.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$636.33
|
| Rate for Payer: Ohio Health Group HMO |
$542.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$578.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$629.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$498.94
|
| Rate for Payer: PHCS Commercial |
$694.18
|
| Rate for Payer: United Healthcare All Payer |
$636.33
|
|
|
RADIOFR ABLAT LUMB/SAC EA AD(P
|
Professional
|
Both
|
$550.00
|
|
|
Service Code
|
HCPCS 64636
|
| Hospital Charge Code |
761P2349
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$29.94 |
| Max. Negotiated Rate |
$330.00 |
| Rate for Payer: Ambetter Exchange |
$55.68
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$29.94
|
| Rate for Payer: Anthem Medicaid |
$144.74
|
| Rate for Payer: Buckeye Individual/Medicaid |
$55.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$55.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$66.82
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$108.27
|
| Rate for Payer: Healthspan PPO |
$172.88
|
| Rate for Payer: Humana Medicaid |
$144.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$77.39
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$55.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$147.63
|
| Rate for Payer: Molina Healthcare Passport |
$144.74
|
| Rate for Payer: Multiplan PHCS |
$330.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$72.38
|
| Rate for Payer: UHCCP Medicaid |
$31.44
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$146.19
|
| Rate for Payer: Wellcare Medicare Advantage |
$55.68
|
|
|
RADIOFREQ ABLAT LUMB/SAC EA AD
|
Facility
|
OP
|
$550.00
|
|
|
Service Code
|
HCPCS 64636
|
| Hospital Charge Code |
76102349
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$528.00 |
| Rate for Payer: Aetna Commercial |
$423.50
|
| Rate for Payer: Anthem Medicaid |
$189.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$429.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$456.50
|
| Rate for Payer: First Health Commercial |
$522.50
|
| Rate for Payer: Humana Commercial |
$467.50
|
| Rate for Payer: Humana KY Medicaid |
$189.15
|
| Rate for Payer: Kentucky WC Medicaid |
$191.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$451.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$405.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$165.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$192.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$484.00
|
| Rate for Payer: Ohio Health Group HMO |
$412.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$478.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$379.50
|
| Rate for Payer: PHCS Commercial |
$528.00
|
| Rate for Payer: United Healthcare All Payer |
$484.00
|
|
|
RADIOFREQ ABLAT LUMB/SAC EA AD
|
Facility
|
IP
|
$550.00
|
|
|
Service Code
|
HCPCS 64636
|
| Hospital Charge Code |
76102349
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$165.00 |
| Max. Negotiated Rate |
$528.00 |
| Rate for Payer: Aetna Commercial |
$423.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$429.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$456.50
|
| Rate for Payer: First Health Commercial |
$522.50
|
| Rate for Payer: Humana Commercial |
$467.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$451.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$405.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$165.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$484.00
|
| Rate for Payer: Ohio Health Group HMO |
$412.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$478.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$379.50
|
| Rate for Payer: PHCS Commercial |
$528.00
|
| Rate for Payer: United Healthcare All Payer |
$484.00
|
|
|
RADIOFREQ ABLAT LUMB/SAC EA AD
|
Professional
|
Both
|
$550.00
|
|
|
Service Code
|
HCPCS 64636
|
| Hospital Charge Code |
76102349
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$29.94 |
| Max. Negotiated Rate |
$330.00 |
| Rate for Payer: Ambetter Exchange |
$55.68
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$29.94
|
| Rate for Payer: Anthem Medicaid |
$144.74
|
| Rate for Payer: Buckeye Individual/Medicaid |
$55.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$55.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$66.82
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$108.27
|
| Rate for Payer: Healthspan PPO |
$172.88
|
| Rate for Payer: Humana Medicaid |
$144.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$77.39
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$55.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$147.63
|
| Rate for Payer: Molina Healthcare Passport |
$144.74
|
| Rate for Payer: Multiplan PHCS |
$330.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$72.38
|
| Rate for Payer: UHCCP Medicaid |
$31.44
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$146.19
|
| Rate for Payer: Wellcare Medicare Advantage |
$55.68
|
|
|
RADIOFREQ ABLAT LUMB/SAC FCT J
|
Facility
|
IP
|
$1,040.00
|
|
|
Service Code
|
HCPCS 64635
|
| Hospital Charge Code |
76102348
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$312.00 |
| Max. Negotiated Rate |
$998.40 |
| Rate for Payer: Aetna Commercial |
$800.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$811.20
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cigna Commercial |
$863.20
|
| Rate for Payer: First Health Commercial |
$988.00
|
| Rate for Payer: Humana Commercial |
$884.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$852.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$767.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$312.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$915.20
|
| Rate for Payer: Ohio Health Group HMO |
$780.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$832.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$904.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$717.60
|
| Rate for Payer: PHCS Commercial |
$998.40
|
| Rate for Payer: United Healthcare All Payer |
$915.20
|
|
|
RADIOFREQ ABLAT LUMB/SAC FCT J
|
Facility
|
OP
|
$1,040.00
|
|
|
Service Code
|
HCPCS 64635
|
| Hospital Charge Code |
76102348
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$357.66 |
| Max. Negotiated Rate |
$2,526.05 |
| Rate for Payer: Aetna Commercial |
$800.80
|
| Rate for Payer: Anthem Medicaid |
$357.66
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,804.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$811.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,526.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,435.83
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cigna Commercial |
$863.20
|
| Rate for Payer: First Health Commercial |
$988.00
|
| Rate for Payer: Humana Commercial |
$884.00
|
| Rate for Payer: Humana KY Medicaid |
$357.66
|
| Rate for Payer: Humana Medicare Advantage |
$1,804.32
|
| Rate for Payer: Kentucky WC Medicaid |
$361.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$852.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$767.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,165.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$364.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$915.20
|
| Rate for Payer: Ohio Health Group HMO |
$780.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$832.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$904.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$717.60
|
| Rate for Payer: PHCS Commercial |
$998.40
|
| Rate for Payer: United Healthcare All Payer |
$915.20
|
|
|
RADIOFREQ ABLAT LUMB/SAC FCT J
|
Professional
|
Both
|
$1,040.00
|
|
|
Service Code
|
HCPCS 64635
|
| Hospital Charge Code |
76102348
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$97.25 |
| Max. Negotiated Rate |
$624.00 |
| Rate for Payer: Ambetter Exchange |
$180.73
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$97.25
|
| Rate for Payer: Anthem Medicaid |
$347.59
|
| Rate for Payer: Buckeye Individual/Medicaid |
$180.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$180.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$216.88
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cigna Commercial |
$405.37
|
| Rate for Payer: Healthspan PPO |
$415.50
|
| Rate for Payer: Humana Medicaid |
$347.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$289.36
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$180.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.73
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$354.54
|
| Rate for Payer: Molina Healthcare Passport |
$347.59
|
| Rate for Payer: Multiplan PHCS |
$624.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$234.95
|
| Rate for Payer: UHCCP Medicaid |
$102.11
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$351.07
|
| Rate for Payer: Wellcare Medicare Advantage |
$180.73
|
|
|
RADIOFREQ ABLAT LUMN/SAC FAC(P
|
Professional
|
Both
|
$1,040.00
|
|
|
Service Code
|
HCPCS 64635
|
| Hospital Charge Code |
761P2348
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$97.25 |
| Max. Negotiated Rate |
$624.00 |
| Rate for Payer: Ambetter Exchange |
$180.73
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$97.25
|
| Rate for Payer: Anthem Medicaid |
$347.59
|
| Rate for Payer: Buckeye Individual/Medicaid |
$180.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$180.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$216.88
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cigna Commercial |
$405.37
|
| Rate for Payer: Healthspan PPO |
$415.50
|
| Rate for Payer: Humana Medicaid |
$347.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$289.36
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$180.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.73
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$354.54
|
| Rate for Payer: Molina Healthcare Passport |
$347.59
|
| Rate for Payer: Multiplan PHCS |
$624.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$234.95
|
| Rate for Payer: UHCCP Medicaid |
$102.11
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$351.07
|
| Rate for Payer: Wellcare Medicare Advantage |
$180.73
|
|
|
RADIOFREQUENCY ABLATION, NERVES INNERVATING THE SACROILIAC JOINT, WITH IMAGE GUIDANCE (IE, FLUOROSCOPY OR COMPUTED TOMOGRAPHY)
|
Facility
|
OP
|
$2,526.05
|
|
|
Service Code
|
CPT 64625
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,804.32 |
| Max. Negotiated Rate |
$2,526.05 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,804.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,526.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,435.83
|
| Rate for Payer: Humana Medicare Advantage |
$1,804.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,165.18
|
|
|
RADIOLOGIC EXAM CLAVICLE, COMP
|
Professional
|
Both
|
$50.00
|
|
|
Service Code
|
HCPCS 73000
|
| Hospital Charge Code |
320P0275
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$41.35 |
| Rate for Payer: Aetna Commercial |
$41.35
|
| Rate for Payer: Ambetter Exchange |
$29.42
|
| Rate for Payer: Anthem Medicaid |
$20.96
|
| Rate for Payer: Buckeye Individual/Medicaid |
$29.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$29.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$35.30
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$40.84
|
| Rate for Payer: Healthspan PPO |
$38.74
|
| Rate for Payer: Humana Medicaid |
$20.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$10.38
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$29.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.42
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$21.38
|
| Rate for Payer: Molina Healthcare Passport |
$20.96
|
| Rate for Payer: Multiplan PHCS |
$30.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$38.25
|
| Rate for Payer: UHCCP Medicaid |
$17.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$21.17
|
| Rate for Payer: Wellcare Medicare Advantage |
$29.42
|
|
|
RADIOLOGIC EXAM CLAVICLE, COMP
|
Facility
|
OP
|
$310.00
|
|
|
Service Code
|
HCPCS 73000
|
| Hospital Charge Code |
32000275
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$297.60 |
| Rate for Payer: Aetna Commercial |
$238.70
|
| Rate for Payer: Anthem Medicaid |
$106.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$241.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$155.00
|
| Rate for Payer: Cash Price |
$155.00
|
| Rate for Payer: Cigna Commercial |
$257.30
|
| Rate for Payer: First Health Commercial |
$294.50
|
| Rate for Payer: Humana Commercial |
$263.50
|
| Rate for Payer: Humana KY Medicaid |
$106.61
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$107.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$254.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$228.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$108.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$272.80
|
| Rate for Payer: Ohio Health Group HMO |
$232.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$248.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$269.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$213.90
|
| Rate for Payer: PHCS Commercial |
$297.60
|
| Rate for Payer: United Healthcare All Payer |
$272.80
|
|
|
RADIOLOGIC EXAM CLAVICLE, COMP
|
Facility
|
OP
|
$260.00
|
|
|
Service Code
|
HCPCS 73000
|
| Hospital Charge Code |
320T0275
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$249.60 |
| Rate for Payer: Aetna Commercial |
$200.20
|
| Rate for Payer: Anthem Medicaid |
$89.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$202.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Cigna Commercial |
$215.80
|
| Rate for Payer: First Health Commercial |
$247.00
|
| Rate for Payer: Humana Commercial |
$221.00
|
| Rate for Payer: Humana KY Medicaid |
$89.41
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$90.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$213.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$191.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$91.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$228.80
|
| Rate for Payer: Ohio Health Group HMO |
$195.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$208.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$226.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$179.40
|
| Rate for Payer: PHCS Commercial |
$249.60
|
| Rate for Payer: United Healthcare All Payer |
$228.80
|
|
|
RADIOLOGIC EXAM CLAVICLE, COMP
|
Facility
|
IP
|
$260.00
|
|
|
Service Code
|
HCPCS 73000
|
| Hospital Charge Code |
320T0275
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$78.00 |
| Max. Negotiated Rate |
$249.60 |
| Rate for Payer: Aetna Commercial |
$200.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$202.80
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Cigna Commercial |
$215.80
|
| Rate for Payer: First Health Commercial |
$247.00
|
| Rate for Payer: Humana Commercial |
$221.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$213.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$191.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$228.80
|
| Rate for Payer: Ohio Health Group HMO |
$195.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$208.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$226.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$179.40
|
| Rate for Payer: PHCS Commercial |
$249.60
|
| Rate for Payer: United Healthcare All Payer |
$228.80
|
|
|
RADIOLOGIC EXAM CLAVICLE, COMP
|
Facility
|
IP
|
$310.00
|
|
|
Service Code
|
HCPCS 73000
|
| Hospital Charge Code |
32000275
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$93.00 |
| Max. Negotiated Rate |
$297.60 |
| Rate for Payer: Aetna Commercial |
$238.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$241.80
|
| Rate for Payer: Cash Price |
$155.00
|
| Rate for Payer: Cigna Commercial |
$257.30
|
| Rate for Payer: First Health Commercial |
$294.50
|
| Rate for Payer: Humana Commercial |
$263.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$254.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$228.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$93.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$272.80
|
| Rate for Payer: Ohio Health Group HMO |
$232.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$248.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$269.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$213.90
|
| Rate for Payer: PHCS Commercial |
$297.60
|
| Rate for Payer: United Healthcare All Payer |
$272.80
|
|
|
RADIOLOGIC EXAM CLAVICLE, COMP
|
Professional
|
Both
|
$310.00
|
|
|
Service Code
|
HCPCS 73000
|
| Hospital Charge Code |
32000275
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$186.00 |
| Rate for Payer: Aetna Commercial |
$41.35
|
| Rate for Payer: Ambetter Exchange |
$29.42
|
| Rate for Payer: Anthem Medicaid |
$20.96
|
| Rate for Payer: Buckeye Individual/Medicaid |
$29.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$29.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$35.30
|
| Rate for Payer: Cash Price |
$155.00
|
| Rate for Payer: Cash Price |
$155.00
|
| Rate for Payer: Cigna Commercial |
$40.84
|
| Rate for Payer: Healthspan PPO |
$38.74
|
| Rate for Payer: Humana Medicaid |
$20.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$10.38
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$29.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.42
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$21.38
|
| Rate for Payer: Molina Healthcare Passport |
$20.96
|
| Rate for Payer: Multiplan PHCS |
$186.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$38.25
|
| Rate for Payer: UHCCP Medicaid |
$108.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$21.17
|
| Rate for Payer: Wellcare Medicare Advantage |
$29.42
|
|
|
RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW
|
Facility
|
OP
|
$113.90
|
|
|
Service Code
|
CPT 71045
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$113.90 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
|
|
RADIOLOGIC EXAM WRIST 2 VIEW(P
|
Professional
|
Both
|
$50.00
|
|
|
Service Code
|
HCPCS 73100
|
| Hospital Charge Code |
320P0084
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$11.87 |
| Max. Negotiated Rate |
$42.42 |
| Rate for Payer: Aetna Commercial |
$42.42
|
| Rate for Payer: Ambetter Exchange |
$30.30
|
| Rate for Payer: Anthem Medicaid |
$20.15
|
| Rate for Payer: Buckeye Individual/Medicaid |
$30.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$30.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$36.36
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$40.29
|
| Rate for Payer: Healthspan PPO |
$39.75
|
| Rate for Payer: Humana Medicaid |
$20.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$11.87
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$30.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$20.55
|
| Rate for Payer: Molina Healthcare Passport |
$20.15
|
| Rate for Payer: Multiplan PHCS |
$30.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$39.39
|
| Rate for Payer: UHCCP Medicaid |
$17.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.35
|
| Rate for Payer: Wellcare Medicare Advantage |
$30.30
|
|
|
RADIOLOGIC EXAM WRIST 2 VIEWS
|
Facility
|
OP
|
$404.00
|
|
|
Service Code
|
HCPCS 73100
|
| Hospital Charge Code |
32000084
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$387.84 |
| Rate for Payer: Aetna Commercial |
$311.08
|
| Rate for Payer: Anthem Medicaid |
$138.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$315.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$202.00
|
| Rate for Payer: Cash Price |
$202.00
|
| Rate for Payer: Cigna Commercial |
$335.32
|
| Rate for Payer: First Health Commercial |
$383.80
|
| Rate for Payer: Humana Commercial |
$343.40
|
| Rate for Payer: Humana KY Medicaid |
$138.94
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$140.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$331.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$298.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$141.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$355.52
|
| Rate for Payer: Ohio Health Group HMO |
$303.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$323.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$351.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$278.76
|
| Rate for Payer: PHCS Commercial |
$387.84
|
| Rate for Payer: United Healthcare All Payer |
$355.52
|
|
|
RADIOLOGIC EXAM WRIST 2 VIEWS
|
Professional
|
Both
|
$404.00
|
|
|
Service Code
|
HCPCS 73100
|
| Hospital Charge Code |
32000084
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$11.87 |
| Max. Negotiated Rate |
$242.40 |
| Rate for Payer: Aetna Commercial |
$42.42
|
| Rate for Payer: Ambetter Exchange |
$30.30
|
| Rate for Payer: Anthem Medicaid |
$20.15
|
| Rate for Payer: Buckeye Individual/Medicaid |
$30.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$30.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$36.36
|
| Rate for Payer: Cash Price |
$202.00
|
| Rate for Payer: Cash Price |
$202.00
|
| Rate for Payer: Cigna Commercial |
$40.29
|
| Rate for Payer: Healthspan PPO |
$39.75
|
| Rate for Payer: Humana Medicaid |
$20.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$11.87
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$30.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$20.55
|
| Rate for Payer: Molina Healthcare Passport |
$20.15
|
| Rate for Payer: Multiplan PHCS |
$242.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$39.39
|
| Rate for Payer: UHCCP Medicaid |
$141.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.35
|
| Rate for Payer: Wellcare Medicare Advantage |
$30.30
|
|
|
RADIOLOGIC EXAM WRIST 2 VIEWS
|
Facility
|
IP
|
$404.00
|
|
|
Service Code
|
HCPCS 73100
|
| Hospital Charge Code |
32000084
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$121.20 |
| Max. Negotiated Rate |
$387.84 |
| Rate for Payer: Aetna Commercial |
$311.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$315.12
|
| Rate for Payer: Cash Price |
$202.00
|
| Rate for Payer: Cigna Commercial |
$335.32
|
| Rate for Payer: First Health Commercial |
$383.80
|
| Rate for Payer: Humana Commercial |
$343.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$331.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$298.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$121.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$355.52
|
| Rate for Payer: Ohio Health Group HMO |
$303.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$323.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$351.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$278.76
|
| Rate for Payer: PHCS Commercial |
$387.84
|
| Rate for Payer: United Healthcare All Payer |
$355.52
|
|
