|
ELBOW LT 2V(T
|
Facility
|
OP
|
$332.00
|
|
|
Service Code
|
HCPCS 73070
|
| Hospital Charge Code |
320T0079
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$43.16 |
| Max. Negotiated Rate |
$318.72 |
| Rate for Payer: Aetna Commercial |
$255.64
|
| Rate for Payer: Anthem Medicaid |
$114.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$78.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$258.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$110.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$106.08
|
| Rate for Payer: Cash Price |
$166.00
|
| Rate for Payer: Cash Price |
$166.00
|
| Rate for Payer: Cigna Commercial |
$275.56
|
| Rate for Payer: First Health Commercial |
$315.40
|
| Rate for Payer: Humana Commercial |
$282.20
|
| Rate for Payer: Humana KY Medicaid |
$114.17
|
| Rate for Payer: Humana Medicare Advantage |
$78.58
|
| Rate for Payer: Kentucky WC Medicaid |
$115.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$272.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$245.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$116.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$292.16
|
| Rate for Payer: Ohio Health Group HMO |
$249.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$66.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$43.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$102.92
|
| Rate for Payer: PHCS Commercial |
$318.72
|
| Rate for Payer: United Healthcare All Payer |
$292.16
|
|
|
ELBOW LT: ROUTINE 3V
|
Facility
|
IP
|
$443.00
|
|
|
Service Code
|
HCPCS 73080
|
| Hospital Charge Code |
32000080
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$57.59 |
| Max. Negotiated Rate |
$425.28 |
| Rate for Payer: Aetna Commercial |
$341.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$345.54
|
| Rate for Payer: Cash Price |
$221.50
|
| Rate for Payer: Cigna Commercial |
$367.69
|
| Rate for Payer: First Health Commercial |
$420.85
|
| Rate for Payer: Humana Commercial |
$376.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$363.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$326.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$389.84
|
| Rate for Payer: Ohio Health Group HMO |
$332.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$88.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$57.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$137.33
|
| Rate for Payer: PHCS Commercial |
$425.28
|
| Rate for Payer: United Healthcare All Payer |
$389.84
|
|
|
ELBOW LT: ROUTINE 3V
|
Professional
|
Both
|
$443.00
|
|
|
Service Code
|
HCPCS 73080
|
| Hospital Charge Code |
32000080
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$10.82 |
| Max. Negotiated Rate |
$443.00 |
| Rate for Payer: Aetna Commercial |
$51.91
|
| Rate for Payer: Anthem Medicaid |
$22.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$443.00
|
| Rate for Payer: Cash Price |
$221.50
|
| Rate for Payer: Cash Price |
$221.50
|
| Rate for Payer: Cigna Commercial |
$48.09
|
| Rate for Payer: Healthspan PPO |
$48.64
|
| Rate for Payer: Humana Medicaid |
$22.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$10.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$23.29
|
| Rate for Payer: Molina Healthcare Passport |
$22.83
|
| Rate for Payer: Multiplan PHCS |
$265.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$310.10
|
| Rate for Payer: UHCCP Medicaid |
$155.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$23.06
|
|
|
ELBOW LT: ROUTINE 3V
|
Facility
|
OP
|
$443.00
|
|
|
Service Code
|
HCPCS 73080
|
| Hospital Charge Code |
32000080
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$57.59 |
| Max. Negotiated Rate |
$425.28 |
| Rate for Payer: Aetna Commercial |
$341.11
|
| Rate for Payer: Anthem Medicaid |
$152.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$78.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$345.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$110.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$106.08
|
| Rate for Payer: Cash Price |
$221.50
|
| Rate for Payer: Cash Price |
$221.50
|
| Rate for Payer: Cigna Commercial |
$367.69
|
| Rate for Payer: First Health Commercial |
$420.85
|
| Rate for Payer: Humana Commercial |
$376.55
|
| Rate for Payer: Humana KY Medicaid |
$152.35
|
| Rate for Payer: Humana Medicare Advantage |
$78.58
|
| Rate for Payer: Kentucky WC Medicaid |
$153.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$363.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$326.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$155.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$389.84
|
| Rate for Payer: Ohio Health Group HMO |
$332.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$88.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$57.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$137.33
|
| Rate for Payer: PHCS Commercial |
$425.28
|
| Rate for Payer: United Healthcare All Payer |
$389.84
|
|
|
ELBOW LT: ROUTINE 3V(P
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 73080
|
| Hospital Charge Code |
320P0080
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$10.82 |
| Max. Negotiated Rate |
$51.91 |
| Rate for Payer: Aetna Commercial |
$51.91
|
| Rate for Payer: Anthem Medicaid |
$22.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$40.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$48.09
|
| Rate for Payer: Healthspan PPO |
$48.64
|
| Rate for Payer: Humana Medicaid |
$22.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$10.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$23.29
|
| Rate for Payer: Molina Healthcare Passport |
$22.83
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$28.00
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$23.06
|
|
|
ELBOW LT: ROUTINE 3V(T
|
Facility
|
IP
|
$403.00
|
|
|
Service Code
|
HCPCS 73080
|
| Hospital Charge Code |
320T0080
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$52.39 |
| Max. Negotiated Rate |
$386.88 |
| Rate for Payer: Aetna Commercial |
$310.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$314.34
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Cigna Commercial |
$334.49
|
| Rate for Payer: First Health Commercial |
$382.85
|
| Rate for Payer: Humana Commercial |
$342.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$330.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$297.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$120.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$354.64
|
| Rate for Payer: Ohio Health Group HMO |
$302.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.93
|
| Rate for Payer: PHCS Commercial |
$386.88
|
| Rate for Payer: United Healthcare All Payer |
$354.64
|
|
|
ELBOW LT: ROUTINE 3V(T
|
Facility
|
OP
|
$403.00
|
|
|
Service Code
|
HCPCS 73080
|
| Hospital Charge Code |
320T0080
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$52.39 |
| Max. Negotiated Rate |
$386.88 |
| Rate for Payer: Aetna Commercial |
$310.31
|
| Rate for Payer: Anthem Medicaid |
$138.59
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$78.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$314.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$110.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$106.08
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Cigna Commercial |
$334.49
|
| Rate for Payer: First Health Commercial |
$382.85
|
| Rate for Payer: Humana Commercial |
$342.55
|
| Rate for Payer: Humana KY Medicaid |
$138.59
|
| Rate for Payer: Humana Medicare Advantage |
$78.58
|
| Rate for Payer: Kentucky WC Medicaid |
$140.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$330.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$297.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$141.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$354.64
|
| Rate for Payer: Ohio Health Group HMO |
$302.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.93
|
| Rate for Payer: PHCS Commercial |
$386.88
|
| Rate for Payer: United Healthcare All Payer |
$354.64
|
|
|
ELCA 0.9MM*80
|
Facility
|
OP
|
$12,534.50
|
|
|
Service Code
|
HCPCS C1885
|
| Hospital Charge Code |
27000283
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,629.48 |
| Max. Negotiated Rate |
$12,033.12 |
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,776.91
|
| Rate for Payer: Aetna Commercial |
$9,651.56
|
| Rate for Payer: Anthem Medicaid |
$4,310.61
|
| Rate for Payer: Cash Price |
$6,267.25
|
| Rate for Payer: Cigna Commercial |
$10,403.64
|
| Rate for Payer: First Health Commercial |
$11,907.78
|
| Rate for Payer: Humana Commercial |
$10,654.32
|
| Rate for Payer: Humana KY Medicaid |
$4,310.61
|
| Rate for Payer: Kentucky WC Medicaid |
$4,354.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,278.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,250.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,760.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,397.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,030.36
|
| Rate for Payer: Ohio Health Group HMO |
$9,400.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,506.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,629.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,885.70
|
| Rate for Payer: PHCS Commercial |
$12,033.12
|
| Rate for Payer: United Healthcare All Payer |
$11,030.36
|
|
|
ELCA 0.9MM*80
|
Facility
|
IP
|
$12,534.50
|
|
|
Service Code
|
HCPCS C1885
|
| Hospital Charge Code |
27000283
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,629.48 |
| Max. Negotiated Rate |
$12,033.12 |
| Rate for Payer: Aetna Commercial |
$9,651.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,776.91
|
| Rate for Payer: Cash Price |
$6,267.25
|
| Rate for Payer: Cigna Commercial |
$10,403.64
|
| Rate for Payer: First Health Commercial |
$11,907.78
|
| Rate for Payer: Humana Commercial |
$10,654.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,278.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,250.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,760.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,030.36
|
| Rate for Payer: Ohio Health Group HMO |
$9,400.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,506.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,629.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,885.70
|
| Rate for Payer: PHCS Commercial |
$12,033.12
|
| Rate for Payer: United Healthcare All Payer |
$11,030.36
|
|
|
ELCA 1.4MM
|
Facility
|
IP
|
$14,122.25
|
|
|
Service Code
|
HCPCS C1885
|
| Hospital Charge Code |
27000283
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,835.89 |
| Max. Negotiated Rate |
$13,557.36 |
| Rate for Payer: Aetna Commercial |
$10,874.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,015.36
|
| Rate for Payer: Cash Price |
$7,061.12
|
| Rate for Payer: Cigna Commercial |
$11,721.47
|
| Rate for Payer: First Health Commercial |
$13,416.14
|
| Rate for Payer: Humana Commercial |
$12,003.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,580.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,422.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,236.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,427.58
|
| Rate for Payer: Ohio Health Group HMO |
$10,591.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,824.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,835.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,377.90
|
| Rate for Payer: PHCS Commercial |
$13,557.36
|
| Rate for Payer: United Healthcare All Payer |
$12,427.58
|
|
|
ELCA 1.4MM
|
Facility
|
OP
|
$14,122.25
|
|
|
Service Code
|
HCPCS C1885
|
| Hospital Charge Code |
27000283
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,835.89 |
| Max. Negotiated Rate |
$13,557.36 |
| Rate for Payer: Aetna Commercial |
$10,874.13
|
| Rate for Payer: Anthem Medicaid |
$4,856.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,015.36
|
| Rate for Payer: Cash Price |
$7,061.12
|
| Rate for Payer: Cigna Commercial |
$11,721.47
|
| Rate for Payer: First Health Commercial |
$13,416.14
|
| Rate for Payer: Humana Commercial |
$12,003.91
|
| Rate for Payer: Humana KY Medicaid |
$4,856.64
|
| Rate for Payer: Kentucky WC Medicaid |
$4,906.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,580.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,422.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,236.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,954.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,427.58
|
| Rate for Payer: Ohio Health Group HMO |
$10,591.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,824.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,835.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,377.90
|
| Rate for Payer: PHCS Commercial |
$13,557.36
|
| Rate for Payer: United Healthcare All Payer |
$12,427.58
|
|
|
ELC ANLYS IMP NUROSTIMPLSGEN(T
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
HCPCS 95976
|
| Hospital Charge Code |
510T0150
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$134.40 |
| Rate for Payer: Aetna Commercial |
$107.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$109.20
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Cigna Commercial |
$116.20
|
| Rate for Payer: First Health Commercial |
$133.00
|
| Rate for Payer: Humana Commercial |
$119.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$114.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$103.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$123.20
|
| Rate for Payer: Ohio Health Group HMO |
$105.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.40
|
| Rate for Payer: PHCS Commercial |
$134.40
|
| Rate for Payer: United Healthcare All Payer |
$123.20
|
|
|
ELC ANLYS IMP NUROSTIMPLSGEN(T
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
HCPCS 95976
|
| Hospital Charge Code |
510T0150
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$134.40 |
| Rate for Payer: Aetna Commercial |
$107.80
|
| Rate for Payer: Anthem Medicaid |
$48.15
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$32.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$109.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$45.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$44.02
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Cigna Commercial |
$116.20
|
| Rate for Payer: First Health Commercial |
$133.00
|
| Rate for Payer: Humana Commercial |
$119.00
|
| Rate for Payer: Humana KY Medicaid |
$48.15
|
| Rate for Payer: Humana Medicare Advantage |
$32.61
|
| Rate for Payer: Kentucky WC Medicaid |
$48.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$114.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$103.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$49.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$123.20
|
| Rate for Payer: Ohio Health Group HMO |
$105.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.40
|
| Rate for Payer: PHCS Commercial |
$134.40
|
| Rate for Payer: United Healthcare All Payer |
$123.20
|
|
|
ELCTANLYS IMP NUROSTIMPLSGEN(P
|
Professional
|
Both
|
$140.00
|
|
|
Service Code
|
HCPCS 95976
|
| Hospital Charge Code |
510P0150
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$32.06 |
| Max. Negotiated Rate |
$140.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$32.06
|
| Rate for Payer: Anthem Medicaid |
$32.24
|
| 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 |
$68.89
|
| Rate for Payer: Humana Medicaid |
$32.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$32.88
|
| Rate for Payer: Molina Healthcare Passport |
$32.24
|
| Rate for Payer: Multiplan PHCS |
$84.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$98.00
|
| Rate for Payer: UHCCP Medicaid |
$33.66
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$32.56
|
|
|
ELCTR ANLYS IMP NUROSTIMPLSGEN
|
Professional
|
Both
|
$280.00
|
|
|
Service Code
|
HCPCS 95976
|
| Hospital Charge Code |
51000150
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$32.06 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$32.06
|
| Rate for Payer: Anthem Medicaid |
$32.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$280.00
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cigna Commercial |
$68.89
|
| Rate for Payer: Humana Medicaid |
$32.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$32.88
|
| Rate for Payer: Molina Healthcare Passport |
$32.24
|
| Rate for Payer: Multiplan PHCS |
$168.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$196.00
|
| Rate for Payer: UHCCP Medicaid |
$33.66
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$32.56
|
|
|
ELCTR ANLYS IMP NUROSTIMPLSGEN
|
Facility
|
OP
|
$280.00
|
|
|
Service Code
|
HCPCS 95976
|
| Hospital Charge Code |
51000150
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$32.61 |
| Max. Negotiated Rate |
$268.80 |
| Rate for Payer: Aetna Commercial |
$215.60
|
| Rate for Payer: Anthem Medicaid |
$96.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$32.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$218.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$45.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$44.02
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cigna Commercial |
$232.40
|
| Rate for Payer: First Health Commercial |
$266.00
|
| Rate for Payer: Humana Commercial |
$238.00
|
| Rate for Payer: Humana KY Medicaid |
$96.29
|
| Rate for Payer: Humana Medicare Advantage |
$32.61
|
| Rate for Payer: Kentucky WC Medicaid |
$97.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$229.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$206.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$98.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$246.40
|
| Rate for Payer: Ohio Health Group HMO |
$210.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$56.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$86.80
|
| Rate for Payer: PHCS Commercial |
$268.80
|
| Rate for Payer: United Healthcare All Payer |
$246.40
|
|
|
ELCTR ANLYS IMP NUROSTIMPLSGEN
|
Facility
|
IP
|
$280.00
|
|
|
Service Code
|
HCPCS 95976
|
| Hospital Charge Code |
51000150
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$36.40 |
| Max. Negotiated Rate |
$268.80 |
| Rate for Payer: Aetna Commercial |
$215.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$218.40
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cigna Commercial |
$232.40
|
| Rate for Payer: First Health Commercial |
$266.00
|
| Rate for Payer: Humana Commercial |
$238.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$229.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$206.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$84.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$246.40
|
| Rate for Payer: Ohio Health Group HMO |
$210.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$56.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$86.80
|
| Rate for Payer: PHCS Commercial |
$268.80
|
| Rate for Payer: United Healthcare All Payer |
$246.40
|
|
|
ELDEPRYL (SELEGILINE) 5MG/1TAB
|
Facility
|
OP
|
$9.68
|
|
|
Service Code
|
NDC 60505005501
|
| Hospital Charge Code |
25000608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$9.29 |
| Rate for Payer: Aetna Commercial |
$7.45
|
| Rate for Payer: Anthem Medicaid |
$3.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.55
|
| Rate for Payer: Cash Price |
$4.84
|
| Rate for Payer: Cigna Commercial |
$8.03
|
| Rate for Payer: First Health Commercial |
$9.20
|
| Rate for Payer: Humana Commercial |
$8.23
|
| Rate for Payer: Humana KY Medicaid |
$3.33
|
| Rate for Payer: Kentucky WC Medicaid |
$3.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.52
|
| Rate for Payer: Ohio Health Group HMO |
$7.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.00
|
| Rate for Payer: PHCS Commercial |
$9.29
|
| Rate for Payer: United Healthcare All Payer |
$8.52
|
|
|
ELDEPRYL (SELEGILINE) 5MG/1TAB
|
Facility
|
IP
|
$9.68
|
|
|
Service Code
|
NDC 60505005501
|
| Hospital Charge Code |
25000608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$9.29 |
| Rate for Payer: Aetna Commercial |
$7.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.55
|
| Rate for Payer: Cash Price |
$4.84
|
| Rate for Payer: Cigna Commercial |
$8.03
|
| Rate for Payer: First Health Commercial |
$9.20
|
| Rate for Payer: Humana Commercial |
$8.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.52
|
| Rate for Payer: Ohio Health Group HMO |
$7.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.00
|
| Rate for Payer: PHCS Commercial |
$9.29
|
| Rate for Payer: United Healthcare All Payer |
$8.52
|
|
|
ELEC STIM MANUAL 15 MIN
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
HCPCS 97032
|
| Hospital Charge Code |
42000012
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$16.64 |
| Max. Negotiated Rate |
$122.88 |
| Rate for Payer: Aetna Commercial |
$98.56
|
| Rate for Payer: Anthem Medicaid |
$44.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$99.84
|
| Rate for Payer: Cash Price |
$64.00
|
| Rate for Payer: Cigna Commercial |
$106.24
|
| Rate for Payer: First Health Commercial |
$121.60
|
| Rate for Payer: Humana Commercial |
$108.80
|
| Rate for Payer: Humana KY Medicaid |
$44.02
|
| Rate for Payer: Kentucky WC Medicaid |
$44.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$104.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$94.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$44.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$112.64
|
| Rate for Payer: Ohio Health Group HMO |
$96.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.68
|
| Rate for Payer: PHCS Commercial |
$122.88
|
| Rate for Payer: United Healthcare All Payer |
$112.64
|
|
|
ELEC STIM MANUAL 15 MIN
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
HCPCS 97032
|
| Hospital Charge Code |
42000012
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$16.64 |
| Max. Negotiated Rate |
$122.88 |
| Rate for Payer: Aetna Commercial |
$98.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$99.84
|
| Rate for Payer: Cash Price |
$64.00
|
| Rate for Payer: Cigna Commercial |
$106.24
|
| Rate for Payer: First Health Commercial |
$121.60
|
| Rate for Payer: Humana Commercial |
$108.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$104.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$94.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$112.64
|
| Rate for Payer: Ohio Health Group HMO |
$96.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.68
|
| Rate for Payer: PHCS Commercial |
$122.88
|
| Rate for Payer: United Healthcare All Payer |
$112.64
|
|
|
ELEC STIM UNATTEND
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
HCPCS G0283
|
| Hospital Charge Code |
42000007
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$16.77 |
| Max. Negotiated Rate |
$123.84 |
| Rate for Payer: Aetna Commercial |
$99.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$100.62
|
| Rate for Payer: Cash Price |
$64.50
|
| Rate for Payer: Cigna Commercial |
$107.07
|
| Rate for Payer: First Health Commercial |
$122.55
|
| Rate for Payer: Humana Commercial |
$109.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$105.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$113.52
|
| Rate for Payer: Ohio Health Group HMO |
$96.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.99
|
| Rate for Payer: PHCS Commercial |
$123.84
|
| Rate for Payer: United Healthcare All Payer |
$113.52
|
|
|
ELEC STIM UNATTEND
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
HCPCS G0283
|
| Hospital Charge Code |
42000007
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$16.77 |
| Max. Negotiated Rate |
$123.84 |
| Rate for Payer: Aetna Commercial |
$99.33
|
| Rate for Payer: Anthem Medicaid |
$44.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$100.62
|
| Rate for Payer: Cash Price |
$64.50
|
| Rate for Payer: Cigna Commercial |
$107.07
|
| Rate for Payer: First Health Commercial |
$122.55
|
| Rate for Payer: Humana Commercial |
$109.65
|
| Rate for Payer: Humana KY Medicaid |
$44.36
|
| Rate for Payer: Kentucky WC Medicaid |
$44.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$105.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$45.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$113.52
|
| Rate for Payer: Ohio Health Group HMO |
$96.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.99
|
| Rate for Payer: PHCS Commercial |
$123.84
|
| Rate for Payer: United Healthcare All Payer |
$113.52
|
|
|
ELEC STIM UNATTENDED
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
HCPCS G0283
|
| Hospital Charge Code |
43000004
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$16.77 |
| Max. Negotiated Rate |
$123.84 |
| Rate for Payer: Aetna Commercial |
$99.33
|
| Rate for Payer: Anthem Medicaid |
$44.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$100.62
|
| Rate for Payer: Cash Price |
$64.50
|
| Rate for Payer: Cigna Commercial |
$107.07
|
| Rate for Payer: First Health Commercial |
$122.55
|
| Rate for Payer: Humana Commercial |
$109.65
|
| Rate for Payer: Humana KY Medicaid |
$44.36
|
| Rate for Payer: Kentucky WC Medicaid |
$44.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$105.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$45.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$113.52
|
| Rate for Payer: Ohio Health Group HMO |
$96.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.99
|
| Rate for Payer: PHCS Commercial |
$123.84
|
| Rate for Payer: United Healthcare All Payer |
$113.52
|
|
|
ELEC STIM UNATTENDED
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
HCPCS G0283
|
| Hospital Charge Code |
43000004
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$16.77 |
| Max. Negotiated Rate |
$123.84 |
| Rate for Payer: Aetna Commercial |
$99.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$100.62
|
| Rate for Payer: Cash Price |
$64.50
|
| Rate for Payer: Cigna Commercial |
$107.07
|
| Rate for Payer: First Health Commercial |
$122.55
|
| Rate for Payer: Humana Commercial |
$109.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$105.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$113.52
|
| Rate for Payer: Ohio Health Group HMO |
$96.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.99
|
| Rate for Payer: PHCS Commercial |
$123.84
|
| Rate for Payer: United Healthcare All Payer |
$113.52
|
|
