|
EXC ARM/ELBOW LES SC 3 CM/>
|
Facility
|
IP
|
$5,853.25
|
|
|
Service Code
|
HCPCS 24071
|
| Hospital Charge Code |
76100500
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$760.92 |
| Max. Negotiated Rate |
$5,619.12 |
| Rate for Payer: Aetna Commercial |
$4,507.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,565.54
|
| Rate for Payer: Cash Price |
$2,926.62
|
| Rate for Payer: Cigna Commercial |
$4,858.20
|
| Rate for Payer: First Health Commercial |
$5,560.59
|
| Rate for Payer: Humana Commercial |
$4,975.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,799.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,319.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,755.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,150.86
|
| Rate for Payer: Ohio Health Group HMO |
$4,389.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,170.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$760.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,814.51
|
| Rate for Payer: PHCS Commercial |
$5,619.12
|
| Rate for Payer: United Healthcare All Payer |
$5,150.86
|
|
|
EXC ARM/ELBOW LES SC 3 CM/>(P
|
Professional
|
Both
|
$725.00
|
|
|
Service Code
|
HCPCS 24071
|
| Hospital Charge Code |
761P0500
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$253.75 |
| Max. Negotiated Rate |
$725.00 |
| Rate for Payer: Aetna Commercial |
$622.35
|
| Rate for Payer: Anthem Medicaid |
$292.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$725.00
|
| Rate for Payer: Cash Price |
$362.50
|
| Rate for Payer: Cash Price |
$362.50
|
| Rate for Payer: Cigna Commercial |
$709.09
|
| Rate for Payer: Healthspan PPO |
$444.02
|
| Rate for Payer: Humana Medicaid |
$292.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$517.72
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$298.70
|
| Rate for Payer: Molina Healthcare Passport |
$292.84
|
| Rate for Payer: Multiplan PHCS |
$435.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$507.50
|
| Rate for Payer: UHCCP Medicaid |
$253.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$295.77
|
|
|
EXC ARM/ELBOW LES SC 3 CM/>(T
|
Facility
|
OP
|
$5,128.25
|
|
|
Service Code
|
HCPCS 24071
|
| Hospital Charge Code |
761T0500
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$666.67 |
| Max. Negotiated Rate |
$4,923.12 |
| Rate for Payer: Aetna Commercial |
$3,948.75
|
| Rate for Payer: Anthem Medicaid |
$1,763.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,000.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,440.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,317.21
|
| Rate for Payer: Cash Price |
$2,564.12
|
| Rate for Payer: Cash Price |
$2,564.12
|
| Rate for Payer: Cigna Commercial |
$4,256.45
|
| Rate for Payer: First Health Commercial |
$4,871.84
|
| Rate for Payer: Humana Commercial |
$4,359.01
|
| Rate for Payer: Humana KY Medicaid |
$1,763.61
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$1,781.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,205.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,784.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,798.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,512.86
|
| Rate for Payer: Ohio Health Group HMO |
$3,846.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,025.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$666.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,589.76
|
| Rate for Payer: PHCS Commercial |
$4,923.12
|
| Rate for Payer: United Healthcare All Payer |
$4,512.86
|
|
|
EXC ARM/ELBOW LES SC 3 CM/>(T
|
Facility
|
IP
|
$5,128.25
|
|
|
Service Code
|
HCPCS 24071
|
| Hospital Charge Code |
761T0500
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$666.67 |
| Max. Negotiated Rate |
$4,923.12 |
| Rate for Payer: Aetna Commercial |
$3,948.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,000.04
|
| Rate for Payer: Cash Price |
$2,564.12
|
| Rate for Payer: Cigna Commercial |
$4,256.45
|
| Rate for Payer: First Health Commercial |
$4,871.84
|
| Rate for Payer: Humana Commercial |
$4,359.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,205.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,784.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,538.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,512.86
|
| Rate for Payer: Ohio Health Group HMO |
$3,846.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,025.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$666.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,589.76
|
| Rate for Payer: PHCS Commercial |
$4,923.12
|
| Rate for Payer: United Healthcare All Payer |
$4,512.86
|
|
|
EXC BACK LES SC < 3 CM
|
Facility
|
IP
|
$2,050.00
|
|
|
Service Code
|
HCPCS 21930
|
| Hospital Charge Code |
45000105
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
EXC BACK LES SC < 3 CM
|
Facility
|
OP
|
$2,050.00
|
|
|
Service Code
|
HCPCS 21930
|
| Hospital Charge Code |
45000105
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem Medicaid |
$705.00
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Humana KY Medicaid |
$705.00
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$712.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$719.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
EXC BACK LES SC < 3 CM
|
Facility
|
IP
|
$3,050.00
|
|
|
Service Code
|
HCPCS 21930
|
| Hospital Charge Code |
76100412
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$396.50 |
| Max. Negotiated Rate |
$2,928.00 |
| Rate for Payer: Aetna Commercial |
$2,348.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,379.00
|
| Rate for Payer: Cash Price |
$1,525.00
|
| Rate for Payer: Cigna Commercial |
$2,531.50
|
| Rate for Payer: First Health Commercial |
$2,897.50
|
| Rate for Payer: Humana Commercial |
$2,592.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,501.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,250.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$915.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,684.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,287.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$610.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$396.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$945.50
|
| Rate for Payer: PHCS Commercial |
$2,928.00
|
| Rate for Payer: United Healthcare All Payer |
$2,684.00
|
|
|
EXC BACK LES SC < 3 CM
|
Professional
|
Both
|
$3,050.00
|
|
|
Service Code
|
HCPCS 21930
|
| Hospital Charge Code |
76100412
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$187.22 |
| Max. Negotiated Rate |
$3,050.00 |
| Rate for Payer: Aetna Commercial |
$538.20
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$187.22
|
| Rate for Payer: Anthem Medicaid |
$277.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,050.00
|
| Rate for Payer: Cash Price |
$1,525.00
|
| Rate for Payer: Cash Price |
$1,525.00
|
| Rate for Payer: Cigna Commercial |
$583.18
|
| Rate for Payer: Healthspan PPO |
$596.08
|
| Rate for Payer: Humana Medicaid |
$277.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$452.53
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$282.60
|
| Rate for Payer: Molina Healthcare Passport |
$277.06
|
| Rate for Payer: Multiplan PHCS |
$1,830.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,135.00
|
| Rate for Payer: UHCCP Medicaid |
$196.58
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$279.83
|
|
|
EXC BACK LES SC < 3 CM
|
Facility
|
OP
|
$3,050.00
|
|
|
Service Code
|
HCPCS 21930
|
| Hospital Charge Code |
76100412
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$396.50 |
| Max. Negotiated Rate |
$2,928.00 |
| Rate for Payer: Aetna Commercial |
$2,348.50
|
| Rate for Payer: Anthem Medicaid |
$1,048.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,379.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$1,525.00
|
| Rate for Payer: Cash Price |
$1,525.00
|
| Rate for Payer: Cigna Commercial |
$2,531.50
|
| Rate for Payer: First Health Commercial |
$2,897.50
|
| Rate for Payer: Humana Commercial |
$2,592.50
|
| Rate for Payer: Humana KY Medicaid |
$1,048.90
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,059.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,501.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,250.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,069.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,684.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,287.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$610.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$396.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$945.50
|
| Rate for Payer: PHCS Commercial |
$2,928.00
|
| Rate for Payer: United Healthcare All Payer |
$2,684.00
|
|
|
EXC BACK LES SC = 3 CM
|
Facility
|
OP
|
$6,891.00
|
|
|
Service Code
|
HCPCS 21931
|
| Hospital Charge Code |
76100413
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$895.83 |
| Max. Negotiated Rate |
$6,615.36 |
| Rate for Payer: Aetna Commercial |
$5,306.07
|
| Rate for Payer: Anthem Medicaid |
$2,369.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,374.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$3,445.50
|
| Rate for Payer: Cash Price |
$3,445.50
|
| Rate for Payer: Cigna Commercial |
$5,719.53
|
| Rate for Payer: First Health Commercial |
$6,546.45
|
| Rate for Payer: Humana Commercial |
$5,857.35
|
| Rate for Payer: Humana KY Medicaid |
$2,369.81
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$2,393.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,650.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,085.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,417.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,064.08
|
| Rate for Payer: Ohio Health Group HMO |
$5,168.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,378.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$895.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,136.21
|
| Rate for Payer: PHCS Commercial |
$6,615.36
|
| Rate for Payer: United Healthcare All Payer |
$6,064.08
|
|
|
EXC BACK LES SC = 3 CM
|
Facility
|
IP
|
$6,891.00
|
|
|
Service Code
|
HCPCS 21931
|
| Hospital Charge Code |
76100413
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$895.83 |
| Max. Negotiated Rate |
$6,615.36 |
| Rate for Payer: Aetna Commercial |
$5,306.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,374.98
|
| Rate for Payer: Cash Price |
$3,445.50
|
| Rate for Payer: Cigna Commercial |
$5,719.53
|
| Rate for Payer: First Health Commercial |
$6,546.45
|
| Rate for Payer: Humana Commercial |
$5,857.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,650.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,085.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,067.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,064.08
|
| Rate for Payer: Ohio Health Group HMO |
$5,168.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,378.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$895.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,136.21
|
| Rate for Payer: PHCS Commercial |
$6,615.36
|
| Rate for Payer: United Healthcare All Payer |
$6,064.08
|
|
|
EXC BACK LES SC = 3 CM
|
Professional
|
Both
|
$6,891.00
|
|
|
Service Code
|
HCPCS 21931
|
| Hospital Charge Code |
76100413
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$340.33 |
| Max. Negotiated Rate |
$6,891.00 |
| Rate for Payer: Aetna Commercial |
$724.63
|
| Rate for Payer: Anthem Medicaid |
$340.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,891.00
|
| Rate for Payer: Cash Price |
$3,445.50
|
| Rate for Payer: Cash Price |
$3,445.50
|
| Rate for Payer: Cigna Commercial |
$824.35
|
| Rate for Payer: Healthspan PPO |
$516.39
|
| Rate for Payer: Humana Medicaid |
$340.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$597.20
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$347.14
|
| Rate for Payer: Molina Healthcare Passport |
$340.33
|
| Rate for Payer: Multiplan PHCS |
$4,134.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,823.70
|
| Rate for Payer: UHCCP Medicaid |
$2,411.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$343.73
|
|
|
EXC BACK LES SC < 3 CM(P
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 21930
|
| Hospital Charge Code |
761P0412
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$187.22 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Aetna Commercial |
$538.20
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$187.22
|
| Rate for Payer: Anthem Medicaid |
$277.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,000.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$583.18
|
| Rate for Payer: Healthspan PPO |
$596.08
|
| Rate for Payer: Humana Medicaid |
$277.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$452.53
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$282.60
|
| Rate for Payer: Molina Healthcare Passport |
$277.06
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$196.58
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$279.83
|
|
|
EXC BACK LES SC = 3 CM(P
|
Professional
|
Both
|
$1,100.00
|
|
|
Service Code
|
HCPCS 21931
|
| Hospital Charge Code |
761P0413
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$340.33 |
| Max. Negotiated Rate |
$1,100.00 |
| Rate for Payer: Aetna Commercial |
$724.63
|
| Rate for Payer: Anthem Medicaid |
$340.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,100.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$824.35
|
| Rate for Payer: Healthspan PPO |
$516.39
|
| Rate for Payer: Humana Medicaid |
$340.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$597.20
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$347.14
|
| Rate for Payer: Molina Healthcare Passport |
$340.33
|
| Rate for Payer: Multiplan PHCS |
$660.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$770.00
|
| Rate for Payer: UHCCP Medicaid |
$385.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$343.73
|
|
|
EXC BACK LES SC < 3 CM(T
|
Facility
|
OP
|
$2,050.00
|
|
|
Service Code
|
HCPCS 21930
|
| Hospital Charge Code |
761T0412
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem Medicaid |
$705.00
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Humana KY Medicaid |
$705.00
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$712.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$719.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
EXC BACK LES SC < 3 CM(T
|
Facility
|
IP
|
$2,050.00
|
|
|
Service Code
|
HCPCS 21930
|
| Hospital Charge Code |
761T0412
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
EXC BACK LES SC = 3 CM(T
|
Facility
|
IP
|
$5,791.00
|
|
|
Service Code
|
HCPCS 21931
|
| Hospital Charge Code |
761T0413
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$752.83 |
| Max. Negotiated Rate |
$5,559.36 |
| Rate for Payer: Aetna Commercial |
$4,459.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,516.98
|
| Rate for Payer: Cash Price |
$2,895.50
|
| Rate for Payer: Cigna Commercial |
$4,806.53
|
| Rate for Payer: First Health Commercial |
$5,501.45
|
| Rate for Payer: Humana Commercial |
$4,922.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,748.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,273.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,737.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,096.08
|
| Rate for Payer: Ohio Health Group HMO |
$4,343.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,158.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$752.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,795.21
|
| Rate for Payer: PHCS Commercial |
$5,559.36
|
| Rate for Payer: United Healthcare All Payer |
$5,096.08
|
|
|
EXC BACK LES SC = 3 CM(T
|
Facility
|
OP
|
$5,791.00
|
|
|
Service Code
|
HCPCS 21931
|
| Hospital Charge Code |
761T0413
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$752.83 |
| Max. Negotiated Rate |
$5,559.36 |
| Rate for Payer: Aetna Commercial |
$4,459.07
|
| Rate for Payer: Anthem Medicaid |
$1,991.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,516.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$2,895.50
|
| Rate for Payer: Cash Price |
$2,895.50
|
| Rate for Payer: Cigna Commercial |
$4,806.53
|
| Rate for Payer: First Health Commercial |
$5,501.45
|
| Rate for Payer: Humana Commercial |
$4,922.35
|
| Rate for Payer: Humana KY Medicaid |
$1,991.52
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$2,011.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,748.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,273.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,031.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,096.08
|
| Rate for Payer: Ohio Health Group HMO |
$4,343.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,158.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$752.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,795.21
|
| Rate for Payer: PHCS Commercial |
$5,559.36
|
| Rate for Payer: United Healthcare All Payer |
$5,096.08
|
|
|
EXC BACK TUM DEEP < 5 CM
|
Facility
|
IP
|
$6,923.00
|
|
|
Service Code
|
HCPCS 21932
|
| Hospital Charge Code |
76100414
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$899.99 |
| Max. Negotiated Rate |
$6,646.08 |
| Rate for Payer: Aetna Commercial |
$5,330.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,399.94
|
| Rate for Payer: Cash Price |
$3,461.50
|
| Rate for Payer: Cigna Commercial |
$5,746.09
|
| Rate for Payer: First Health Commercial |
$6,576.85
|
| Rate for Payer: Humana Commercial |
$5,884.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,676.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,109.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,076.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,092.24
|
| Rate for Payer: Ohio Health Group HMO |
$5,192.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,384.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$899.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,146.13
|
| Rate for Payer: PHCS Commercial |
$6,646.08
|
| Rate for Payer: United Healthcare All Payer |
$6,092.24
|
|
|
EXC BACK TUM DEEP < 5 CM
|
Professional
|
Both
|
$6,923.00
|
|
|
Service Code
|
HCPCS 21932
|
| Hospital Charge Code |
76100414
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$488.30 |
| Max. Negotiated Rate |
$6,923.00 |
| Rate for Payer: Aetna Commercial |
$1,040.77
|
| Rate for Payer: Anthem Medicaid |
$488.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,923.00
|
| Rate for Payer: Cash Price |
$3,461.50
|
| Rate for Payer: Cash Price |
$3,461.50
|
| Rate for Payer: Cigna Commercial |
$1,183.46
|
| Rate for Payer: Healthspan PPO |
$742.69
|
| Rate for Payer: Humana Medicaid |
$488.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$852.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$498.07
|
| Rate for Payer: Molina Healthcare Passport |
$488.30
|
| Rate for Payer: Multiplan PHCS |
$4,153.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,846.10
|
| Rate for Payer: UHCCP Medicaid |
$2,423.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$493.18
|
|
|
EXC BACK TUM DEEP < 5 CM
|
Facility
|
OP
|
$6,923.00
|
|
|
Service Code
|
HCPCS 21932
|
| Hospital Charge Code |
76100414
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$899.99 |
| Max. Negotiated Rate |
$6,646.08 |
| Rate for Payer: Aetna Commercial |
$5,330.71
|
| Rate for Payer: Anthem Medicaid |
$2,380.82
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,399.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,440.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,317.21
|
| Rate for Payer: Cash Price |
$3,461.50
|
| Rate for Payer: Cash Price |
$3,461.50
|
| Rate for Payer: Cigna Commercial |
$5,746.09
|
| Rate for Payer: First Health Commercial |
$6,576.85
|
| Rate for Payer: Humana Commercial |
$5,884.55
|
| Rate for Payer: Humana KY Medicaid |
$2,380.82
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$2,405.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,676.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,109.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,428.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,092.24
|
| Rate for Payer: Ohio Health Group HMO |
$5,192.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,384.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$899.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,146.13
|
| Rate for Payer: PHCS Commercial |
$6,646.08
|
| Rate for Payer: United Healthcare All Payer |
$6,092.24
|
|
|
EXC BACK TUM DEEP 5 CM/>
|
Professional
|
Both
|
$7,745.00
|
|
|
Service Code
|
HCPCS 21933
|
| Hospital Charge Code |
76100415
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$539.01 |
| Max. Negotiated Rate |
$7,745.00 |
| Rate for Payer: Aetna Commercial |
$1,149.42
|
| Rate for Payer: Anthem Medicaid |
$539.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$7,745.00
|
| Rate for Payer: Cash Price |
$3,872.50
|
| Rate for Payer: Cash Price |
$3,872.50
|
| Rate for Payer: Cigna Commercial |
$1,306.12
|
| Rate for Payer: Healthspan PPO |
$820.63
|
| Rate for Payer: Humana Medicaid |
$539.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$940.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$549.79
|
| Rate for Payer: Molina Healthcare Passport |
$539.01
|
| Rate for Payer: Multiplan PHCS |
$4,647.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5,421.50
|
| Rate for Payer: UHCCP Medicaid |
$2,710.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$544.40
|
|
|
EXC BACK TUM DEEP 5 CM/>
|
Facility
|
IP
|
$7,745.00
|
|
|
Service Code
|
HCPCS 21933
|
| Hospital Charge Code |
76100415
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,006.85 |
| Max. Negotiated Rate |
$7,435.20 |
| Rate for Payer: Aetna Commercial |
$5,963.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,041.10
|
| Rate for Payer: Cash Price |
$3,872.50
|
| Rate for Payer: Cigna Commercial |
$6,428.35
|
| Rate for Payer: First Health Commercial |
$7,357.75
|
| Rate for Payer: Humana Commercial |
$6,583.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,350.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,715.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,323.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,815.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,808.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,549.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,006.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,400.95
|
| Rate for Payer: PHCS Commercial |
$7,435.20
|
| Rate for Payer: United Healthcare All Payer |
$6,815.60
|
|
|
EXC BACK TUM DEEP 5 CM/>
|
Facility
|
OP
|
$7,745.00
|
|
|
Service Code
|
HCPCS 21933
|
| Hospital Charge Code |
76100415
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,006.85 |
| Max. Negotiated Rate |
$7,435.20 |
| Rate for Payer: Aetna Commercial |
$5,963.65
|
| Rate for Payer: Anthem Medicaid |
$2,663.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,041.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,440.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,317.21
|
| Rate for Payer: Cash Price |
$3,872.50
|
| Rate for Payer: Cash Price |
$3,872.50
|
| Rate for Payer: Cigna Commercial |
$6,428.35
|
| Rate for Payer: First Health Commercial |
$7,357.75
|
| Rate for Payer: Humana Commercial |
$6,583.25
|
| Rate for Payer: Humana KY Medicaid |
$2,663.51
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$2,690.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,350.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,715.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,716.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,815.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,808.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,549.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,006.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,400.95
|
| Rate for Payer: PHCS Commercial |
$7,435.20
|
| Rate for Payer: United Healthcare All Payer |
$6,815.60
|
|
|
EXC BACK TUM DEEP < 5 CM(P
|
Professional
|
Both
|
$1,077.00
|
|
|
Service Code
|
HCPCS 21932
|
| Hospital Charge Code |
761P0414
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$376.95 |
| Max. Negotiated Rate |
$1,183.46 |
| Rate for Payer: Aetna Commercial |
$1,040.77
|
| Rate for Payer: Anthem Medicaid |
$488.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,077.00
|
| Rate for Payer: Cash Price |
$538.50
|
| Rate for Payer: Cash Price |
$538.50
|
| Rate for Payer: Cigna Commercial |
$1,183.46
|
| Rate for Payer: Healthspan PPO |
$742.69
|
| Rate for Payer: Humana Medicaid |
$488.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$852.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$498.07
|
| Rate for Payer: Molina Healthcare Passport |
$488.30
|
| Rate for Payer: Multiplan PHCS |
$646.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$753.90
|
| Rate for Payer: UHCCP Medicaid |
$376.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$493.18
|
|
