|
OS TESTOSTERONE FREE
|
Facility
|
IP
|
$275.00
|
|
|
Service Code
|
HCPCS 84402
|
| Hospital Charge Code |
30000521
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$82.50 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Aetna Commercial |
$211.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$220.82
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$228.25
|
| Rate for Payer: First Health Commercial |
$261.25
|
| Rate for Payer: Humana Commercial |
$233.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$225.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$202.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$82.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$242.00
|
| Rate for Payer: Ohio Health Group HMO |
$206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$239.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$189.75
|
| Rate for Payer: PHCS Commercial |
$264.00
|
| Rate for Payer: United Healthcare All Payer |
$242.00
|
|
|
OS TESTOSTERONE FREE
|
Professional
|
Both
|
$275.00
|
|
|
Service Code
|
HCPCS 84402
|
| Hospital Charge Code |
30000521
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.28 |
| Max. Negotiated Rate |
$165.00 |
| Rate for Payer: Aetna Commercial |
$48.99
|
| Rate for Payer: Ambetter Exchange |
$25.47
|
| Rate for Payer: Buckeye Individual/Medicaid |
$25.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$25.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$30.56
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$22.54
|
| Rate for Payer: Healthspan PPO |
$26.68
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$25.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.47
|
| Rate for Payer: Multiplan PHCS |
$165.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$33.11
|
| Rate for Payer: UHCCP Medicaid |
$96.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$15.28
|
| Rate for Payer: Wellcare Medicare Advantage |
$25.47
|
|
|
OS TESTOSTERONE FREE
|
Facility
|
OP
|
$275.00
|
|
|
Service Code
|
HCPCS 84402
|
| Hospital Charge Code |
30000521
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$25.47 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Aetna Commercial |
$211.75
|
| Rate for Payer: Anthem Medicaid |
$25.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$25.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$220.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$35.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$25.47
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$228.25
|
| Rate for Payer: First Health Commercial |
$261.25
|
| Rate for Payer: Humana Commercial |
$233.75
|
| Rate for Payer: Humana KY Medicaid |
$25.47
|
| Rate for Payer: Humana Medicare Advantage |
$25.47
|
| Rate for Payer: Kentucky WC Medicaid |
$25.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$225.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$202.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$25.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$242.00
|
| Rate for Payer: Ohio Health Group HMO |
$206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$239.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$189.75
|
| Rate for Payer: PHCS Commercial |
$264.00
|
| Rate for Payer: United Healthcare All Payer |
$242.00
|
|
|
OS TESTOSTERONE TOTAL
|
Facility
|
OP
|
$278.00
|
|
|
Service Code
|
HCPCS 84403
|
| Hospital Charge Code |
30000523
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.81 |
| Max. Negotiated Rate |
$266.88 |
| Rate for Payer: Aetna Commercial |
$214.06
|
| Rate for Payer: Anthem Medicaid |
$25.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$25.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$223.23
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$36.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$25.81
|
| Rate for Payer: Cash Price |
$139.00
|
| Rate for Payer: Cash Price |
$139.00
|
| Rate for Payer: Cigna Commercial |
$230.74
|
| Rate for Payer: First Health Commercial |
$264.10
|
| Rate for Payer: Humana Commercial |
$236.30
|
| Rate for Payer: Humana KY Medicaid |
$25.81
|
| Rate for Payer: Humana Medicare Advantage |
$25.81
|
| Rate for Payer: Kentucky WC Medicaid |
$26.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$227.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$205.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$244.64
|
| Rate for Payer: Ohio Health Group HMO |
$208.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$222.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$241.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$191.82
|
| Rate for Payer: PHCS Commercial |
$266.88
|
| Rate for Payer: United Healthcare All Payer |
$244.64
|
|
|
OS TESTOSTERONE TOTAL
|
Facility
|
IP
|
$278.00
|
|
|
Service Code
|
HCPCS 84403
|
| Hospital Charge Code |
30000523
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.40 |
| Max. Negotiated Rate |
$266.88 |
| Rate for Payer: Aetna Commercial |
$214.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$223.23
|
| Rate for Payer: Cash Price |
$139.00
|
| Rate for Payer: Cigna Commercial |
$230.74
|
| Rate for Payer: First Health Commercial |
$264.10
|
| Rate for Payer: Humana Commercial |
$236.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$227.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$205.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$83.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$244.64
|
| Rate for Payer: Ohio Health Group HMO |
$208.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$222.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$241.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$191.82
|
| Rate for Payer: PHCS Commercial |
$266.88
|
| Rate for Payer: United Healthcare All Payer |
$244.64
|
|
|
OS TESTOSTERONE TOTAL
|
Professional
|
Both
|
$278.00
|
|
|
Service Code
|
HCPCS 84403
|
| Hospital Charge Code |
30000523
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.49 |
| Max. Negotiated Rate |
$166.80 |
| Rate for Payer: Aetna Commercial |
$47.61
|
| Rate for Payer: Ambetter Exchange |
$25.81
|
| Rate for Payer: Buckeye Individual/Medicaid |
$25.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$25.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$30.97
|
| Rate for Payer: Cash Price |
$139.00
|
| Rate for Payer: Cash Price |
$139.00
|
| Rate for Payer: Cigna Commercial |
$22.78
|
| Rate for Payer: Healthspan PPO |
$21.34
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$25.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.81
|
| Rate for Payer: Multiplan PHCS |
$166.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$33.55
|
| Rate for Payer: UHCCP Medicaid |
$97.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$15.49
|
| Rate for Payer: Wellcare Medicare Advantage |
$25.81
|
|
|
OS TETANUS TOX IGG AB S
|
Facility
|
OP
|
$177.00
|
|
|
Service Code
|
HCPCS 86774
|
| Hospital Charge Code |
30001213
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.80 |
| Max. Negotiated Rate |
$169.92 |
| Rate for Payer: Aetna Commercial |
$136.29
|
| Rate for Payer: Anthem Medicaid |
$14.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$14.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$142.13
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$20.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$14.80
|
| Rate for Payer: Cash Price |
$88.50
|
| Rate for Payer: Cash Price |
$88.50
|
| Rate for Payer: Cigna Commercial |
$146.91
|
| Rate for Payer: First Health Commercial |
$168.15
|
| Rate for Payer: Humana Commercial |
$150.45
|
| Rate for Payer: Humana KY Medicaid |
$14.80
|
| Rate for Payer: Humana Medicare Advantage |
$14.80
|
| Rate for Payer: Kentucky WC Medicaid |
$14.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$145.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$130.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$15.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$155.76
|
| Rate for Payer: Ohio Health Group HMO |
$132.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$141.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$153.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$122.13
|
| Rate for Payer: PHCS Commercial |
$169.92
|
| Rate for Payer: United Healthcare All Payer |
$155.76
|
|
|
OS TETANUS TOX IGG AB S
|
Facility
|
IP
|
$177.00
|
|
|
Service Code
|
HCPCS 86774
|
| Hospital Charge Code |
30001213
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$53.10 |
| Max. Negotiated Rate |
$169.92 |
| Rate for Payer: Aetna Commercial |
$136.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$142.13
|
| Rate for Payer: Cash Price |
$88.50
|
| Rate for Payer: Cigna Commercial |
$146.91
|
| Rate for Payer: First Health Commercial |
$168.15
|
| Rate for Payer: Humana Commercial |
$150.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$145.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$130.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$155.76
|
| Rate for Payer: Ohio Health Group HMO |
$132.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$141.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$153.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$122.13
|
| Rate for Payer: PHCS Commercial |
$169.92
|
| Rate for Payer: United Healthcare All Payer |
$155.76
|
|
|
OS THC CONFIRMATION
|
Facility
|
OP
|
$98.00
|
|
|
Service Code
|
HCPCS G0480
|
| Hospital Charge Code |
30000121
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$67.62 |
| Max. Negotiated Rate |
$160.20 |
| Rate for Payer: Aetna Commercial |
$75.46
|
| Rate for Payer: Anthem Medicaid |
$114.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$114.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.69
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$160.20
|
| Rate for Payer: CareSource Just4Me Medicare |
$114.43
|
| Rate for Payer: Cash Price |
$49.00
|
| Rate for Payer: Cash Price |
$49.00
|
| Rate for Payer: Cigna Commercial |
$81.34
|
| Rate for Payer: First Health Commercial |
$93.10
|
| Rate for Payer: Humana Commercial |
$83.30
|
| Rate for Payer: Humana KY Medicaid |
$114.43
|
| Rate for Payer: Humana Medicare Advantage |
$114.43
|
| Rate for Payer: Kentucky WC Medicaid |
$115.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$116.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.24
|
| Rate for Payer: Ohio Health Group HMO |
$73.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.62
|
| Rate for Payer: PHCS Commercial |
$94.08
|
| Rate for Payer: United Healthcare All Payer |
$86.24
|
|
|
OS THC CONFIRMATION
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
HCPCS 80349
|
| Hospital Charge Code |
30000121
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$94.08 |
| Rate for Payer: Aetna Commercial |
$75.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.69
|
| Rate for Payer: Cash Price |
$49.00
|
| Rate for Payer: Cigna Commercial |
$81.34
|
| Rate for Payer: First Health Commercial |
$93.10
|
| Rate for Payer: Humana Commercial |
$83.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.24
|
| Rate for Payer: Ohio Health Group HMO |
$73.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.62
|
| Rate for Payer: PHCS Commercial |
$94.08
|
| Rate for Payer: United Healthcare All Payer |
$86.24
|
|
|
OS THC CONFIRMATION
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
HCPCS G0480
|
| Hospital Charge Code |
30000121
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$94.08 |
| Rate for Payer: Aetna Commercial |
$75.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.69
|
| Rate for Payer: Cash Price |
$49.00
|
| Rate for Payer: Cigna Commercial |
$81.34
|
| Rate for Payer: First Health Commercial |
$93.10
|
| Rate for Payer: Humana Commercial |
$83.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.24
|
| Rate for Payer: Ohio Health Group HMO |
$73.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.62
|
| Rate for Payer: PHCS Commercial |
$94.08
|
| Rate for Payer: United Healthcare All Payer |
$86.24
|
|
|
OS THC CONFIRMATION
|
Facility
|
OP
|
$98.00
|
|
|
Service Code
|
HCPCS 80349
|
| Hospital Charge Code |
30000121
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$94.08 |
| Rate for Payer: Aetna Commercial |
$75.46
|
| Rate for Payer: Anthem Medicaid |
$33.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.69
|
| Rate for Payer: Cash Price |
$49.00
|
| Rate for Payer: Cigna Commercial |
$81.34
|
| Rate for Payer: First Health Commercial |
$93.10
|
| Rate for Payer: Humana Commercial |
$83.30
|
| Rate for Payer: Humana KY Medicaid |
$33.70
|
| Rate for Payer: Kentucky WC Medicaid |
$34.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$34.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.24
|
| Rate for Payer: Ohio Health Group HMO |
$73.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.62
|
| Rate for Payer: PHCS Commercial |
$94.08
|
| Rate for Payer: United Healthcare All Payer |
$86.24
|
|
|
OS THC MH
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
HCPCS 80349
|
| Hospital Charge Code |
30000122
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$21.12 |
| Rate for Payer: Aetna Commercial |
$16.94
|
| Rate for Payer: Anthem Medicaid |
$7.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.67
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: Cigna Commercial |
$18.26
|
| Rate for Payer: First Health Commercial |
$20.90
|
| Rate for Payer: Humana Commercial |
$18.70
|
| Rate for Payer: Humana KY Medicaid |
$7.57
|
| Rate for Payer: Kentucky WC Medicaid |
$7.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.36
|
| Rate for Payer: Ohio Health Group HMO |
$16.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.18
|
| Rate for Payer: PHCS Commercial |
$21.12
|
| Rate for Payer: United Healthcare All Payer |
$19.36
|
|
|
OS THC MH
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
HCPCS 80349
|
| Hospital Charge Code |
30000122
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$21.12 |
| Rate for Payer: Aetna Commercial |
$16.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.67
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: Cigna Commercial |
$18.26
|
| Rate for Payer: First Health Commercial |
$20.90
|
| Rate for Payer: Humana Commercial |
$18.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.36
|
| Rate for Payer: Ohio Health Group HMO |
$16.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.18
|
| Rate for Payer: PHCS Commercial |
$21.12
|
| Rate for Payer: United Healthcare All Payer |
$19.36
|
|
|
OS THC MH
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
HCPCS G0480
|
| Hospital Charge Code |
30000122
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$21.12 |
| Rate for Payer: Aetna Commercial |
$16.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.67
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: Cigna Commercial |
$18.26
|
| Rate for Payer: First Health Commercial |
$20.90
|
| Rate for Payer: Humana Commercial |
$18.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.36
|
| Rate for Payer: Ohio Health Group HMO |
$16.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.18
|
| Rate for Payer: PHCS Commercial |
$21.12
|
| Rate for Payer: United Healthcare All Payer |
$19.36
|
|
|
OS THC MH
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
HCPCS G0480
|
| Hospital Charge Code |
30000122
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.18 |
| Max. Negotiated Rate |
$160.20 |
| Rate for Payer: Aetna Commercial |
$16.94
|
| Rate for Payer: Anthem Medicaid |
$114.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$114.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.67
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$160.20
|
| Rate for Payer: CareSource Just4Me Medicare |
$114.43
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: Cigna Commercial |
$18.26
|
| Rate for Payer: First Health Commercial |
$20.90
|
| Rate for Payer: Humana Commercial |
$18.70
|
| Rate for Payer: Humana KY Medicaid |
$114.43
|
| Rate for Payer: Humana Medicare Advantage |
$114.43
|
| Rate for Payer: Kentucky WC Medicaid |
$115.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$116.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.36
|
| Rate for Payer: Ohio Health Group HMO |
$16.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.18
|
| Rate for Payer: PHCS Commercial |
$21.12
|
| Rate for Payer: United Healthcare All Payer |
$19.36
|
|
|
OS THIAMIN VITAMIN B1 WB
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
HCPCS 84425
|
| Hospital Charge Code |
30000524
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$60.00 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial |
$154.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$160.60
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$166.00
|
| Rate for Payer: First Health Commercial |
$190.00
|
| Rate for Payer: Humana Commercial |
$170.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$164.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$147.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$176.00
|
| Rate for Payer: Ohio Health Group HMO |
$150.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$174.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$138.00
|
| Rate for Payer: PHCS Commercial |
$192.00
|
| Rate for Payer: United Healthcare All Payer |
$176.00
|
|
|
OS THIAMIN VITAMIN B1 WB
|
Facility
|
OP
|
$200.00
|
|
|
Service Code
|
HCPCS 84425
|
| Hospital Charge Code |
30000524
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.23 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial |
$154.00
|
| Rate for Payer: Anthem Medicaid |
$21.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$21.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$160.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$29.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$21.23
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$166.00
|
| Rate for Payer: First Health Commercial |
$190.00
|
| Rate for Payer: Humana Commercial |
$170.00
|
| Rate for Payer: Humana KY Medicaid |
$21.23
|
| Rate for Payer: Humana Medicare Advantage |
$21.23
|
| Rate for Payer: Kentucky WC Medicaid |
$21.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$164.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$147.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$176.00
|
| Rate for Payer: Ohio Health Group HMO |
$150.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$174.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$138.00
|
| Rate for Payer: PHCS Commercial |
$192.00
|
| Rate for Payer: United Healthcare All Payer |
$176.00
|
|
|
OS THROMBIN TIME
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
HCPCS 85670
|
| Hospital Charge Code |
30000628
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$34.20 |
| Max. Negotiated Rate |
$109.44 |
| Rate for Payer: Aetna Commercial |
$87.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.54
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cigna Commercial |
$94.62
|
| Rate for Payer: First Health Commercial |
$108.30
|
| Rate for Payer: Humana Commercial |
$96.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.32
|
| Rate for Payer: Ohio Health Group HMO |
$85.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.66
|
| Rate for Payer: PHCS Commercial |
$109.44
|
| Rate for Payer: United Healthcare All Payer |
$100.32
|
|
|
OS THROMBIN TIME
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
HCPCS 85670
|
| Hospital Charge Code |
30000628
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.77 |
| Max. Negotiated Rate |
$109.44 |
| Rate for Payer: Aetna Commercial |
$87.78
|
| Rate for Payer: Anthem Medicaid |
$5.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8.08
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.77
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cigna Commercial |
$94.62
|
| Rate for Payer: First Health Commercial |
$108.30
|
| Rate for Payer: Humana Commercial |
$96.90
|
| Rate for Payer: Humana KY Medicaid |
$5.77
|
| Rate for Payer: Humana Medicare Advantage |
$5.77
|
| Rate for Payer: Kentucky WC Medicaid |
$5.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.32
|
| Rate for Payer: Ohio Health Group HMO |
$85.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.66
|
| Rate for Payer: PHCS Commercial |
$109.44
|
| Rate for Payer: United Healthcare All Payer |
$100.32
|
|
|
OS THYME IGE
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000833
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Humana KY Medicaid |
$5.22
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Kentucky WC Medicaid |
$5.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
OS THYME IGE
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000833
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$20.70 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
OS THYROGLOBULIN
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
HCPCS 86800
|
| Hospital Charge Code |
30001805
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.91 |
| Max. Negotiated Rate |
$140.16 |
| Rate for Payer: Aetna Commercial |
$112.42
|
| Rate for Payer: Anthem Medicaid |
$15.91
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$15.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$22.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$15.91
|
| Rate for Payer: Cash Price |
$73.00
|
| Rate for Payer: Cash Price |
$73.00
|
| Rate for Payer: Cigna Commercial |
$121.18
|
| Rate for Payer: First Health Commercial |
$138.70
|
| Rate for Payer: Humana Commercial |
$124.10
|
| Rate for Payer: Humana KY Medicaid |
$15.91
|
| Rate for Payer: Humana Medicare Advantage |
$15.91
|
| Rate for Payer: Kentucky WC Medicaid |
$16.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$119.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$107.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$16.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$128.48
|
| Rate for Payer: Ohio Health Group HMO |
$109.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$116.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$100.74
|
| Rate for Payer: PHCS Commercial |
$140.16
|
| Rate for Payer: United Healthcare All Payer |
$128.48
|
|
|
OS THYROGLOBULIN
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
HCPCS 86800
|
| Hospital Charge Code |
30001805
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.80 |
| Max. Negotiated Rate |
$140.16 |
| Rate for Payer: Aetna Commercial |
$112.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.24
|
| Rate for Payer: Cash Price |
$73.00
|
| Rate for Payer: Cigna Commercial |
$121.18
|
| Rate for Payer: First Health Commercial |
$138.70
|
| Rate for Payer: Humana Commercial |
$124.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$119.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$107.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$128.48
|
| Rate for Payer: Ohio Health Group HMO |
$109.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$116.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$100.74
|
| Rate for Payer: PHCS Commercial |
$140.16
|
| Rate for Payer: United Healthcare All Payer |
$128.48
|
|
|
OS THYROGLOBULIN
|
Professional
|
Both
|
$146.00
|
|
|
Service Code
|
HCPCS 86800
|
| Hospital Charge Code |
30001805
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.87 |
| Max. Negotiated Rate |
$87.60 |
| Rate for Payer: Aetna Commercial |
$10.87
|
| Rate for Payer: Ambetter Exchange |
$15.91
|
| Rate for Payer: Buckeye Individual/Medicaid |
$15.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$15.91
|
| Rate for Payer: CareSource Just4Me Medicare |
$19.09
|
| Rate for Payer: Cash Price |
$73.00
|
| Rate for Payer: Cash Price |
$73.00
|
| Rate for Payer: Cigna Commercial |
$14.16
|
| Rate for Payer: Healthspan PPO |
$16.66
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$15.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.91
|
| Rate for Payer: Multiplan PHCS |
$87.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$20.68
|
| Rate for Payer: UHCCP Medicaid |
$51.10
|
| Rate for Payer: Wellcare Medicare Advantage |
$15.91
|
|
