|
TCD VASACTIVITY STDY W/INJ(T
|
Facility
|
OP
|
$728.00
|
|
|
Service Code
|
HCPCS 93893
|
| Hospital Charge Code |
320T0300
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$94.64 |
| Max. Negotiated Rate |
$698.88 |
| Rate for Payer: Aetna Commercial |
$560.56
|
| Rate for Payer: Anthem Medicaid |
$250.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$567.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$364.00
|
| Rate for Payer: Cash Price |
$364.00
|
| Rate for Payer: Cigna Commercial |
$604.24
|
| Rate for Payer: First Health Commercial |
$691.60
|
| Rate for Payer: Humana Commercial |
$618.80
|
| Rate for Payer: Humana KY Medicaid |
$250.36
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$252.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$596.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$537.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$255.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$640.64
|
| Rate for Payer: Ohio Health Group HMO |
$546.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$145.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$94.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$225.68
|
| Rate for Payer: PHCS Commercial |
$698.88
|
| Rate for Payer: United Healthcare All Payer |
$640.64
|
|
|
TCD VASACTIVITY STDY W/INJ(T
|
Facility
|
IP
|
$728.00
|
|
|
Service Code
|
HCPCS 93893
|
| Hospital Charge Code |
320T0300
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$94.64 |
| Max. Negotiated Rate |
$698.88 |
| Rate for Payer: Aetna Commercial |
$560.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$567.84
|
| Rate for Payer: Cash Price |
$364.00
|
| Rate for Payer: Cigna Commercial |
$604.24
|
| Rate for Payer: First Health Commercial |
$691.60
|
| Rate for Payer: Humana Commercial |
$618.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$596.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$537.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$218.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$640.64
|
| Rate for Payer: Ohio Health Group HMO |
$546.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$145.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$94.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$225.68
|
| Rate for Payer: PHCS Commercial |
$698.88
|
| Rate for Payer: United Healthcare All Payer |
$640.64
|
|
|
TCD VASACTIVITY STDY W/O INJ
|
Facility
|
IP
|
$1,096.00
|
|
|
Service Code
|
HCPCS 93892
|
| Hospital Charge Code |
32000299
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$142.48 |
| Max. Negotiated Rate |
$1,052.16 |
| Rate for Payer: Aetna Commercial |
$843.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$854.88
|
| Rate for Payer: Cash Price |
$548.00
|
| Rate for Payer: Cigna Commercial |
$909.68
|
| Rate for Payer: First Health Commercial |
$1,041.20
|
| Rate for Payer: Humana Commercial |
$931.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$898.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$808.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$328.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$964.48
|
| Rate for Payer: Ohio Health Group HMO |
$822.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$219.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$142.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$339.76
|
| Rate for Payer: PHCS Commercial |
$1,052.16
|
| Rate for Payer: United Healthcare All Payer |
$964.48
|
|
|
TCD VASACTIVITY STDY W/O INJ
|
Facility
|
OP
|
$1,096.00
|
|
|
Service Code
|
HCPCS 93892
|
| Hospital Charge Code |
32000299
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$1,052.16 |
| Rate for Payer: Aetna Commercial |
$843.92
|
| Rate for Payer: Anthem Medicaid |
$376.91
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$854.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$548.00
|
| Rate for Payer: Cash Price |
$548.00
|
| Rate for Payer: Cigna Commercial |
$909.68
|
| Rate for Payer: First Health Commercial |
$1,041.20
|
| Rate for Payer: Humana Commercial |
$931.60
|
| Rate for Payer: Humana KY Medicaid |
$376.91
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$380.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$898.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$808.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$384.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$964.48
|
| Rate for Payer: Ohio Health Group HMO |
$822.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$219.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$142.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$339.76
|
| Rate for Payer: PHCS Commercial |
$1,052.16
|
| Rate for Payer: United Healthcare All Payer |
$964.48
|
|
|
TCD VASACTIVITY STDY W/O INJ
|
Professional
|
Both
|
$1,096.00
|
|
|
Service Code
|
HCPCS 93892
|
| Hospital Charge Code |
32000299
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$75.75 |
| Max. Negotiated Rate |
$1,096.00 |
| Rate for Payer: Aetna Commercial |
$238.51
|
| Rate for Payer: Anthem Medicaid |
$177.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,096.00
|
| Rate for Payer: Cash Price |
$548.00
|
| Rate for Payer: Cash Price |
$548.00
|
| Rate for Payer: Cigna Commercial |
$339.72
|
| Rate for Payer: Healthspan PPO |
$254.77
|
| Rate for Payer: Humana Medicaid |
$177.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$75.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$180.99
|
| Rate for Payer: Molina Healthcare Passport |
$177.44
|
| Rate for Payer: Multiplan PHCS |
$657.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$767.20
|
| Rate for Payer: UHCCP Medicaid |
$383.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$179.21
|
|
|
TCD VASACTIVITY STDY W/O INJ(P
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
HCPCS 93892
|
| Hospital Charge Code |
320P0299
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$75.75 |
| Max. Negotiated Rate |
$350.00 |
| Rate for Payer: Aetna Commercial |
$238.51
|
| Rate for Payer: Anthem Medicaid |
$177.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$350.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna Commercial |
$339.72
|
| Rate for Payer: Healthspan PPO |
$254.77
|
| Rate for Payer: Humana Medicaid |
$177.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$75.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$180.99
|
| Rate for Payer: Molina Healthcare Passport |
$177.44
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$245.00
|
| Rate for Payer: UHCCP Medicaid |
$122.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$179.21
|
|
|
TCD VASACTIVITY STDY W/O INJ(T
|
Facility
|
OP
|
$746.00
|
|
|
Service Code
|
HCPCS 93892
|
| Hospital Charge Code |
320T0299
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$716.16 |
| Rate for Payer: Aetna Commercial |
$574.42
|
| Rate for Payer: Anthem Medicaid |
$256.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$581.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$373.00
|
| Rate for Payer: Cash Price |
$373.00
|
| Rate for Payer: Cigna Commercial |
$619.18
|
| Rate for Payer: First Health Commercial |
$708.70
|
| Rate for Payer: Humana Commercial |
$634.10
|
| Rate for Payer: Humana KY Medicaid |
$256.55
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$259.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$611.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$550.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$261.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$656.48
|
| Rate for Payer: Ohio Health Group HMO |
$559.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$149.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$96.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$231.26
|
| Rate for Payer: PHCS Commercial |
$716.16
|
| Rate for Payer: United Healthcare All Payer |
$656.48
|
|
|
TCD VASACTIVITY STDY W/O INJ(T
|
Facility
|
IP
|
$746.00
|
|
|
Service Code
|
HCPCS 93892
|
| Hospital Charge Code |
320T0299
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$96.98 |
| Max. Negotiated Rate |
$716.16 |
| Rate for Payer: Aetna Commercial |
$574.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$581.88
|
| Rate for Payer: Cash Price |
$373.00
|
| Rate for Payer: Cigna Commercial |
$619.18
|
| Rate for Payer: First Health Commercial |
$708.70
|
| Rate for Payer: Humana Commercial |
$634.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$611.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$550.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$223.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$656.48
|
| Rate for Payer: Ohio Health Group HMO |
$559.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$149.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$96.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$231.26
|
| Rate for Payer: PHCS Commercial |
$716.16
|
| Rate for Payer: United Healthcare All Payer |
$656.48
|
|
|
TCD VASOREACTIVITY STUDY
|
Facility
|
IP
|
$1,379.00
|
|
|
Service Code
|
HCPCS 93890
|
| Hospital Charge Code |
32000298
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$179.27 |
| Max. Negotiated Rate |
$1,323.84 |
| Rate for Payer: Aetna Commercial |
$1,061.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,075.62
|
| Rate for Payer: Cash Price |
$689.50
|
| Rate for Payer: Cigna Commercial |
$1,144.57
|
| Rate for Payer: First Health Commercial |
$1,310.05
|
| Rate for Payer: Humana Commercial |
$1,172.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,130.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,017.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,213.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,034.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$275.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$179.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$427.49
|
| Rate for Payer: PHCS Commercial |
$1,323.84
|
| Rate for Payer: United Healthcare All Payer |
$1,213.52
|
|
|
TCD VASOREACTIVITY STUDY
|
Professional
|
Both
|
$1,379.00
|
|
|
Service Code
|
HCPCS 93890
|
| Hospital Charge Code |
32000298
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$65.36 |
| Max. Negotiated Rate |
$1,379.00 |
| Rate for Payer: Aetna Commercial |
$227.88
|
| Rate for Payer: Anthem Medicaid |
$166.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,379.00
|
| Rate for Payer: Cash Price |
$689.50
|
| Rate for Payer: Cash Price |
$689.50
|
| Rate for Payer: Cigna Commercial |
$317.72
|
| Rate for Payer: Healthspan PPO |
$243.42
|
| Rate for Payer: Humana Medicaid |
$166.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$65.36
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$169.69
|
| Rate for Payer: Molina Healthcare Passport |
$166.36
|
| Rate for Payer: Multiplan PHCS |
$827.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$965.30
|
| Rate for Payer: UHCCP Medicaid |
$482.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$168.02
|
|
|
TCD VASOREACTIVITY STUDY
|
Facility
|
OP
|
$1,379.00
|
|
|
Service Code
|
HCPCS 93890
|
| Hospital Charge Code |
32000298
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$179.27 |
| Max. Negotiated Rate |
$1,323.84 |
| Rate for Payer: Aetna Commercial |
$1,061.83
|
| Rate for Payer: Anthem Medicaid |
$474.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$211.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,075.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$296.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$286.06
|
| Rate for Payer: Cash Price |
$689.50
|
| Rate for Payer: Cash Price |
$689.50
|
| Rate for Payer: Cigna Commercial |
$1,144.57
|
| Rate for Payer: First Health Commercial |
$1,310.05
|
| Rate for Payer: Humana Commercial |
$1,172.15
|
| Rate for Payer: Humana KY Medicaid |
$474.24
|
| Rate for Payer: Humana Medicare Advantage |
$211.90
|
| Rate for Payer: Kentucky WC Medicaid |
$479.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,130.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,017.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$483.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,213.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,034.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$275.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$179.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$427.49
|
| Rate for Payer: PHCS Commercial |
$1,323.84
|
| Rate for Payer: United Healthcare All Payer |
$1,213.52
|
|
|
TCD VASOREACTIVITY STUDY(P
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
HCPCS 93890
|
| Hospital Charge Code |
320P0298
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$65.36 |
| Max. Negotiated Rate |
$350.00 |
| Rate for Payer: Aetna Commercial |
$227.88
|
| Rate for Payer: Anthem Medicaid |
$166.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$350.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna Commercial |
$317.72
|
| Rate for Payer: Healthspan PPO |
$243.42
|
| Rate for Payer: Humana Medicaid |
$166.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$65.36
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$169.69
|
| Rate for Payer: Molina Healthcare Passport |
$166.36
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$245.00
|
| Rate for Payer: UHCCP Medicaid |
$122.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$168.02
|
|
|
TCD VASOREACTIVITY STUDY(T
|
Facility
|
OP
|
$1,029.00
|
|
|
Service Code
|
HCPCS 93890
|
| Hospital Charge Code |
320T0298
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$133.77 |
| Max. Negotiated Rate |
$987.84 |
| Rate for Payer: Aetna Commercial |
$792.33
|
| Rate for Payer: Anthem Medicaid |
$353.87
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$211.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$802.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$296.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$286.06
|
| Rate for Payer: Cash Price |
$514.50
|
| Rate for Payer: Cash Price |
$514.50
|
| Rate for Payer: Cigna Commercial |
$854.07
|
| Rate for Payer: First Health Commercial |
$977.55
|
| Rate for Payer: Humana Commercial |
$874.65
|
| Rate for Payer: Humana KY Medicaid |
$353.87
|
| Rate for Payer: Humana Medicare Advantage |
$211.90
|
| Rate for Payer: Kentucky WC Medicaid |
$357.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$843.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$759.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$360.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$905.52
|
| Rate for Payer: Ohio Health Group HMO |
$771.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$205.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$133.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$318.99
|
| Rate for Payer: PHCS Commercial |
$987.84
|
| Rate for Payer: United Healthcare All Payer |
$905.52
|
|
|
TCD VASOREACTIVITY STUDY(T
|
Facility
|
IP
|
$1,029.00
|
|
|
Service Code
|
HCPCS 93890
|
| Hospital Charge Code |
320T0298
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$133.77 |
| Max. Negotiated Rate |
$987.84 |
| Rate for Payer: Aetna Commercial |
$792.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$802.62
|
| Rate for Payer: Cash Price |
$514.50
|
| Rate for Payer: Cigna Commercial |
$854.07
|
| Rate for Payer: First Health Commercial |
$977.55
|
| Rate for Payer: Humana Commercial |
$874.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$843.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$759.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$308.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$905.52
|
| Rate for Payer: Ohio Health Group HMO |
$771.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$205.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$133.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$318.99
|
| Rate for Payer: PHCS Commercial |
$987.84
|
| Rate for Payer: United Healthcare All Payer |
$905.52
|
|
|
TD ADSORBED,PRESERVATIVE FREE
|
Professional
|
Both
|
$172.00
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
77000042
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.23 |
| Max. Negotiated Rate |
$172.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$172.00
|
| Rate for Payer: Cash Price |
$86.00
|
| Rate for Payer: Cash Price |
$86.00
|
| Rate for Payer: Healthspan PPO |
$26.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$55.39
|
| Rate for Payer: Multiplan PHCS |
$103.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$120.40
|
| Rate for Payer: UHCCP Medicaid |
$60.20
|
|
|
TD ADSORBED,PRESERVATIVE FREE
|
Facility
|
IP
|
$172.00
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
77000042
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.36 |
| Max. Negotiated Rate |
$165.12 |
| Rate for Payer: Aetna Commercial |
$132.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.16
|
| Rate for Payer: Cash Price |
$86.00
|
| Rate for Payer: Cigna Commercial |
$142.76
|
| Rate for Payer: First Health Commercial |
$163.40
|
| Rate for Payer: Humana Commercial |
$146.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$141.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$126.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$151.36
|
| Rate for Payer: Ohio Health Group HMO |
$129.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.32
|
| Rate for Payer: PHCS Commercial |
$165.12
|
| Rate for Payer: United Healthcare All Payer |
$151.36
|
|
|
TD ADSORBED,PRESERVATIVE FREE
|
Facility
|
OP
|
$172.00
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
77000042
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.36 |
| Max. Negotiated Rate |
$165.12 |
| Rate for Payer: Aetna Commercial |
$132.44
|
| Rate for Payer: Anthem Medicaid |
$59.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.16
|
| Rate for Payer: Cash Price |
$86.00
|
| Rate for Payer: Cigna Commercial |
$142.76
|
| Rate for Payer: First Health Commercial |
$163.40
|
| Rate for Payer: Humana Commercial |
$146.20
|
| Rate for Payer: Humana KY Medicaid |
$59.15
|
| Rate for Payer: Kentucky WC Medicaid |
$59.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$141.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$126.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$60.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$151.36
|
| Rate for Payer: Ohio Health Group HMO |
$129.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.32
|
| Rate for Payer: PHCS Commercial |
$165.12
|
| Rate for Payer: United Healthcare All Payer |
$151.36
|
|
|
TD ADSORBED,PRESERVATIVE FRE(T
|
Facility
|
OP
|
$172.00
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
770T0042
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.36 |
| Max. Negotiated Rate |
$165.12 |
| Rate for Payer: Aetna Commercial |
$132.44
|
| Rate for Payer: Anthem Medicaid |
$59.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.16
|
| Rate for Payer: Cash Price |
$86.00
|
| Rate for Payer: Cigna Commercial |
$142.76
|
| Rate for Payer: First Health Commercial |
$163.40
|
| Rate for Payer: Humana Commercial |
$146.20
|
| Rate for Payer: Humana KY Medicaid |
$59.15
|
| Rate for Payer: Kentucky WC Medicaid |
$59.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$141.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$126.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$60.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$151.36
|
| Rate for Payer: Ohio Health Group HMO |
$129.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.32
|
| Rate for Payer: PHCS Commercial |
$165.12
|
| Rate for Payer: United Healthcare All Payer |
$151.36
|
|
|
TD ADSORBED,PRESERVATIVE FRE(T
|
Facility
|
IP
|
$172.00
|
|
|
Service Code
|
HCPCS 90714
|
| Hospital Charge Code |
770T0042
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.36 |
| Max. Negotiated Rate |
$165.12 |
| Rate for Payer: Aetna Commercial |
$132.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.16
|
| Rate for Payer: Cash Price |
$86.00
|
| Rate for Payer: Cigna Commercial |
$142.76
|
| Rate for Payer: First Health Commercial |
$163.40
|
| Rate for Payer: Humana Commercial |
$146.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$141.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$126.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$151.36
|
| Rate for Payer: Ohio Health Group HMO |
$129.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.32
|
| Rate for Payer: PHCS Commercial |
$165.12
|
| Rate for Payer: United Healthcare All Payer |
$151.36
|
|
|
TDAP 7 YEARS OR OLDER
|
Facility
|
OP
|
$242.00
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
77000043
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.46 |
| Max. Negotiated Rate |
$232.32 |
| Rate for Payer: Aetna Commercial |
$186.34
|
| Rate for Payer: Anthem Medicaid |
$83.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$188.76
|
| Rate for Payer: Cash Price |
$121.00
|
| Rate for Payer: Cigna Commercial |
$200.86
|
| Rate for Payer: First Health Commercial |
$229.90
|
| Rate for Payer: Humana Commercial |
$205.70
|
| Rate for Payer: Humana KY Medicaid |
$83.22
|
| Rate for Payer: Kentucky WC Medicaid |
$84.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$198.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$178.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$72.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$84.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$212.96
|
| Rate for Payer: Ohio Health Group HMO |
$181.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$75.02
|
| Rate for Payer: PHCS Commercial |
$232.32
|
| Rate for Payer: United Healthcare All Payer |
$212.96
|
|
|
TDAP 7 YEARS OR OLDER
|
Professional
|
Both
|
$242.00
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
77000043
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.05 |
| Max. Negotiated Rate |
$242.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$242.00
|
| Rate for Payer: Cash Price |
$121.00
|
| Rate for Payer: Cash Price |
$121.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$75.05
|
| Rate for Payer: Multiplan PHCS |
$145.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$169.40
|
| Rate for Payer: UHCCP Medicaid |
$84.70
|
|
|
TDAP 7 YEARS OR OLDER
|
Facility
|
IP
|
$242.00
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
77000043
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.46 |
| Max. Negotiated Rate |
$232.32 |
| Rate for Payer: Aetna Commercial |
$186.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$188.76
|
| Rate for Payer: Cash Price |
$121.00
|
| Rate for Payer: Cigna Commercial |
$200.86
|
| Rate for Payer: First Health Commercial |
$229.90
|
| Rate for Payer: Humana Commercial |
$205.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$198.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$178.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$72.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$212.96
|
| Rate for Payer: Ohio Health Group HMO |
$181.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$75.02
|
| Rate for Payer: PHCS Commercial |
$232.32
|
| Rate for Payer: United Healthcare All Payer |
$212.96
|
|
|
TDAP 7 YEARS OR OLDER(T
|
Facility
|
IP
|
$242.00
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
770T0043
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.46 |
| Max. Negotiated Rate |
$232.32 |
| Rate for Payer: Aetna Commercial |
$186.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$188.76
|
| Rate for Payer: Cash Price |
$121.00
|
| Rate for Payer: Cigna Commercial |
$200.86
|
| Rate for Payer: First Health Commercial |
$229.90
|
| Rate for Payer: Humana Commercial |
$205.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$198.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$178.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$72.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$212.96
|
| Rate for Payer: Ohio Health Group HMO |
$181.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$75.02
|
| Rate for Payer: PHCS Commercial |
$232.32
|
| Rate for Payer: United Healthcare All Payer |
$212.96
|
|
|
TDAP 7 YEARS OR OLDER(T
|
Facility
|
OP
|
$242.00
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
770T0043
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.46 |
| Max. Negotiated Rate |
$232.32 |
| Rate for Payer: Aetna Commercial |
$186.34
|
| Rate for Payer: Anthem Medicaid |
$83.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$188.76
|
| Rate for Payer: Cash Price |
$121.00
|
| Rate for Payer: Cigna Commercial |
$200.86
|
| Rate for Payer: First Health Commercial |
$229.90
|
| Rate for Payer: Humana Commercial |
$205.70
|
| Rate for Payer: Humana KY Medicaid |
$83.22
|
| Rate for Payer: Kentucky WC Medicaid |
$84.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$198.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$178.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$72.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$84.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$212.96
|
| Rate for Payer: Ohio Health Group HMO |
$181.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$75.02
|
| Rate for Payer: PHCS Commercial |
$232.32
|
| Rate for Payer: United Healthcare All Payer |
$212.96
|
|
|
TDAP BOOSTRIX 0.5ML DISP SYR
|
Professional
|
Both
|
$242.00
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
63600006
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.05 |
| Max. Negotiated Rate |
$242.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$242.00
|
| Rate for Payer: Cash Price |
$121.00
|
| Rate for Payer: Cash Price |
$121.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$75.05
|
| Rate for Payer: Multiplan PHCS |
$145.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$169.40
|
| Rate for Payer: UHCCP Medicaid |
$84.70
|
|
