|
TDAP BOOSTRIX 0.5ML DISP SYR
|
Facility
|
IP
|
$201.14
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
25000040
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.15 |
| Max. Negotiated Rate |
$193.09 |
| Rate for Payer: Aetna Commercial |
$154.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$156.89
|
| Rate for Payer: Cash Price |
$100.57
|
| Rate for Payer: Cigna Commercial |
$166.95
|
| Rate for Payer: First Health Commercial |
$191.08
|
| Rate for Payer: Humana Commercial |
$170.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$164.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$148.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$177.00
|
| Rate for Payer: Ohio Health Group HMO |
$150.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.35
|
| Rate for Payer: PHCS Commercial |
$193.09
|
| Rate for Payer: United Healthcare All Payer |
$177.00
|
|
|
TDAP BOOSTRIX 0.5ML DISP SYR
|
Facility
|
OP
|
$242.00
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
63600006
|
|
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
|
Facility
|
OP
|
$201.14
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
25000040
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.15 |
| Max. Negotiated Rate |
$193.09 |
| Rate for Payer: Aetna Commercial |
$154.88
|
| Rate for Payer: Anthem Medicaid |
$69.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$156.89
|
| Rate for Payer: Cash Price |
$100.57
|
| Rate for Payer: Cigna Commercial |
$166.95
|
| Rate for Payer: First Health Commercial |
$191.08
|
| Rate for Payer: Humana Commercial |
$170.97
|
| Rate for Payer: Humana KY Medicaid |
$69.17
|
| Rate for Payer: Kentucky WC Medicaid |
$69.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$164.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$148.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$70.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$177.00
|
| Rate for Payer: Ohio Health Group HMO |
$150.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.35
|
| Rate for Payer: PHCS Commercial |
$193.09
|
| Rate for Payer: United Healthcare All Payer |
$177.00
|
|
|
TDAP BOOSTRIX 0.5ML DISP SYR
|
Facility
|
IP
|
$242.00
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
63600006
|
|
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 BOOSTRIX 0.5ML DISP SYR
|
Facility
|
OP
|
$242.00
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
636T0006
|
|
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
|
Facility
|
IP
|
$242.00
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
636T0006
|
|
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
|
|
|
TECENTRIQ 10MG (1200MG VL)
|
Facility
|
IP
|
$59,536.29
|
|
|
Service Code
|
HCPCS J9022
|
| Hospital Charge Code |
25002559
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,739.72 |
| Max. Negotiated Rate |
$57,154.84 |
| Rate for Payer: Aetna Commercial |
$45,842.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46,438.31
|
| Rate for Payer: Cash Price |
$29,768.14
|
| Rate for Payer: Cigna Commercial |
$49,415.12
|
| Rate for Payer: First Health Commercial |
$56,559.48
|
| Rate for Payer: Humana Commercial |
$50,605.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$48,819.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$43,937.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17,860.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$52,391.94
|
| Rate for Payer: Ohio Health Group HMO |
$44,652.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,907.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,739.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,456.25
|
| Rate for Payer: PHCS Commercial |
$57,154.84
|
| Rate for Payer: United Healthcare All Payer |
$52,391.94
|
|
|
TECENTRIQ 10MG (1200MG VL)
|
Facility
|
OP
|
$59,536.29
|
|
|
Service Code
|
HCPCS J9022
|
| Hospital Charge Code |
25002559
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.01 |
| Max. Negotiated Rate |
$57,154.84 |
| Rate for Payer: Aetna Commercial |
$45,842.94
|
| Rate for Payer: Anthem Medicaid |
$20,474.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$85.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46,438.31
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$119.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$114.76
|
| Rate for Payer: Cash Price |
$29,768.14
|
| Rate for Payer: Cash Price |
$29,768.14
|
| Rate for Payer: Cigna Commercial |
$49,415.12
|
| Rate for Payer: First Health Commercial |
$56,559.48
|
| Rate for Payer: Humana Commercial |
$50,605.85
|
| Rate for Payer: Humana KY Medicaid |
$20,474.53
|
| Rate for Payer: Humana Medicare Advantage |
$85.01
|
| Rate for Payer: Kentucky WC Medicaid |
$20,682.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$48,819.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$43,937.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$102.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$20,885.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$52,391.94
|
| Rate for Payer: Ohio Health Group HMO |
$44,652.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,907.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,739.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,456.25
|
| Rate for Payer: PHCS Commercial |
$57,154.84
|
| Rate for Payer: United Healthcare All Payer |
$52,391.94
|
|
|
TECENTRIQ 10MG (840MG VL)
|
Facility
|
OP
|
$41,675.39
|
|
|
Service Code
|
HCPCS J9022
|
| Hospital Charge Code |
25004175
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.01 |
| Max. Negotiated Rate |
$40,008.37 |
| Rate for Payer: Aetna Commercial |
$32,090.05
|
| Rate for Payer: Anthem Medicaid |
$14,332.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$85.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$32,506.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$119.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$114.76
|
| Rate for Payer: Cash Price |
$20,837.70
|
| Rate for Payer: Cash Price |
$20,837.70
|
| Rate for Payer: Cigna Commercial |
$34,590.57
|
| Rate for Payer: First Health Commercial |
$39,591.62
|
| Rate for Payer: Humana Commercial |
$35,424.08
|
| Rate for Payer: Humana KY Medicaid |
$14,332.17
|
| Rate for Payer: Humana Medicare Advantage |
$85.01
|
| Rate for Payer: Kentucky WC Medicaid |
$14,478.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34,173.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$30,756.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$102.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,619.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$36,674.34
|
| Rate for Payer: Ohio Health Group HMO |
$31,256.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,335.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,417.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,919.37
|
| Rate for Payer: PHCS Commercial |
$40,008.37
|
| Rate for Payer: United Healthcare All Payer |
$36,674.34
|
|
|
TECENTRIQ 10MG (840MG VL)
|
Facility
|
IP
|
$41,675.39
|
|
|
Service Code
|
HCPCS J9022
|
| Hospital Charge Code |
25004175
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,417.80 |
| Max. Negotiated Rate |
$40,008.37 |
| Rate for Payer: Aetna Commercial |
$32,090.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$32,506.80
|
| Rate for Payer: Cash Price |
$20,837.70
|
| Rate for Payer: Cigna Commercial |
$34,590.57
|
| Rate for Payer: First Health Commercial |
$39,591.62
|
| Rate for Payer: Humana Commercial |
$35,424.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34,173.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$30,756.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,502.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$36,674.34
|
| Rate for Payer: Ohio Health Group HMO |
$31,256.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,335.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,417.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,919.37
|
| Rate for Payer: PHCS Commercial |
$40,008.37
|
| Rate for Payer: United Healthcare All Payer |
$36,674.34
|
|
|
TECHETIUM TC 99M MEDRONATE
|
Professional
|
Both
|
$146.00
|
|
| Hospital Charge Code |
34000048
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$51.10 |
| Max. Negotiated Rate |
$146.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$146.00
|
| Rate for Payer: Cash Price |
$73.00
|
| Rate for Payer: Multiplan PHCS |
$87.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$102.20
|
| Rate for Payer: UHCCP Medicaid |
$51.10
|
|
|
TECHETIUM TC 99M MEDRONATE
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
34000048
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$140.16 |
| Rate for Payer: Aetna Commercial |
$112.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$113.88
|
| 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 |
$29.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.26
|
| Rate for Payer: PHCS Commercial |
$140.16
|
| Rate for Payer: United Healthcare All Payer |
$128.48
|
|
|
TECHETIUM TC 99M MEDRONATE
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
34000048
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$140.16 |
| Rate for Payer: Aetna Commercial |
$112.42
|
| Rate for Payer: Anthem Medicaid |
$50.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$113.88
|
| 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 |
$50.21
|
| Rate for Payer: Kentucky WC Medicaid |
$50.72
|
| 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: Molina Healthcare Medicaid |
$51.22
|
| 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 |
$29.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.26
|
| Rate for Payer: PHCS Commercial |
$140.16
|
| Rate for Payer: United Healthcare All Payer |
$128.48
|
|
|
TECHETIUM TC 99M MEDRONATE(T
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
340T0048
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$140.16 |
| Rate for Payer: Aetna Commercial |
$112.42
|
| Rate for Payer: Anthem Medicaid |
$50.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$113.88
|
| 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 |
$50.21
|
| Rate for Payer: Kentucky WC Medicaid |
$50.72
|
| 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: Molina Healthcare Medicaid |
$51.22
|
| 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 |
$29.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.26
|
| Rate for Payer: PHCS Commercial |
$140.16
|
| Rate for Payer: United Healthcare All Payer |
$128.48
|
|
|
TECHETIUM TC 99M MEDRONATE(T
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
340T0048
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$140.16 |
| Rate for Payer: Aetna Commercial |
$112.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$113.88
|
| 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 |
$29.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.26
|
| Rate for Payer: PHCS Commercial |
$140.16
|
| Rate for Payer: United Healthcare All Payer |
$128.48
|
|
|
TECHNETIUM TC-99M AEROSOL
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
HCPCS A9567
|
| Hospital Charge Code |
34000067
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$22.49 |
| Max. Negotiated Rate |
$166.08 |
| Rate for Payer: Aetna Commercial |
$133.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.94
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cigna Commercial |
$143.59
|
| Rate for Payer: First Health Commercial |
$164.35
|
| Rate for Payer: Humana Commercial |
$147.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$141.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$127.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$152.24
|
| Rate for Payer: Ohio Health Group HMO |
$129.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.63
|
| Rate for Payer: PHCS Commercial |
$166.08
|
| Rate for Payer: United Healthcare All Payer |
$152.24
|
|
|
TECHNETIUM TC-99M AEROSOL
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
HCPCS A9567
|
| Hospital Charge Code |
34000067
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$22.49 |
| Max. Negotiated Rate |
$166.08 |
| Rate for Payer: Aetna Commercial |
$133.21
|
| Rate for Payer: Anthem Medicaid |
$59.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.94
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cigna Commercial |
$143.59
|
| Rate for Payer: First Health Commercial |
$164.35
|
| Rate for Payer: Humana Commercial |
$147.05
|
| Rate for Payer: Humana KY Medicaid |
$59.49
|
| Rate for Payer: Kentucky WC Medicaid |
$60.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$141.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$127.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$60.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$152.24
|
| Rate for Payer: Ohio Health Group HMO |
$129.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.63
|
| Rate for Payer: PHCS Commercial |
$166.08
|
| Rate for Payer: United Healthcare All Payer |
$152.24
|
|
|
TECHNETIUM TC99MBICISATEEADOSE
|
Facility
|
IP
|
$618.00
|
|
|
Service Code
|
HCPCS A9557
|
| Hospital Charge Code |
34000064
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$80.34 |
| Max. Negotiated Rate |
$593.28 |
| Rate for Payer: Aetna Commercial |
$475.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$482.04
|
| Rate for Payer: Cash Price |
$309.00
|
| Rate for Payer: Cigna Commercial |
$512.94
|
| Rate for Payer: First Health Commercial |
$587.10
|
| Rate for Payer: Humana Commercial |
$525.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$506.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$456.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$185.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$543.84
|
| Rate for Payer: Ohio Health Group HMO |
$463.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$123.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$191.58
|
| Rate for Payer: PHCS Commercial |
$593.28
|
| Rate for Payer: United Healthcare All Payer |
$543.84
|
|
|
TECHNETIUM TC99MBICISATEEADOSE
|
Facility
|
OP
|
$618.00
|
|
|
Service Code
|
HCPCS A9557
|
| Hospital Charge Code |
340T0064
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$80.34 |
| Max. Negotiated Rate |
$593.28 |
| Rate for Payer: Aetna Commercial |
$475.86
|
| Rate for Payer: Anthem Medicaid |
$212.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$482.04
|
| Rate for Payer: Cash Price |
$309.00
|
| Rate for Payer: Cigna Commercial |
$512.94
|
| Rate for Payer: First Health Commercial |
$587.10
|
| Rate for Payer: Humana Commercial |
$525.30
|
| Rate for Payer: Humana KY Medicaid |
$212.53
|
| Rate for Payer: Kentucky WC Medicaid |
$214.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$506.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$456.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$185.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$216.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$543.84
|
| Rate for Payer: Ohio Health Group HMO |
$463.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$123.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$191.58
|
| Rate for Payer: PHCS Commercial |
$593.28
|
| Rate for Payer: United Healthcare All Payer |
$543.84
|
|
|
TECHNETIUM TC99MBICISATEEADOSE
|
Facility
|
OP
|
$618.00
|
|
|
Service Code
|
HCPCS A9557
|
| Hospital Charge Code |
34000064
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$80.34 |
| Max. Negotiated Rate |
$593.28 |
| Rate for Payer: Aetna Commercial |
$475.86
|
| Rate for Payer: Anthem Medicaid |
$212.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$482.04
|
| Rate for Payer: Cash Price |
$309.00
|
| Rate for Payer: Cigna Commercial |
$512.94
|
| Rate for Payer: First Health Commercial |
$587.10
|
| Rate for Payer: Humana Commercial |
$525.30
|
| Rate for Payer: Humana KY Medicaid |
$212.53
|
| Rate for Payer: Kentucky WC Medicaid |
$214.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$506.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$456.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$185.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$216.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$543.84
|
| Rate for Payer: Ohio Health Group HMO |
$463.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$123.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$191.58
|
| Rate for Payer: PHCS Commercial |
$593.28
|
| Rate for Payer: United Healthcare All Payer |
$543.84
|
|
|
TECHNETIUM TC99MBICISATEEADOSE
|
Facility
|
IP
|
$618.00
|
|
|
Service Code
|
HCPCS A9557
|
| Hospital Charge Code |
340T0064
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$80.34 |
| Max. Negotiated Rate |
$593.28 |
| Rate for Payer: Aetna Commercial |
$475.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$482.04
|
| Rate for Payer: Cash Price |
$309.00
|
| Rate for Payer: Cigna Commercial |
$512.94
|
| Rate for Payer: First Health Commercial |
$587.10
|
| Rate for Payer: Humana Commercial |
$525.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$506.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$456.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$185.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$543.84
|
| Rate for Payer: Ohio Health Group HMO |
$463.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$123.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$191.58
|
| Rate for Payer: PHCS Commercial |
$593.28
|
| Rate for Payer: United Healthcare All Payer |
$543.84
|
|
|
TECHNETIUM TC99M DISOFENIN
|
Facility
|
OP
|
$229.00
|
|
|
Service Code
|
HCPCS A9510
|
| Hospital Charge Code |
34000051
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$29.77 |
| Max. Negotiated Rate |
$219.84 |
| Rate for Payer: Aetna Commercial |
$176.33
|
| Rate for Payer: Anthem Medicaid |
$78.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$178.62
|
| Rate for Payer: Cash Price |
$114.50
|
| Rate for Payer: Cigna Commercial |
$190.07
|
| Rate for Payer: First Health Commercial |
$217.55
|
| Rate for Payer: Humana Commercial |
$194.65
|
| Rate for Payer: Humana KY Medicaid |
$78.75
|
| Rate for Payer: Kentucky WC Medicaid |
$79.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$187.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$169.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$68.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$80.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$201.52
|
| Rate for Payer: Ohio Health Group HMO |
$171.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$45.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$70.99
|
| Rate for Payer: PHCS Commercial |
$219.84
|
| Rate for Payer: United Healthcare All Payer |
$201.52
|
|
|
TECHNETIUM TC99M DISOFENIN
|
Facility
|
IP
|
$229.00
|
|
|
Service Code
|
HCPCS A9510
|
| Hospital Charge Code |
34000051
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$29.77 |
| Max. Negotiated Rate |
$219.84 |
| Rate for Payer: Aetna Commercial |
$176.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$178.62
|
| Rate for Payer: Cash Price |
$114.50
|
| Rate for Payer: Cigna Commercial |
$190.07
|
| Rate for Payer: First Health Commercial |
$217.55
|
| Rate for Payer: Humana Commercial |
$194.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$187.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$169.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$68.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$201.52
|
| Rate for Payer: Ohio Health Group HMO |
$171.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$45.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$70.99
|
| Rate for Payer: PHCS Commercial |
$219.84
|
| Rate for Payer: United Healthcare All Payer |
$201.52
|
|
|
TECHNETIUM THYROID
|
Facility
|
OP
|
$748.00
|
|
|
Service Code
|
HCPCS 78013
|
| Hospital Charge Code |
34000001
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$97.24 |
| Max. Negotiated Rate |
$718.08 |
| Rate for Payer: Aetna Commercial |
$575.96
|
| Rate for Payer: Anthem Medicaid |
$257.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$356.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$583.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$499.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$481.49
|
| Rate for Payer: Cash Price |
$374.00
|
| Rate for Payer: Cash Price |
$374.00
|
| Rate for Payer: Cigna Commercial |
$620.84
|
| Rate for Payer: First Health Commercial |
$710.60
|
| Rate for Payer: Humana Commercial |
$635.80
|
| Rate for Payer: Humana KY Medicaid |
$257.24
|
| Rate for Payer: Humana Medicare Advantage |
$356.66
|
| Rate for Payer: Kentucky WC Medicaid |
$259.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$613.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$552.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$427.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$262.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$658.24
|
| Rate for Payer: Ohio Health Group HMO |
$561.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$149.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$231.88
|
| Rate for Payer: PHCS Commercial |
$718.08
|
| Rate for Payer: United Healthcare All Payer |
$658.24
|
|
|
TECHNETIUM THYROID
|
Professional
|
Both
|
$748.00
|
|
|
Service Code
|
HCPCS 78013
|
| Hospital Charge Code |
34000001
|
|
Hospital Revenue Code
|
340
|
| Min. Negotiated Rate |
$19.77 |
| Max. Negotiated Rate |
$748.00 |
| Rate for Payer: Anthem Medicaid |
$160.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$748.00
|
| Rate for Payer: Cash Price |
$374.00
|
| Rate for Payer: Cash Price |
$374.00
|
| Rate for Payer: Cigna Commercial |
$340.80
|
| Rate for Payer: Healthspan PPO |
$231.09
|
| Rate for Payer: Humana Medicaid |
$160.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$19.77
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$164.14
|
| Rate for Payer: Molina Healthcare Passport |
$160.92
|
| Rate for Payer: Multiplan PHCS |
$448.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$523.60
|
| Rate for Payer: UHCCP Medicaid |
$261.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$162.53
|
|
