|
TEGRETOL (CARBAMAZE 200MG/1TAB
|
Facility
|
OP
|
$4.61
|
|
|
Service Code
|
NDC 51672400501
|
| Hospital Charge Code |
25001496
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.43 |
| Rate for Payer: Aetna Commercial |
$3.55
|
| Rate for Payer: Anthem Medicaid |
$1.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: First Health Commercial |
$4.38
|
| Rate for Payer: Humana Commercial |
$3.92
|
| Rate for Payer: Humana KY Medicaid |
$1.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.06
|
| Rate for Payer: Ohio Health Group HMO |
$3.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.43
|
| Rate for Payer: PHCS Commercial |
$4.43
|
| Rate for Payer: United Healthcare All Payer |
$4.06
|
|
|
TEGRETOL(CARBAMAZEP 200MG/10ML
|
Facility
|
IP
|
$9.57
|
|
|
Service Code
|
NDC 70954024010
|
| Hospital Charge Code |
25001502
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$9.19 |
| Rate for Payer: Aetna Commercial |
$7.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.46
|
| Rate for Payer: Cash Price |
$4.78
|
| Rate for Payer: Cigna Commercial |
$7.94
|
| Rate for Payer: First Health Commercial |
$9.09
|
| Rate for Payer: Humana Commercial |
$8.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.42
|
| Rate for Payer: Ohio Health Group HMO |
$7.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.97
|
| Rate for Payer: PHCS Commercial |
$9.19
|
| Rate for Payer: United Healthcare All Payer |
$8.42
|
|
|
TEGRETOL(CARBAMAZEP 200MG/10ML
|
Facility
|
OP
|
$9.57
|
|
|
Service Code
|
NDC 70954024010
|
| Hospital Charge Code |
25001502
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$9.19 |
| Rate for Payer: Aetna Commercial |
$7.37
|
| Rate for Payer: Anthem Medicaid |
$3.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.46
|
| Rate for Payer: Cash Price |
$4.78
|
| Rate for Payer: Cigna Commercial |
$7.94
|
| Rate for Payer: First Health Commercial |
$9.09
|
| Rate for Payer: Humana Commercial |
$8.13
|
| Rate for Payer: Humana KY Medicaid |
$3.29
|
| Rate for Payer: Kentucky WC Medicaid |
$3.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.42
|
| Rate for Payer: Ohio Health Group HMO |
$7.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.97
|
| Rate for Payer: PHCS Commercial |
$9.19
|
| Rate for Payer: United Healthcare All Payer |
$8.42
|
|
|
TEKTURNA 150MG TABLET
|
Facility
|
IP
|
$22.54
|
|
|
Service Code
|
NDC 49884042411
|
| Hospital Charge Code |
25001503
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.93 |
| Max. Negotiated Rate |
$21.64 |
| Rate for Payer: Aetna Commercial |
$17.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.58
|
| Rate for Payer: Cash Price |
$11.27
|
| Rate for Payer: Cigna Commercial |
$18.71
|
| Rate for Payer: First Health Commercial |
$21.41
|
| Rate for Payer: Humana Commercial |
$19.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.84
|
| Rate for Payer: Ohio Health Group HMO |
$16.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.99
|
| Rate for Payer: PHCS Commercial |
$21.64
|
| Rate for Payer: United Healthcare All Payer |
$19.84
|
|
|
TEKTURNA 150MG TABLET
|
Facility
|
OP
|
$22.54
|
|
|
Service Code
|
NDC 49884042411
|
| Hospital Charge Code |
25001503
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.93 |
| Max. Negotiated Rate |
$21.64 |
| Rate for Payer: Aetna Commercial |
$17.36
|
| Rate for Payer: Anthem Medicaid |
$7.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.58
|
| Rate for Payer: Cash Price |
$11.27
|
| Rate for Payer: Cigna Commercial |
$18.71
|
| Rate for Payer: First Health Commercial |
$21.41
|
| Rate for Payer: Humana Commercial |
$19.16
|
| Rate for Payer: Humana KY Medicaid |
$7.75
|
| Rate for Payer: Kentucky WC Medicaid |
$7.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.84
|
| Rate for Payer: Ohio Health Group HMO |
$16.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.99
|
| Rate for Payer: PHCS Commercial |
$21.64
|
| Rate for Payer: United Healthcare All Payer |
$19.84
|
|
|
TELEHEALTH FACIITY FEE
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
HCPCS Q3014
|
| Hospital Charge Code |
45000337
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$6.50 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna Commercial |
$38.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$41.50
|
| Rate for Payer: First Health Commercial |
$47.50
|
| Rate for Payer: Humana Commercial |
$42.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$41.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$36.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.00
|
| Rate for Payer: Ohio Health Group HMO |
$37.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.50
|
| Rate for Payer: PHCS Commercial |
$48.00
|
| Rate for Payer: United Healthcare All Payer |
$44.00
|
|
|
TELEHEALTH FACIITY FEE
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
HCPCS Q3014
|
| Hospital Charge Code |
45000337
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$6.50 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna Commercial |
$38.50
|
| Rate for Payer: Anthem Medicaid |
$17.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$41.50
|
| Rate for Payer: First Health Commercial |
$47.50
|
| Rate for Payer: Humana Commercial |
$42.50
|
| Rate for Payer: Humana KY Medicaid |
$17.20
|
| Rate for Payer: Kentucky WC Medicaid |
$17.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$41.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$36.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$17.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.00
|
| Rate for Payer: Ohio Health Group HMO |
$37.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.50
|
| Rate for Payer: PHCS Commercial |
$48.00
|
| Rate for Payer: United Healthcare All Payer |
$44.00
|
|
|
TELEHEALTH LEVEL 1
|
Professional
|
Both
|
$215.00
|
|
|
Service Code
|
HCPCS 99211
|
| Hospital Charge Code |
51000168
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$5.88 |
| Max. Negotiated Rate |
$215.00 |
| Rate for Payer: Aetna Commercial |
$13.74
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$5.88
|
| Rate for Payer: Anthem Medicaid |
$7.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$215.00
|
| Rate for Payer: Cash Price |
$107.50
|
| Rate for Payer: Cash Price |
$107.50
|
| Rate for Payer: Cigna Commercial |
$29.84
|
| Rate for Payer: Healthspan PPO |
$21.35
|
| Rate for Payer: Humana Medicaid |
$7.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$12.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$7.63
|
| Rate for Payer: Molina Healthcare Passport |
$7.48
|
| Rate for Payer: Multiplan PHCS |
$129.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$150.50
|
| Rate for Payer: UHCCP Medicaid |
$6.17
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$7.55
|
|
|
TELEHEALTH LEVEL 2
|
Professional
|
Both
|
$315.00
|
|
|
Service Code
|
HCPCS 99212
|
| Hospital Charge Code |
51000169
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$18.34 |
| Max. Negotiated Rate |
$315.00 |
| Rate for Payer: Aetna Commercial |
$36.67
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$18.34
|
| Rate for Payer: Anthem Medicaid |
$20.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$315.00
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cigna Commercial |
$55.08
|
| Rate for Payer: Healthspan PPO |
$42.78
|
| Rate for Payer: Humana Medicaid |
$20.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$34.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$20.82
|
| Rate for Payer: Molina Healthcare Passport |
$20.41
|
| Rate for Payer: Multiplan PHCS |
$189.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$220.50
|
| Rate for Payer: UHCCP Medicaid |
$19.26
|
| Rate for Payer: United Healthcare Non-Options |
$25.26
|
| Rate for Payer: United Healthcare Options |
$20.67
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.61
|
|
|
TELEHEALTH LEVEL 3
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
HCPCS 99213
|
| Hospital Charge Code |
51000170
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$33.74 |
| Max. Negotiated Rate |
$350.00 |
| Rate for Payer: Aetna Commercial |
$70.77
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$33.74
|
| Rate for Payer: Anthem Medicaid |
$40.36
|
| 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 |
$89.85
|
| Rate for Payer: Healthspan PPO |
$70.91
|
| Rate for Payer: Humana Medicaid |
$40.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$65.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$41.17
|
| Rate for Payer: Molina Healthcare Passport |
$40.36
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$245.00
|
| Rate for Payer: UHCCP Medicaid |
$35.43
|
| Rate for Payer: United Healthcare Non-Options |
$48.74
|
| Rate for Payer: United Healthcare Options |
$39.90
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$40.76
|
|
|
TELEHEALTH LEVEL 4
|
Professional
|
Both
|
$440.00
|
|
|
Service Code
|
HCPCS 99214
|
| Hospital Charge Code |
51000171
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$49.49 |
| Max. Negotiated Rate |
$440.00 |
| Rate for Payer: Aetna Commercial |
$109.62
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$49.49
|
| Rate for Payer: Anthem Medicaid |
$61.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$440.00
|
| Rate for Payer: Cash Price |
$220.00
|
| Rate for Payer: Cash Price |
$220.00
|
| Rate for Payer: Cigna Commercial |
$136.31
|
| Rate for Payer: Healthspan PPO |
$106.96
|
| Rate for Payer: Humana Medicaid |
$61.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$89.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$63.22
|
| Rate for Payer: Molina Healthcare Passport |
$61.98
|
| Rate for Payer: Multiplan PHCS |
$264.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$308.00
|
| Rate for Payer: UHCCP Medicaid |
$51.96
|
| Rate for Payer: United Healthcare Non-Options |
$75.50
|
| Rate for Payer: United Healthcare Options |
$61.81
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$62.60
|
|
|
TELEHEALTH LEVEL 5
|
Professional
|
Both
|
$550.00
|
|
|
Service Code
|
HCPCS 99215
|
| Hospital Charge Code |
51000172
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$73.54 |
| Max. Negotiated Rate |
$550.00 |
| Rate for Payer: Aetna Commercial |
$155.95
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$73.54
|
| Rate for Payer: Anthem Medicaid |
$87.17
|
| Rate for Payer: Buckeye Medicare Advantage |
$550.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$184.70
|
| Rate for Payer: Healthspan PPO |
$144.98
|
| Rate for Payer: Humana Medicaid |
$87.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$145.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$88.91
|
| Rate for Payer: Molina Healthcare Passport |
$87.17
|
| Rate for Payer: Multiplan PHCS |
$330.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$385.00
|
| Rate for Payer: UHCCP Medicaid |
$77.22
|
| Rate for Payer: United Healthcare Non-Options |
$107.40
|
| Rate for Payer: United Healthcare Options |
$87.92
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$88.04
|
|
|
TELEHEALTH PSYCH 30MIN W/PT EV
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 90833
|
| Hospital Charge Code |
90000022
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$36.85 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Aetna Commercial |
$101.60
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$36.85
|
| Rate for Payer: Anthem Medicaid |
$48.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$300.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$61.81
|
| Rate for Payer: Healthspan PPO |
$37.00
|
| Rate for Payer: Humana Medicaid |
$48.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$87.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$49.07
|
| Rate for Payer: Molina Healthcare Passport |
$48.11
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$210.00
|
| Rate for Payer: UHCCP Medicaid |
$38.69
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$48.59
|
|
|
TELEHEALTH PSYCH 60 MIN PT/FAM
|
Professional
|
Both
|
$515.00
|
|
|
Service Code
|
HCPCS 90837
|
| Hospital Charge Code |
90000023
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$75.77 |
| Max. Negotiated Rate |
$515.00 |
| Rate for Payer: Aetna Commercial |
$207.93
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$75.77
|
| Rate for Payer: Anthem Medicaid |
$93.67
|
| Rate for Payer: Buckeye Medicare Advantage |
$515.00
|
| Rate for Payer: Cash Price |
$257.50
|
| Rate for Payer: Cash Price |
$257.50
|
| Rate for Payer: Cigna Commercial |
$175.91
|
| Rate for Payer: Healthspan PPO |
$165.72
|
| Rate for Payer: Humana Medicaid |
$93.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$152.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$95.54
|
| Rate for Payer: Molina Healthcare Passport |
$93.67
|
| Rate for Payer: Multiplan PHCS |
$309.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$360.50
|
| Rate for Payer: UHCCP Medicaid |
$79.56
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$94.61
|
|
|
TELEHEALTH PSYCH DIAG INTERV
|
Professional
|
Both
|
$570.32
|
|
|
Service Code
|
HCPCS 90791
|
| Hospital Charge Code |
90000021
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$77.14 |
| Max. Negotiated Rate |
$570.32 |
| Rate for Payer: Aetna Commercial |
$213.04
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$77.14
|
| Rate for Payer: Anthem Medicaid |
$94.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$570.32
|
| Rate for Payer: Cash Price |
$285.16
|
| Rate for Payer: Cash Price |
$285.16
|
| Rate for Payer: Cigna Commercial |
$221.80
|
| Rate for Payer: Healthspan PPO |
$132.37
|
| Rate for Payer: Humana Medicaid |
$94.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$177.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$96.74
|
| Rate for Payer: Molina Healthcare Passport |
$94.84
|
| Rate for Payer: Multiplan PHCS |
$342.19
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$399.22
|
| Rate for Payer: UHCCP Medicaid |
$81.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$95.79
|
|
|
TELEHEALTH PSYCH TX W PT 45MIN
|
Professional
|
Both
|
$406.47
|
|
|
Service Code
|
HCPCS 90834
|
| Hospital Charge Code |
90000024
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$49.43 |
| Max. Negotiated Rate |
$406.47 |
| Rate for Payer: Aetna Commercial |
$138.25
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$49.43
|
| Rate for Payer: Anthem Medicaid |
$62.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$406.47
|
| Rate for Payer: Cash Price |
$203.24
|
| Rate for Payer: Cash Price |
$203.24
|
| Rate for Payer: Cigna Commercial |
$120.00
|
| Rate for Payer: Healthspan PPO |
$112.63
|
| Rate for Payer: Humana Medicaid |
$62.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$103.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$63.91
|
| Rate for Payer: Molina Healthcare Passport |
$62.66
|
| Rate for Payer: Multiplan PHCS |
$243.88
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$284.53
|
| Rate for Payer: UHCCP Medicaid |
$51.90
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$63.29
|
|
|
TELEH NURSING FAC CARE SUBSQNT
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
HCPCS 99310
|
| Hospital Charge Code |
51000178
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$61.25 |
| Max. Negotiated Rate |
$187.39 |
| Rate for Payer: Aetna Commercial |
$187.39
|
| Rate for Payer: Anthem Medicaid |
$74.49
|
| Rate for Payer: Buckeye Medicare Advantage |
$175.00
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cigna Commercial |
$140.89
|
| Rate for Payer: Healthspan PPO |
$139.30
|
| Rate for Payer: Humana Medicaid |
$74.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$172.41
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$75.98
|
| Rate for Payer: Molina Healthcare Passport |
$74.49
|
| Rate for Payer: Multiplan PHCS |
$105.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$122.50
|
| Rate for Payer: UHCCP Medicaid |
$61.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$75.23
|
|
|
TELEH NURSING FAC CARE SUBSQNT
|
Professional
|
Both
|
$294.30
|
|
|
Service Code
|
HCPCS 99309
|
| Hospital Charge Code |
51000177
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$59.51 |
| Max. Negotiated Rate |
$294.30 |
| Rate for Payer: Aetna Commercial |
$126.94
|
| Rate for Payer: Anthem Medicaid |
$59.51
|
| Rate for Payer: Buckeye Medicare Advantage |
$294.30
|
| Rate for Payer: Cash Price |
$147.15
|
| Rate for Payer: Cash Price |
$147.15
|
| Rate for Payer: Cigna Commercial |
$112.61
|
| Rate for Payer: Healthspan PPO |
$94.37
|
| Rate for Payer: Humana Medicaid |
$59.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$116.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$60.70
|
| Rate for Payer: Molina Healthcare Passport |
$59.51
|
| Rate for Payer: Multiplan PHCS |
$176.58
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$206.01
|
| Rate for Payer: UHCCP Medicaid |
$103.00
|
| Rate for Payer: United Healthcare Non-Options |
$87.43
|
| Rate for Payer: United Healthcare Options |
$71.57
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$60.11
|
|
|
TELEH PREVENT VISIT - 12-17 YR
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
HCPCS 99394
|
| Hospital Charge Code |
51000175
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.91 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Aetna Commercial |
$107.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$42.91
|
| Rate for Payer: Anthem Medicaid |
$68.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$235.00
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$134.42
|
| Rate for Payer: Healthspan PPO |
$111.74
|
| Rate for Payer: Humana Medicaid |
$68.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$90.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$69.63
|
| Rate for Payer: Molina Healthcare Passport |
$68.26
|
| Rate for Payer: Multiplan PHCS |
$141.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$164.50
|
| Rate for Payer: UHCCP Medicaid |
$45.06
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$68.94
|
|
|
TELEH PREVENT VISIT - 18-39 YR
|
Professional
|
Both
|
$377.50
|
|
|
Service Code
|
HCPCS 99395
|
| Hospital Charge Code |
51000176
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$44.13 |
| Max. Negotiated Rate |
$377.50 |
| Rate for Payer: Aetna Commercial |
$107.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$44.13
|
| Rate for Payer: Anthem Medicaid |
$70.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$377.50
|
| Rate for Payer: Cash Price |
$188.75
|
| Rate for Payer: Cash Price |
$188.75
|
| Rate for Payer: Cigna Commercial |
$135.52
|
| Rate for Payer: Healthspan PPO |
$111.74
|
| Rate for Payer: Humana Medicaid |
$70.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$90.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$71.62
|
| Rate for Payer: Molina Healthcare Passport |
$70.22
|
| Rate for Payer: Multiplan PHCS |
$226.50
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$264.25
|
| Rate for Payer: UHCCP Medicaid |
$46.34
|
| Rate for Payer: United Healthcare Non-Options |
$73.86
|
| Rate for Payer: United Healthcare Options |
$60.46
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$70.92
|
|
|
TELEH PSYCHOTHERAPY 30MIN W/PT
|
Professional
|
Both
|
$288.00
|
|
|
Service Code
|
HCPCS 90832
|
| Hospital Charge Code |
90000025
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$35.58 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: Aetna Commercial |
$90.22
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$35.58
|
| Rate for Payer: Anthem Medicaid |
$46.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$288.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cigna Commercial |
$92.42
|
| Rate for Payer: Healthspan PPO |
$80.30
|
| Rate for Payer: Humana Medicaid |
$46.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$76.56
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$47.88
|
| Rate for Payer: Molina Healthcare Passport |
$46.94
|
| Rate for Payer: Multiplan PHCS |
$172.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$201.60
|
| Rate for Payer: UHCCP Medicaid |
$37.36
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$47.41
|
|
|
TELEH SMOKE TOBAC CESS 3-10MIN
|
Professional
|
Both
|
$66.00
|
|
|
Service Code
|
HCPCS 99406
|
| Hospital Charge Code |
94200016
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$7.72 |
| Max. Negotiated Rate |
$66.00 |
| Rate for Payer: Aetna Commercial |
$18.31
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$7.72
|
| Rate for Payer: Anthem Medicaid |
$9.77
|
| Rate for Payer: Buckeye Medicare Advantage |
$66.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$18.48
|
| Rate for Payer: Healthspan PPO |
$15.98
|
| Rate for Payer: Humana Medicaid |
$9.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$16.22
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$9.97
|
| Rate for Payer: Molina Healthcare Passport |
$9.77
|
| Rate for Payer: Multiplan PHCS |
$39.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$46.20
|
| Rate for Payer: UHCCP Medicaid |
$8.11
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$9.87
|
|
|
TELEH SMOKE TOBAC CESS 3-10MIN
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
HCPCS 99406
|
| Hospital Charge Code |
94200016
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$63.36 |
| Rate for Payer: Aetna Commercial |
$50.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.48
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$54.78
|
| Rate for Payer: First Health Commercial |
$62.70
|
| Rate for Payer: Humana Commercial |
$56.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.08
|
| Rate for Payer: Ohio Health Group HMO |
$49.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.46
|
| Rate for Payer: PHCS Commercial |
$63.36
|
| Rate for Payer: United Healthcare All Payer |
$58.08
|
|
|
TELEH SMOKE TOBAC CESS 3-10MIN
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
HCPCS 99406
|
| Hospital Charge Code |
94200016
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$63.36 |
| Rate for Payer: Aetna Commercial |
$50.82
|
| Rate for Payer: Anthem Medicaid |
$22.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$24.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$34.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$33.49
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$54.78
|
| Rate for Payer: First Health Commercial |
$62.70
|
| Rate for Payer: Humana Commercial |
$56.10
|
| Rate for Payer: Humana KY Medicaid |
$22.70
|
| Rate for Payer: Humana Medicare Advantage |
$24.81
|
| Rate for Payer: Kentucky WC Medicaid |
$22.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.08
|
| Rate for Payer: Ohio Health Group HMO |
$49.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.46
|
| Rate for Payer: PHCS Commercial |
$63.36
|
| Rate for Payer: United Healthcare All Payer |
$58.08
|
|
|
TELEPH E&M BY PHY/QHP 5-10 MIN
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
HCPCS 99441
|
| Hospital Charge Code |
51000022
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$10.40 |
| Max. Negotiated Rate |
$76.80 |
| Rate for Payer: Aetna Commercial |
$61.60
|
| Rate for Payer: Anthem Medicaid |
$27.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.40
|
| Rate for Payer: Cash Price |
$40.00
|
| Rate for Payer: Cigna Commercial |
$66.40
|
| Rate for Payer: First Health Commercial |
$76.00
|
| Rate for Payer: Humana Commercial |
$68.00
|
| Rate for Payer: Humana KY Medicaid |
$27.51
|
| Rate for Payer: Kentucky WC Medicaid |
$27.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.40
|
| Rate for Payer: Ohio Health Group HMO |
$60.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.80
|
| Rate for Payer: PHCS Commercial |
$76.80
|
| Rate for Payer: United Healthcare All Payer |
$70.40
|
|
