|
TERAZOL 3 (TERCONAZOL 80MG/1EA
|
Facility
|
OP
|
$65.21
|
|
|
Service Code
|
NDC 713055273
|
| Hospital Charge Code |
25001510
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.48 |
| Max. Negotiated Rate |
$62.60 |
| Rate for Payer: Aetna Commercial |
$50.21
|
| Rate for Payer: Anthem Medicaid |
$22.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.86
|
| Rate for Payer: Cash Price |
$32.60
|
| Rate for Payer: Cigna Commercial |
$54.12
|
| Rate for Payer: First Health Commercial |
$61.95
|
| Rate for Payer: Humana Commercial |
$55.43
|
| Rate for Payer: Humana KY Medicaid |
$22.43
|
| Rate for Payer: Kentucky WC Medicaid |
$22.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.38
|
| Rate for Payer: Ohio Health Group HMO |
$48.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.22
|
| Rate for Payer: PHCS Commercial |
$62.60
|
| Rate for Payer: United Healthcare All Payer |
$57.38
|
|
|
TERAZOL 7(TERCONAZOLE)VAG 45GM
|
Facility
|
OP
|
$26.72
|
|
|
Service Code
|
NDC 51672130406
|
| Hospital Charge Code |
25001511
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.47 |
| Max. Negotiated Rate |
$25.65 |
| Rate for Payer: Aetna Commercial |
$20.57
|
| Rate for Payer: Anthem Medicaid |
$9.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.84
|
| Rate for Payer: Cash Price |
$13.36
|
| Rate for Payer: Cigna Commercial |
$22.18
|
| Rate for Payer: First Health Commercial |
$25.38
|
| Rate for Payer: Humana Commercial |
$22.71
|
| Rate for Payer: Humana KY Medicaid |
$9.19
|
| Rate for Payer: Kentucky WC Medicaid |
$9.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.51
|
| Rate for Payer: Ohio Health Group HMO |
$20.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.28
|
| Rate for Payer: PHCS Commercial |
$25.65
|
| Rate for Payer: United Healthcare All Payer |
$23.51
|
|
|
TERAZOL 7(TERCONAZOLE)VAG 45GM
|
Facility
|
IP
|
$26.72
|
|
|
Service Code
|
NDC 51672130406
|
| Hospital Charge Code |
25001511
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.47 |
| Max. Negotiated Rate |
$25.65 |
| Rate for Payer: Aetna Commercial |
$20.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.84
|
| Rate for Payer: Cash Price |
$13.36
|
| Rate for Payer: Cigna Commercial |
$22.18
|
| Rate for Payer: First Health Commercial |
$25.38
|
| Rate for Payer: Humana Commercial |
$22.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.51
|
| Rate for Payer: Ohio Health Group HMO |
$20.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.28
|
| Rate for Payer: PHCS Commercial |
$25.65
|
| Rate for Payer: United Healthcare All Payer |
$23.51
|
|
|
TESSALON PERLES (BE 100MG/1CAP
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
NDC 69452014320
|
| Hospital Charge Code |
25001512
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
TESSALON PERLES (BE 100MG/1CAP
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
NDC 69452014320
|
| Hospital Charge Code |
25001512
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
TESTES PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$24,834.10
|
|
|
Service Code
|
MSDRG 711
|
| Min. Negotiated Rate |
$16,851.71 |
| Max. Negotiated Rate |
$24,834.10 |
| Rate for Payer: Anthem Medicaid |
$16,851.71
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$17,738.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$24,834.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$23,947.16
|
| Rate for Payer: Humana KY Medicaid |
$16,851.71
|
| Rate for Payer: Humana Medicare Advantage |
$17,738.64
|
| Rate for Payer: Kentucky WC Medicaid |
$17,020.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,286.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$17,188.74
|
|
|
TESTES PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$13,902.14
|
|
|
Service Code
|
MSDRG 712
|
| Min. Negotiated Rate |
$9,433.60 |
| Max. Negotiated Rate |
$13,902.14 |
| Rate for Payer: Anthem Medicaid |
$9,433.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9,930.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13,902.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$13,405.64
|
| Rate for Payer: Humana KY Medicaid |
$9,433.60
|
| Rate for Payer: Humana Medicare Advantage |
$9,930.10
|
| Rate for Payer: Kentucky WC Medicaid |
$9,527.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,916.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,622.27
|
|
|
TESTICLES ULTRASOUND
|
Professional
|
Both
|
$943.00
|
|
|
Service Code
|
HCPCS 76870
|
| Hospital Charge Code |
40200051
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$41.12 |
| Max. Negotiated Rate |
$943.00 |
| Rate for Payer: Aetna Commercial |
$181.61
|
| Rate for Payer: Anthem Medicaid |
$68.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$943.00
|
| Rate for Payer: Cash Price |
$471.50
|
| Rate for Payer: Cash Price |
$471.50
|
| Rate for Payer: Cigna Commercial |
$150.23
|
| Rate for Payer: Healthspan PPO |
$170.18
|
| Rate for Payer: Humana Medicaid |
$68.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$41.12
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$70.23
|
| Rate for Payer: Molina Healthcare Passport |
$68.85
|
| Rate for Payer: Multiplan PHCS |
$565.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$660.10
|
| Rate for Payer: UHCCP Medicaid |
$330.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$69.54
|
|
|
TESTICLES ULTRASOUND
|
Facility
|
IP
|
$943.00
|
|
|
Service Code
|
HCPCS 76870
|
| Hospital Charge Code |
40200051
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$122.59 |
| Max. Negotiated Rate |
$905.28 |
| Rate for Payer: Aetna Commercial |
$726.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$735.54
|
| Rate for Payer: Cash Price |
$471.50
|
| Rate for Payer: Cigna Commercial |
$782.69
|
| Rate for Payer: First Health Commercial |
$895.85
|
| Rate for Payer: Humana Commercial |
$801.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$773.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$695.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$282.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$829.84
|
| Rate for Payer: Ohio Health Group HMO |
$707.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$188.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$122.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$292.33
|
| Rate for Payer: PHCS Commercial |
$905.28
|
| Rate for Payer: United Healthcare All Payer |
$829.84
|
|
|
TESTICLES ULTRASOUND
|
Facility
|
OP
|
$943.00
|
|
|
Service Code
|
HCPCS 76870
|
| Hospital Charge Code |
40200051
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$905.28 |
| Rate for Payer: Aetna Commercial |
$726.11
|
| Rate for Payer: Anthem Medicaid |
$324.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$735.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$471.50
|
| Rate for Payer: Cash Price |
$471.50
|
| Rate for Payer: Cigna Commercial |
$782.69
|
| Rate for Payer: First Health Commercial |
$895.85
|
| Rate for Payer: Humana Commercial |
$801.55
|
| Rate for Payer: Humana KY Medicaid |
$324.30
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$327.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$773.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$695.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$330.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$829.84
|
| Rate for Payer: Ohio Health Group HMO |
$707.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$188.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$122.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$292.33
|
| Rate for Payer: PHCS Commercial |
$905.28
|
| Rate for Payer: United Healthcare All Payer |
$829.84
|
|
|
TESTICLES ULTRASOUND(P
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 76870
|
| Hospital Charge Code |
402P0051
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$41.12 |
| Max. Negotiated Rate |
$181.61 |
| Rate for Payer: Aetna Commercial |
$181.61
|
| Rate for Payer: Anthem Medicaid |
$68.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$125.00
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$150.23
|
| Rate for Payer: Healthspan PPO |
$170.18
|
| Rate for Payer: Humana Medicaid |
$68.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$41.12
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$70.23
|
| Rate for Payer: Molina Healthcare Passport |
$68.85
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.50
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$69.54
|
|
|
TESTICLES ULTRASOUND(T
|
Facility
|
OP
|
$818.00
|
|
|
Service Code
|
HCPCS 76870
|
| Hospital Charge Code |
402T0051
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$785.28 |
| Rate for Payer: Aetna Commercial |
$629.86
|
| Rate for Payer: Anthem Medicaid |
$281.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$638.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$409.00
|
| Rate for Payer: Cash Price |
$409.00
|
| Rate for Payer: Cigna Commercial |
$678.94
|
| Rate for Payer: First Health Commercial |
$777.10
|
| Rate for Payer: Humana Commercial |
$695.30
|
| Rate for Payer: Humana KY Medicaid |
$281.31
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$284.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$670.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$603.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$286.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$719.84
|
| Rate for Payer: Ohio Health Group HMO |
$613.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$163.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$253.58
|
| Rate for Payer: PHCS Commercial |
$785.28
|
| Rate for Payer: United Healthcare All Payer |
$719.84
|
|
|
TESTICLES ULTRASOUND(T
|
Facility
|
IP
|
$818.00
|
|
|
Service Code
|
HCPCS 76870
|
| Hospital Charge Code |
402T0051
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$106.34 |
| Max. Negotiated Rate |
$785.28 |
| Rate for Payer: Aetna Commercial |
$629.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$638.04
|
| Rate for Payer: Cash Price |
$409.00
|
| Rate for Payer: Cigna Commercial |
$678.94
|
| Rate for Payer: First Health Commercial |
$777.10
|
| Rate for Payer: Humana Commercial |
$695.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$670.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$603.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$245.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$719.84
|
| Rate for Payer: Ohio Health Group HMO |
$613.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$163.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$253.58
|
| Rate for Payer: PHCS Commercial |
$785.28
|
| Rate for Payer: United Healthcare All Payer |
$719.84
|
|
|
TESTOSTERONE 100MG PELLET
|
Professional
|
Both
|
$129.05
|
|
|
Service Code
|
HCPCS J7999
|
| Hospital Charge Code |
63600225
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.17 |
| Max. Negotiated Rate |
$129.05 |
| Rate for Payer: Buckeye Medicare Advantage |
$129.05
|
| Rate for Payer: Cash Price |
$64.53
|
| Rate for Payer: Multiplan PHCS |
$77.43
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$90.34
|
| Rate for Payer: UHCCP Medicaid |
$45.17
|
|
|
TESTOSTERONE 100MG PELLET
|
Facility
|
OP
|
$129.05
|
|
|
Service Code
|
HCPCS J7999
|
| Hospital Charge Code |
63600225
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.78 |
| Max. Negotiated Rate |
$123.89 |
| Rate for Payer: Aetna Commercial |
$99.37
|
| Rate for Payer: Anthem Medicaid |
$44.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$100.66
|
| Rate for Payer: Cash Price |
$64.53
|
| Rate for Payer: Cigna Commercial |
$107.11
|
| Rate for Payer: First Health Commercial |
$122.60
|
| Rate for Payer: Humana Commercial |
$109.69
|
| Rate for Payer: Humana KY Medicaid |
$44.38
|
| Rate for Payer: Kentucky WC Medicaid |
$44.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$105.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$45.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$113.56
|
| Rate for Payer: Ohio Health Group HMO |
$96.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.01
|
| Rate for Payer: PHCS Commercial |
$123.89
|
| Rate for Payer: United Healthcare All Payer |
$113.56
|
|
|
TESTOSTERONE 100MG PELLET
|
Facility
|
OP
|
$129.05
|
|
|
Service Code
|
HCPCS J7999
|
| Hospital Charge Code |
636T0225
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.78 |
| Max. Negotiated Rate |
$123.89 |
| Rate for Payer: Aetna Commercial |
$99.37
|
| Rate for Payer: Anthem Medicaid |
$44.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$100.66
|
| Rate for Payer: Cash Price |
$64.53
|
| Rate for Payer: Cigna Commercial |
$107.11
|
| Rate for Payer: First Health Commercial |
$122.60
|
| Rate for Payer: Humana Commercial |
$109.69
|
| Rate for Payer: Humana KY Medicaid |
$44.38
|
| Rate for Payer: Kentucky WC Medicaid |
$44.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$105.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$45.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$113.56
|
| Rate for Payer: Ohio Health Group HMO |
$96.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.01
|
| Rate for Payer: PHCS Commercial |
$123.89
|
| Rate for Payer: United Healthcare All Payer |
$113.56
|
|
|
TESTOSTERONE 100MG PELLET
|
Facility
|
IP
|
$129.05
|
|
|
Service Code
|
HCPCS J7999
|
| Hospital Charge Code |
636T0225
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.78 |
| Max. Negotiated Rate |
$123.89 |
| Rate for Payer: Aetna Commercial |
$99.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$100.66
|
| Rate for Payer: Cash Price |
$64.53
|
| Rate for Payer: Cigna Commercial |
$107.11
|
| Rate for Payer: First Health Commercial |
$122.60
|
| Rate for Payer: Humana Commercial |
$109.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$105.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$113.56
|
| Rate for Payer: Ohio Health Group HMO |
$96.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.01
|
| Rate for Payer: PHCS Commercial |
$123.89
|
| Rate for Payer: United Healthcare All Payer |
$113.56
|
|
|
TESTOSTERONE 100MG PELLET
|
Facility
|
IP
|
$129.05
|
|
|
Service Code
|
HCPCS J7999
|
| Hospital Charge Code |
63600225
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.78 |
| Max. Negotiated Rate |
$123.89 |
| Rate for Payer: Aetna Commercial |
$99.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$100.66
|
| Rate for Payer: Cash Price |
$64.53
|
| Rate for Payer: Cigna Commercial |
$107.11
|
| Rate for Payer: First Health Commercial |
$122.60
|
| Rate for Payer: Humana Commercial |
$109.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$105.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$113.56
|
| Rate for Payer: Ohio Health Group HMO |
$96.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.01
|
| Rate for Payer: PHCS Commercial |
$123.89
|
| Rate for Payer: United Healthcare All Payer |
$113.56
|
|
|
TESTOSTERONE CYP 1mg(200mgSDV)
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
63600028
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Aetna Commercial |
$0.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.37
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna Commercial |
$0.39
|
| Rate for Payer: First Health Commercial |
$0.45
|
| Rate for Payer: Humana Commercial |
$0.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.41
|
| Rate for Payer: Ohio Health Group HMO |
$0.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.15
|
| Rate for Payer: PHCS Commercial |
$0.45
|
| Rate for Payer: United Healthcare All Payer |
$0.41
|
|
|
TESTOSTERONE CYP 1mg(200mgSDV)
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
636T0028
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Aetna Commercial |
$0.36
|
| Rate for Payer: Anthem Medicaid |
$0.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.37
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna Commercial |
$0.39
|
| Rate for Payer: First Health Commercial |
$0.45
|
| Rate for Payer: Humana Commercial |
$0.40
|
| Rate for Payer: Humana KY Medicaid |
$0.16
|
| Rate for Payer: Kentucky WC Medicaid |
$0.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.41
|
| Rate for Payer: Ohio Health Group HMO |
$0.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.15
|
| Rate for Payer: PHCS Commercial |
$0.45
|
| Rate for Payer: United Healthcare All Payer |
$0.41
|
|
|
TESTOSTERONE CYP 1mg(200mgSDV)
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
63600028
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Aetna Commercial |
$0.36
|
| Rate for Payer: Anthem Medicaid |
$0.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.37
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna Commercial |
$0.39
|
| Rate for Payer: First Health Commercial |
$0.45
|
| Rate for Payer: Humana Commercial |
$0.40
|
| Rate for Payer: Humana KY Medicaid |
$0.16
|
| Rate for Payer: Kentucky WC Medicaid |
$0.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.41
|
| Rate for Payer: Ohio Health Group HMO |
$0.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.15
|
| Rate for Payer: PHCS Commercial |
$0.45
|
| Rate for Payer: United Healthcare All Payer |
$0.41
|
|
|
TESTOSTERONE CYP 1mg(200mgSDV)
|
Professional
|
Both
|
$0.47
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
63600028
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna Commercial |
$0.04
|
| Rate for Payer: Buckeye Medicare Advantage |
$0.47
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$0.04
|
| Rate for Payer: Multiplan PHCS |
$0.28
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$0.33
|
| Rate for Payer: UHCCP Medicaid |
$0.16
|
|
|
TESTOSTERONE CYP 1mg(200mgSDV)
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
636T0028
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Aetna Commercial |
$0.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.37
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna Commercial |
$0.39
|
| Rate for Payer: First Health Commercial |
$0.45
|
| Rate for Payer: Humana Commercial |
$0.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.41
|
| Rate for Payer: Ohio Health Group HMO |
$0.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.15
|
| Rate for Payer: PHCS Commercial |
$0.45
|
| Rate for Payer: United Healthcare All Payer |
$0.41
|
|
|
TESTOSTERONE CYP 1mg(200mgSDV)
|
Facility
|
IP
|
$98.79
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
25002011
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.84 |
| Max. Negotiated Rate |
$94.84 |
| Rate for Payer: Aetna Commercial |
$76.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$77.06
|
| Rate for Payer: Cash Price |
$49.40
|
| Rate for Payer: Cigna Commercial |
$82.00
|
| Rate for Payer: First Health Commercial |
$93.85
|
| Rate for Payer: Humana Commercial |
$83.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$81.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.94
|
| Rate for Payer: Ohio Health Group HMO |
$74.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.62
|
| Rate for Payer: PHCS Commercial |
$94.84
|
| Rate for Payer: United Healthcare All Payer |
$86.94
|
|
|
TESTOSTERONE CYP 1mg(200mgSDV)
|
Facility
|
OP
|
$98.79
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
25002011
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.84 |
| Max. Negotiated Rate |
$94.84 |
| Rate for Payer: Aetna Commercial |
$76.07
|
| Rate for Payer: Anthem Medicaid |
$33.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$77.06
|
| Rate for Payer: Cash Price |
$49.40
|
| Rate for Payer: Cigna Commercial |
$82.00
|
| Rate for Payer: First Health Commercial |
$93.85
|
| Rate for Payer: Humana Commercial |
$83.97
|
| Rate for Payer: Humana KY Medicaid |
$33.97
|
| Rate for Payer: Kentucky WC Medicaid |
$34.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$81.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$34.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.94
|
| Rate for Payer: Ohio Health Group HMO |
$74.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.62
|
| Rate for Payer: PHCS Commercial |
$94.84
|
| Rate for Payer: United Healthcare All Payer |
$86.94
|
|
