|
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 |
$72.60 |
| 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 |
$193.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$210.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$166.98
|
| 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 |
$72.60 |
| 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 |
$193.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$210.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$166.98
|
| Rate for Payer: PHCS Commercial |
$232.32
|
| Rate for Payer: United Healthcare All Payer |
$212.96
|
|
|
TDAP BOOSTRIX 0.5ML DISP SYR
|
Facility
|
OP
|
$202.50
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
636T0006
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.75 |
| Max. Negotiated Rate |
$194.40 |
| Rate for Payer: Aetna Commercial |
$155.93
|
| Rate for Payer: Anthem Medicaid |
$69.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$157.95
|
| Rate for Payer: Cash Price |
$101.25
|
| Rate for Payer: Cigna Commercial |
$168.07
|
| Rate for Payer: First Health Commercial |
$192.38
|
| Rate for Payer: Humana Commercial |
$172.12
|
| Rate for Payer: Humana KY Medicaid |
$69.64
|
| Rate for Payer: Kentucky WC Medicaid |
$70.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$166.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$149.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$71.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$178.20
|
| Rate for Payer: Ohio Health Group HMO |
$151.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$162.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$176.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$139.72
|
| Rate for Payer: PHCS Commercial |
$194.40
|
| Rate for Payer: United Healthcare All Payer |
$178.20
|
|
|
TDAP BOOSTRIX 0.5ML DISP SYR
|
Facility
|
IP
|
$202.50
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
63600006
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.75 |
| Max. Negotiated Rate |
$194.40 |
| Rate for Payer: Aetna Commercial |
$155.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$157.95
|
| Rate for Payer: Cash Price |
$101.25
|
| Rate for Payer: Cigna Commercial |
$168.07
|
| Rate for Payer: First Health Commercial |
$192.38
|
| Rate for Payer: Humana Commercial |
$172.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$166.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$149.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$178.20
|
| Rate for Payer: Ohio Health Group HMO |
$151.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$162.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$176.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$139.72
|
| Rate for Payer: PHCS Commercial |
$194.40
|
| Rate for Payer: United Healthcare All Payer |
$178.20
|
|
|
TDAP BOOSTRIX 0.5ML DISP SYR
|
Facility
|
OP
|
$202.50
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
63600006
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.75 |
| Max. Negotiated Rate |
$194.40 |
| Rate for Payer: Aetna Commercial |
$155.93
|
| Rate for Payer: Anthem Medicaid |
$69.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$157.95
|
| Rate for Payer: Cash Price |
$101.25
|
| Rate for Payer: Cigna Commercial |
$168.07
|
| Rate for Payer: First Health Commercial |
$192.38
|
| Rate for Payer: Humana Commercial |
$172.12
|
| Rate for Payer: Humana KY Medicaid |
$69.64
|
| Rate for Payer: Kentucky WC Medicaid |
$70.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$166.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$149.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$71.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$178.20
|
| Rate for Payer: Ohio Health Group HMO |
$151.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$162.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$176.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$139.72
|
| Rate for Payer: PHCS Commercial |
$194.40
|
| Rate for Payer: United Healthcare All Payer |
$178.20
|
|
|
TDAP BOOSTRIX 0.5ML DISP SYR
|
Facility
|
IP
|
$202.50
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
25000040
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.75 |
| Max. Negotiated Rate |
$194.40 |
| Rate for Payer: Aetna Commercial |
$155.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$157.95
|
| Rate for Payer: Cash Price |
$101.25
|
| Rate for Payer: Cigna Commercial |
$168.07
|
| Rate for Payer: First Health Commercial |
$192.38
|
| Rate for Payer: Humana Commercial |
$172.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$166.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$149.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$178.20
|
| Rate for Payer: Ohio Health Group HMO |
$151.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$162.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$176.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$139.72
|
| Rate for Payer: PHCS Commercial |
$194.40
|
| Rate for Payer: United Healthcare All Payer |
$178.20
|
|
|
TDAP BOOSTRIX 0.5ML DISP SYR
|
Facility
|
OP
|
$202.50
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
25000040
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.75 |
| Max. Negotiated Rate |
$194.40 |
| Rate for Payer: Aetna Commercial |
$155.93
|
| Rate for Payer: Anthem Medicaid |
$69.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$157.95
|
| Rate for Payer: Cash Price |
$101.25
|
| Rate for Payer: Cigna Commercial |
$168.07
|
| Rate for Payer: First Health Commercial |
$192.38
|
| Rate for Payer: Humana Commercial |
$172.12
|
| Rate for Payer: Humana KY Medicaid |
$69.64
|
| Rate for Payer: Kentucky WC Medicaid |
$70.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$166.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$149.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$71.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$178.20
|
| Rate for Payer: Ohio Health Group HMO |
$151.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$162.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$176.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$139.72
|
| Rate for Payer: PHCS Commercial |
$194.40
|
| Rate for Payer: United Healthcare All Payer |
$178.20
|
|
|
TDAP BOOSTRIX 0.5ML DISP SYR
|
Facility
|
IP
|
$202.50
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
636T0006
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.75 |
| Max. Negotiated Rate |
$194.40 |
| Rate for Payer: Aetna Commercial |
$155.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$157.95
|
| Rate for Payer: Cash Price |
$101.25
|
| Rate for Payer: Cigna Commercial |
$168.07
|
| Rate for Payer: First Health Commercial |
$192.38
|
| Rate for Payer: Humana Commercial |
$172.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$166.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$149.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$178.20
|
| Rate for Payer: Ohio Health Group HMO |
$151.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$162.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$176.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$139.72
|
| Rate for Payer: PHCS Commercial |
$194.40
|
| Rate for Payer: United Healthcare All Payer |
$178.20
|
|
|
TDAP BOOSTRIX 0.5ML DISP SYR
|
Professional
|
Both
|
$202.50
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
63600006
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.64 |
| Max. Negotiated Rate |
$121.50 |
| Rate for Payer: Ambetter Exchange |
$39.71
|
| Rate for Payer: Anthem Medicaid |
$35.64
|
| Rate for Payer: Buckeye Individual/Medicaid |
$39.71
|
| Rate for Payer: Buckeye Medicare Advantage |
$39.71
|
| Rate for Payer: CareSource Just4Me Medicare |
$47.65
|
| Rate for Payer: Cash Price |
$101.25
|
| Rate for Payer: Cash Price |
$101.25
|
| Rate for Payer: Humana Medicaid |
$35.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$75.05
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$39.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$36.35
|
| Rate for Payer: Molina Healthcare Passport |
$35.64
|
| Rate for Payer: Multiplan PHCS |
$121.50
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$51.62
|
| Rate for Payer: UHCCP Medicaid |
$70.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$36.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$39.71
|
|
|
TECENTRIQ 10MG (1200MG VL)
|
Facility
|
IP
|
$61,322.36
|
|
|
Service Code
|
HCPCS J9022
|
| Hospital Charge Code |
25002559
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18,396.71 |
| Max. Negotiated Rate |
$58,869.47 |
| Rate for Payer: Aetna Commercial |
$47,218.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47,831.44
|
| Rate for Payer: Cash Price |
$30,661.18
|
| Rate for Payer: Cigna Commercial |
$50,897.56
|
| Rate for Payer: First Health Commercial |
$58,256.24
|
| Rate for Payer: Humana Commercial |
$52,124.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50,284.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45,255.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18,396.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$53,963.68
|
| Rate for Payer: Ohio Health Group HMO |
$45,991.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49,057.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53,350.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42,312.43
|
| Rate for Payer: PHCS Commercial |
$58,869.47
|
| Rate for Payer: United Healthcare All Payer |
$53,963.68
|
|
|
TECENTRIQ 10MG (1200MG VL)
|
Facility
|
OP
|
$61,322.36
|
|
|
Service Code
|
HCPCS J9022
|
| Hospital Charge Code |
25002559
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.02 |
| Max. Negotiated Rate |
$58,869.47 |
| Rate for Payer: Aetna Commercial |
$47,218.22
|
| Rate for Payer: Anthem Medicaid |
$21,088.76
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$91.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47,831.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$127.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$122.88
|
| Rate for Payer: Cash Price |
$30,661.18
|
| Rate for Payer: Cash Price |
$30,661.18
|
| Rate for Payer: Cigna Commercial |
$50,897.56
|
| Rate for Payer: First Health Commercial |
$58,256.24
|
| Rate for Payer: Humana Commercial |
$52,124.01
|
| Rate for Payer: Humana KY Medicaid |
$21,088.76
|
| Rate for Payer: Humana Medicare Advantage |
$91.02
|
| Rate for Payer: Kentucky WC Medicaid |
$21,303.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50,284.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45,255.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$109.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$21,511.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$53,963.68
|
| Rate for Payer: Ohio Health Group HMO |
$45,991.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49,057.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53,350.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42,312.43
|
| Rate for Payer: PHCS Commercial |
$58,869.47
|
| Rate for Payer: United Healthcare All Payer |
$53,963.68
|
|
|
TECENTRIQ 10MG (840MG VL)
|
Facility
|
IP
|
$42,925.67
|
|
|
Service Code
|
HCPCS J9022
|
| Hospital Charge Code |
25004175
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12,877.70 |
| Max. Negotiated Rate |
$41,208.64 |
| Rate for Payer: Aetna Commercial |
$33,052.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$33,482.02
|
| Rate for Payer: Cash Price |
$21,462.83
|
| Rate for Payer: Cigna Commercial |
$35,628.31
|
| Rate for Payer: First Health Commercial |
$40,779.39
|
| Rate for Payer: Humana Commercial |
$36,486.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$35,199.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31,679.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,877.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$37,774.59
|
| Rate for Payer: Ohio Health Group HMO |
$32,194.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34,340.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37,345.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29,618.71
|
| Rate for Payer: PHCS Commercial |
$41,208.64
|
| Rate for Payer: United Healthcare All Payer |
$37,774.59
|
|
|
TECENTRIQ 10MG (840MG VL)
|
Facility
|
OP
|
$42,925.67
|
|
|
Service Code
|
HCPCS J9022
|
| Hospital Charge Code |
25004175
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.02 |
| Max. Negotiated Rate |
$41,208.64 |
| Rate for Payer: Aetna Commercial |
$33,052.77
|
| Rate for Payer: Anthem Medicaid |
$14,762.14
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$91.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$33,482.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$127.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$122.88
|
| Rate for Payer: Cash Price |
$21,462.83
|
| Rate for Payer: Cash Price |
$21,462.83
|
| Rate for Payer: Cigna Commercial |
$35,628.31
|
| Rate for Payer: First Health Commercial |
$40,779.39
|
| Rate for Payer: Humana Commercial |
$36,486.82
|
| Rate for Payer: Humana KY Medicaid |
$14,762.14
|
| Rate for Payer: Humana Medicare Advantage |
$91.02
|
| Rate for Payer: Kentucky WC Medicaid |
$14,912.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$35,199.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31,679.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$109.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$15,058.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$37,774.59
|
| Rate for Payer: Ohio Health Group HMO |
$32,194.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34,340.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37,345.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29,618.71
|
| Rate for Payer: PHCS Commercial |
$41,208.64
|
| Rate for Payer: United Healthcare All Payer |
$37,774.59
|
|
|
TECHETIUM TC 99M MEDRONATE
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
34000048
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$45.30 |
| Max. Negotiated Rate |
$144.96 |
| Rate for Payer: Aetna Commercial |
$116.27
|
| Rate for Payer: Anthem Medicaid |
$51.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.78
|
| Rate for Payer: Cash Price |
$75.50
|
| Rate for Payer: Cigna Commercial |
$125.33
|
| Rate for Payer: First Health Commercial |
$143.45
|
| Rate for Payer: Humana Commercial |
$128.35
|
| Rate for Payer: Humana KY Medicaid |
$51.93
|
| Rate for Payer: Kentucky WC Medicaid |
$52.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$111.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$52.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.88
|
| Rate for Payer: Ohio Health Group HMO |
$113.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$131.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$104.19
|
| Rate for Payer: PHCS Commercial |
$144.96
|
| Rate for Payer: United Healthcare All Payer |
$132.88
|
|
|
TECHETIUM TC 99M MEDRONATE
|
Professional
|
Both
|
$151.00
|
|
| Hospital Charge Code |
34000048
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$52.85 |
| Max. Negotiated Rate |
$105.70 |
| Rate for Payer: Cash Price |
$75.50
|
| Rate for Payer: Multiplan PHCS |
$90.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.70
|
| Rate for Payer: UHCCP Medicaid |
$52.85
|
|
|
TECHETIUM TC 99M MEDRONATE
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
34000048
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$45.30 |
| Max. Negotiated Rate |
$144.96 |
| Rate for Payer: Aetna Commercial |
$116.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.78
|
| Rate for Payer: Cash Price |
$75.50
|
| Rate for Payer: Cigna Commercial |
$125.33
|
| Rate for Payer: First Health Commercial |
$143.45
|
| Rate for Payer: Humana Commercial |
$128.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$111.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.88
|
| Rate for Payer: Ohio Health Group HMO |
$113.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$131.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$104.19
|
| Rate for Payer: PHCS Commercial |
$144.96
|
| Rate for Payer: United Healthcare All Payer |
$132.88
|
|
|
TECHETIUM TC 99M MEDRONATE(T
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
340T0048
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$45.30 |
| Max. Negotiated Rate |
$144.96 |
| Rate for Payer: Aetna Commercial |
$116.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.78
|
| Rate for Payer: Cash Price |
$75.50
|
| Rate for Payer: Cigna Commercial |
$125.33
|
| Rate for Payer: First Health Commercial |
$143.45
|
| Rate for Payer: Humana Commercial |
$128.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$111.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.88
|
| Rate for Payer: Ohio Health Group HMO |
$113.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$131.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$104.19
|
| Rate for Payer: PHCS Commercial |
$144.96
|
| Rate for Payer: United Healthcare All Payer |
$132.88
|
|
|
TECHETIUM TC 99M MEDRONATE(T
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
340T0048
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$45.30 |
| Max. Negotiated Rate |
$144.96 |
| Rate for Payer: Aetna Commercial |
$116.27
|
| Rate for Payer: Anthem Medicaid |
$51.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.78
|
| Rate for Payer: Cash Price |
$75.50
|
| Rate for Payer: Cigna Commercial |
$125.33
|
| Rate for Payer: First Health Commercial |
$143.45
|
| Rate for Payer: Humana Commercial |
$128.35
|
| Rate for Payer: Humana KY Medicaid |
$51.93
|
| Rate for Payer: Kentucky WC Medicaid |
$52.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$111.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$52.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.88
|
| Rate for Payer: Ohio Health Group HMO |
$113.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$131.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$104.19
|
| Rate for Payer: PHCS Commercial |
$144.96
|
| Rate for Payer: United Healthcare All Payer |
$132.88
|
|
|
TECHNETIUM TC-99M AEROSOL
|
Facility
|
IP
|
$184.00
|
|
|
Service Code
|
HCPCS A9567
|
| Hospital Charge Code |
34000067
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$55.20 |
| Max. Negotiated Rate |
$176.64 |
| Rate for Payer: Aetna Commercial |
$141.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$143.52
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Cigna Commercial |
$152.72
|
| Rate for Payer: First Health Commercial |
$174.80
|
| Rate for Payer: Humana Commercial |
$156.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$150.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$135.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$161.92
|
| Rate for Payer: Ohio Health Group HMO |
$138.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$160.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$126.96
|
| Rate for Payer: PHCS Commercial |
$176.64
|
| Rate for Payer: United Healthcare All Payer |
$161.92
|
|
|
TECHNETIUM TC-99M AEROSOL
|
Facility
|
OP
|
$184.00
|
|
|
Service Code
|
HCPCS A9567
|
| Hospital Charge Code |
34000067
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$55.20 |
| Max. Negotiated Rate |
$176.64 |
| Rate for Payer: Aetna Commercial |
$141.68
|
| Rate for Payer: Anthem Medicaid |
$63.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$143.52
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Cigna Commercial |
$152.72
|
| Rate for Payer: First Health Commercial |
$174.80
|
| Rate for Payer: Humana Commercial |
$156.40
|
| Rate for Payer: Humana KY Medicaid |
$63.28
|
| Rate for Payer: Kentucky WC Medicaid |
$63.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$150.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$135.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$64.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$161.92
|
| Rate for Payer: Ohio Health Group HMO |
$138.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$160.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$126.96
|
| Rate for Payer: PHCS Commercial |
$176.64
|
| Rate for Payer: United Healthcare All Payer |
$161.92
|
|
|
TECHNETIUM TC99MBICISATEEADOSE
|
Facility
|
IP
|
$636.00
|
|
|
Service Code
|
HCPCS A9557
|
| Hospital Charge Code |
340T0064
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$190.80 |
| Max. Negotiated Rate |
$610.56 |
| Rate for Payer: Aetna Commercial |
$489.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$496.08
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$527.88
|
| Rate for Payer: First Health Commercial |
$604.20
|
| Rate for Payer: Humana Commercial |
$540.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$521.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$469.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$559.68
|
| Rate for Payer: Ohio Health Group HMO |
$477.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$508.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$553.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$438.84
|
| Rate for Payer: PHCS Commercial |
$610.56
|
| Rate for Payer: United Healthcare All Payer |
$559.68
|
|
|
TECHNETIUM TC99MBICISATEEADOSE
|
Professional
|
Both
|
$636.00
|
|
| Hospital Charge Code |
34000064
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$222.60 |
| Max. Negotiated Rate |
$445.20 |
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Multiplan PHCS |
$381.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$445.20
|
| Rate for Payer: UHCCP Medicaid |
$222.60
|
|
|
TECHNETIUM TC99MBICISATEEADOSE
|
Facility
|
OP
|
$636.00
|
|
|
Service Code
|
HCPCS A9557
|
| Hospital Charge Code |
340T0064
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$218.72 |
| Max. Negotiated Rate |
$957.32 |
| Rate for Payer: Aetna Commercial |
$489.72
|
| Rate for Payer: Anthem Medicaid |
$218.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$683.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$496.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$957.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$923.13
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$527.88
|
| Rate for Payer: First Health Commercial |
$604.20
|
| Rate for Payer: Humana Commercial |
$540.60
|
| Rate for Payer: Humana KY Medicaid |
$218.72
|
| Rate for Payer: Humana Medicare Advantage |
$683.80
|
| Rate for Payer: Kentucky WC Medicaid |
$220.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$521.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$469.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$820.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$223.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$559.68
|
| Rate for Payer: Ohio Health Group HMO |
$477.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$508.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$553.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$438.84
|
| Rate for Payer: PHCS Commercial |
$610.56
|
| Rate for Payer: United Healthcare All Payer |
$559.68
|
|
|
TECHNETIUM TC99MBICISATEEADOSE
|
Facility
|
OP
|
$636.00
|
|
|
Service Code
|
HCPCS A9557
|
| Hospital Charge Code |
34000064
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$218.72 |
| Max. Negotiated Rate |
$957.32 |
| Rate for Payer: Aetna Commercial |
$489.72
|
| Rate for Payer: Anthem Medicaid |
$218.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$683.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$496.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$957.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$923.13
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$527.88
|
| Rate for Payer: First Health Commercial |
$604.20
|
| Rate for Payer: Humana Commercial |
$540.60
|
| Rate for Payer: Humana KY Medicaid |
$218.72
|
| Rate for Payer: Humana Medicare Advantage |
$683.80
|
| Rate for Payer: Kentucky WC Medicaid |
$220.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$521.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$469.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$820.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$223.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$559.68
|
| Rate for Payer: Ohio Health Group HMO |
$477.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$508.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$553.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$438.84
|
| Rate for Payer: PHCS Commercial |
$610.56
|
| Rate for Payer: United Healthcare All Payer |
$559.68
|
|
|
TECHNETIUM TC99MBICISATEEADOSE
|
Facility
|
IP
|
$636.00
|
|
|
Service Code
|
HCPCS A9557
|
| Hospital Charge Code |
34000064
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$190.80 |
| Max. Negotiated Rate |
$610.56 |
| Rate for Payer: Aetna Commercial |
$489.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$496.08
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$527.88
|
| Rate for Payer: First Health Commercial |
$604.20
|
| Rate for Payer: Humana Commercial |
$540.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$521.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$469.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$559.68
|
| Rate for Payer: Ohio Health Group HMO |
$477.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$508.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$553.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$438.84
|
| Rate for Payer: PHCS Commercial |
$610.56
|
| Rate for Payer: United Healthcare All Payer |
$559.68
|
|
