|
TEFLARO 10 MG (600MG VIAL)
|
Facility
|
IP
|
$661.52
|
|
|
Service Code
|
HCPCS J0712
|
| Hospital Charge Code |
25001955
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$198.46 |
| Max. Negotiated Rate |
$635.06 |
| Rate for Payer: Aetna Commercial |
$509.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$515.99
|
| Rate for Payer: Cash Price |
$330.76
|
| Rate for Payer: Cigna Commercial |
$549.06
|
| Rate for Payer: First Health Commercial |
$628.44
|
| Rate for Payer: Humana Commercial |
$562.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$542.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$488.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$198.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$582.14
|
| Rate for Payer: Ohio Health Group HMO |
$496.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$529.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$575.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$456.45
|
| Rate for Payer: PHCS Commercial |
$635.06
|
| Rate for Payer: United Healthcare All Payer |
$582.14
|
|
|
TEGRETOL (CARBAM) 100MGTABCHEW
|
Facility
|
IP
|
$4.60
|
|
|
Service Code
|
NDC 51672404101
|
| Hospital Charge Code |
25001495
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$4.42 |
| Rate for Payer: Aetna Commercial |
$3.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.82
|
| Rate for Payer: First Health Commercial |
$4.37
|
| Rate for Payer: Humana Commercial |
$3.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.05
|
| Rate for Payer: Ohio Health Group HMO |
$3.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.17
|
| Rate for Payer: PHCS Commercial |
$4.42
|
| Rate for Payer: United Healthcare All Payer |
$4.05
|
|
|
TEGRETOL (CARBAM) 100MGTABCHEW
|
Facility
|
OP
|
$4.60
|
|
|
Service Code
|
NDC 51672404101
|
| Hospital Charge Code |
25001495
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$4.42 |
| Rate for Payer: Aetna Commercial |
$3.54
|
| Rate for Payer: Anthem Medicaid |
$1.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.82
|
| Rate for Payer: First Health Commercial |
$4.37
|
| Rate for Payer: Humana Commercial |
$3.91
|
| Rate for Payer: Humana KY Medicaid |
$1.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.05
|
| Rate for Payer: Ohio Health Group HMO |
$3.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.17
|
| Rate for Payer: PHCS Commercial |
$4.42
|
| Rate for Payer: United Healthcare All Payer |
$4.05
|
|
|
TEGRETOL (CARBAMAZE 200MG/1TAB
|
Facility
|
IP
|
$4.61
|
|
|
Service Code
|
NDC 51672400501
|
| Hospital Charge Code |
25001496
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$4.43 |
| Rate for Payer: Aetna Commercial |
$3.55
|
| 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: 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: Ohio Health Choice Commercial |
$4.06
|
| Rate for Payer: Ohio Health Group HMO |
$3.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.18
|
| Rate for Payer: PHCS Commercial |
$4.43
|
| Rate for Payer: United Healthcare All Payer |
$4.06
|
|
|
TEGRETOL (CARBAMAZE 200MG/1TAB
|
Facility
|
OP
|
$4.61
|
|
|
Service Code
|
NDC 51672400501
|
| Hospital Charge Code |
25001496
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| 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 |
$3.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.18
|
| 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 |
$2.87 |
| 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 |
$7.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.60
|
| 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 |
$2.87 |
| 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 |
$7.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.60
|
| 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 |
$6.76 |
| 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 |
$16.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.55
|
| 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 |
$6.76 |
| 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 |
$16.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.55
|
| Rate for Payer: PHCS Commercial |
$21.64
|
| Rate for Payer: United Healthcare All Payer |
$19.84
|
|
|
TELEHEALTH FACIITY FEE
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
HCPCS Q3014
|
| Hospital Charge Code |
45000337
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$15.90 |
| Max. Negotiated Rate |
$50.88 |
| Rate for Payer: Aetna Commercial |
$40.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$41.34
|
| Rate for Payer: Cash Price |
$26.50
|
| Rate for Payer: Cigna Commercial |
$43.99
|
| Rate for Payer: First Health Commercial |
$50.35
|
| Rate for Payer: Humana Commercial |
$45.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$43.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$39.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$46.64
|
| Rate for Payer: Ohio Health Group HMO |
$39.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$42.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$46.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.57
|
| Rate for Payer: PHCS Commercial |
$50.88
|
| Rate for Payer: United Healthcare All Payer |
$46.64
|
|
|
TELEHEALTH FACIITY FEE
|
Professional
|
Both
|
$53.00
|
|
|
Service Code
|
HCPCS Q3014
|
| Hospital Charge Code |
45000337
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$18.55 |
| Max. Negotiated Rate |
$37.10 |
| Rate for Payer: Cash Price |
$26.50
|
| Rate for Payer: Cash Price |
$26.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$37.08
|
| Rate for Payer: Multiplan PHCS |
$31.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$37.10
|
| Rate for Payer: UHCCP Medicaid |
$18.55
|
|
|
TELEHEALTH FACIITY FEE
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
HCPCS Q3014
|
| Hospital Charge Code |
45000337
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$15.90 |
| Max. Negotiated Rate |
$50.88 |
| Rate for Payer: Aetna Commercial |
$40.81
|
| Rate for Payer: Anthem Medicaid |
$18.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$41.34
|
| Rate for Payer: Cash Price |
$26.50
|
| Rate for Payer: Cigna Commercial |
$43.99
|
| Rate for Payer: First Health Commercial |
$50.35
|
| Rate for Payer: Humana Commercial |
$45.05
|
| Rate for Payer: Humana KY Medicaid |
$18.23
|
| Rate for Payer: Kentucky WC Medicaid |
$18.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$43.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$39.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$18.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$46.64
|
| Rate for Payer: Ohio Health Group HMO |
$39.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$42.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$46.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.57
|
| Rate for Payer: PHCS Commercial |
$50.88
|
| Rate for Payer: United Healthcare All Payer |
$46.64
|
|
|
TELEHEALTH FACILITY FEE
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
HCPCS Q3014
|
| Hospital Charge Code |
51000363
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$15.90 |
| Max. Negotiated Rate |
$50.88 |
| Rate for Payer: Aetna Commercial |
$40.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$41.34
|
| Rate for Payer: Cash Price |
$26.50
|
| Rate for Payer: Cigna Commercial |
$43.99
|
| Rate for Payer: First Health Commercial |
$50.35
|
| Rate for Payer: Humana Commercial |
$45.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$43.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$39.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$46.64
|
| Rate for Payer: Ohio Health Group HMO |
$39.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$42.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$46.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.57
|
| Rate for Payer: PHCS Commercial |
$50.88
|
| Rate for Payer: United Healthcare All Payer |
$46.64
|
|
|
TELEHEALTH FACILITY FEE
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
HCPCS Q3014
|
| Hospital Charge Code |
51000363
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$15.90 |
| Max. Negotiated Rate |
$50.88 |
| Rate for Payer: Aetna Commercial |
$40.81
|
| Rate for Payer: Anthem Medicaid |
$18.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$41.34
|
| Rate for Payer: Cash Price |
$26.50
|
| Rate for Payer: Cigna Commercial |
$43.99
|
| Rate for Payer: First Health Commercial |
$50.35
|
| Rate for Payer: Humana Commercial |
$45.05
|
| Rate for Payer: Humana KY Medicaid |
$18.23
|
| Rate for Payer: Kentucky WC Medicaid |
$18.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$43.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$39.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$18.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$46.64
|
| Rate for Payer: Ohio Health Group HMO |
$39.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$42.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$46.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.57
|
| Rate for Payer: PHCS Commercial |
$50.88
|
| Rate for Payer: United Healthcare All Payer |
$46.64
|
|
|
TELEHEALTH FACILITY FEE
|
Professional
|
Both
|
$53.00
|
|
|
Service Code
|
HCPCS Q3014
|
| Hospital Charge Code |
51000363
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$18.55 |
| Max. Negotiated Rate |
$37.10 |
| Rate for Payer: Cash Price |
$26.50
|
| Rate for Payer: Cash Price |
$26.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$37.08
|
| Rate for Payer: Multiplan PHCS |
$31.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$37.10
|
| Rate for Payer: UHCCP Medicaid |
$18.55
|
|
|
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 |
$129.00 |
| Rate for Payer: Aetna Commercial |
$13.74
|
| Rate for Payer: Ambetter Exchange |
$8.22
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$5.88
|
| Rate for Payer: Anthem Medicaid |
$16.98
|
| Rate for Payer: Buckeye Individual/Medicaid |
$8.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$8.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$9.86
|
| 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 |
$16.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$12.30
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$8.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.22
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$17.32
|
| Rate for Payer: Molina Healthcare Passport |
$16.98
|
| Rate for Payer: Multiplan PHCS |
$129.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$10.69
|
| Rate for Payer: UHCCP Medicaid |
$6.17
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$17.15
|
| Rate for Payer: Wellcare Medicare Advantage |
$8.22
|
|
|
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 |
$189.00 |
| Rate for Payer: Aetna Commercial |
$36.67
|
| Rate for Payer: Ambetter Exchange |
$33.15
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$18.34
|
| Rate for Payer: Anthem Medicaid |
$31.08
|
| Rate for Payer: Buckeye Individual/Medicaid |
$33.15
|
| Rate for Payer: Buckeye Medicare Advantage |
$33.15
|
| Rate for Payer: CareSource Just4Me Medicare |
$39.78
|
| 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 |
$31.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$34.11
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$33.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$31.70
|
| Rate for Payer: Molina Healthcare Passport |
$31.08
|
| Rate for Payer: Multiplan PHCS |
$189.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$43.09
|
| 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 |
$31.39
|
| Rate for Payer: Wellcare Medicare Advantage |
$33.15
|
|
|
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 |
$210.00 |
| Rate for Payer: Aetna Commercial |
$70.77
|
| Rate for Payer: Ambetter Exchange |
$62.19
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$33.74
|
| Rate for Payer: Anthem Medicaid |
$42.63
|
| Rate for Payer: Buckeye Individual/Medicaid |
$62.19
|
| Rate for Payer: Buckeye Medicare Advantage |
$62.19
|
| Rate for Payer: CareSource Just4Me Medicare |
$74.63
|
| 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 |
$42.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$65.31
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$62.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$62.19
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$43.48
|
| Rate for Payer: Molina Healthcare Passport |
$42.63
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$80.85
|
| 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 |
$43.06
|
| Rate for Payer: Wellcare Medicare Advantage |
$62.19
|
|
|
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 |
$264.00 |
| Rate for Payer: Aetna Commercial |
$109.62
|
| Rate for Payer: Ambetter Exchange |
$91.58
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$49.49
|
| Rate for Payer: Anthem Medicaid |
$67.10
|
| Rate for Payer: Buckeye Individual/Medicaid |
$91.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$91.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.90
|
| 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 |
$67.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$89.62
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$91.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$91.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$68.44
|
| Rate for Payer: Molina Healthcare Passport |
$67.10
|
| Rate for Payer: Multiplan PHCS |
$264.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$119.05
|
| 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 |
$67.77
|
| Rate for Payer: Wellcare Medicare Advantage |
$91.58
|
|
|
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 |
$330.00 |
| Rate for Payer: Aetna Commercial |
$155.95
|
| Rate for Payer: Ambetter Exchange |
$135.31
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$73.54
|
| Rate for Payer: Anthem Medicaid |
$98.39
|
| Rate for Payer: Buckeye Individual/Medicaid |
$135.31
|
| Rate for Payer: Buckeye Medicare Advantage |
$135.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$162.37
|
| 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 |
$98.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$145.06
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$135.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$135.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$100.36
|
| Rate for Payer: Molina Healthcare Passport |
$98.39
|
| Rate for Payer: Multiplan PHCS |
$330.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.90
|
| 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 |
$99.37
|
| Rate for Payer: Wellcare Medicare Advantage |
$135.31
|
|
|
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 |
$180.00 |
| Rate for Payer: Aetna Commercial |
$101.60
|
| Rate for Payer: Ambetter Exchange |
$63.60
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$36.85
|
| Rate for Payer: Anthem Medicaid |
$48.35
|
| Rate for Payer: Buckeye Individual/Medicaid |
$63.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$63.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$76.32
|
| 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 |
$48.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$87.27
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$63.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$63.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$49.32
|
| Rate for Payer: Molina Healthcare Passport |
$48.35
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$82.68
|
| Rate for Payer: UHCCP Medicaid |
$38.69
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$48.83
|
| Rate for Payer: Wellcare Medicare Advantage |
$63.60
|
|
|
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 |
$309.00 |
| Rate for Payer: Aetna Commercial |
$207.93
|
| Rate for Payer: Ambetter Exchange |
$133.35
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$75.77
|
| Rate for Payer: Anthem Medicaid |
$94.13
|
| Rate for Payer: Buckeye Individual/Medicaid |
$133.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$133.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.02
|
| 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 |
$94.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$152.33
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$133.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$133.35
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$96.01
|
| Rate for Payer: Molina Healthcare Passport |
$94.13
|
| Rate for Payer: Multiplan PHCS |
$309.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$173.35
|
| Rate for Payer: UHCCP Medicaid |
$79.56
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$95.07
|
| Rate for Payer: Wellcare Medicare Advantage |
$133.35
|
|
|
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 |
$342.19 |
| Rate for Payer: Aetna Commercial |
$213.04
|
| Rate for Payer: Ambetter Exchange |
$141.70
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$77.14
|
| Rate for Payer: Anthem Medicaid |
$97.80
|
| Rate for Payer: Buckeye Individual/Medicaid |
$141.70
|
| Rate for Payer: Buckeye Medicare Advantage |
$141.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$170.04
|
| 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 |
$97.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$177.47
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$141.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$141.70
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$99.76
|
| Rate for Payer: Molina Healthcare Passport |
$97.80
|
| Rate for Payer: Multiplan PHCS |
$342.19
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$184.21
|
| Rate for Payer: UHCCP Medicaid |
$81.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$98.78
|
| Rate for Payer: Wellcare Medicare Advantage |
$141.70
|
|
|
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 |
$243.88 |
| Rate for Payer: Aetna Commercial |
$138.25
|
| Rate for Payer: Ambetter Exchange |
$90.05
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$49.43
|
| Rate for Payer: Anthem Medicaid |
$62.90
|
| Rate for Payer: Buckeye Individual/Medicaid |
$90.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$90.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$108.06
|
| 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 |
$62.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$103.45
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$90.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$90.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$64.16
|
| Rate for Payer: Molina Healthcare Passport |
$62.90
|
| Rate for Payer: Multiplan PHCS |
$243.88
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$117.06
|
| Rate for Payer: UHCCP Medicaid |
$51.90
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$63.53
|
| Rate for Payer: Wellcare Medicare Advantage |
$90.05
|
|
|
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 |
$176.58 |
| Rate for Payer: Aetna Commercial |
$126.94
|
| Rate for Payer: Ambetter Exchange |
$100.93
|
| Rate for Payer: Anthem Medicaid |
$59.51
|
| Rate for Payer: Buckeye Individual/Medicaid |
$100.93
|
| Rate for Payer: Buckeye Medicare Advantage |
$100.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$121.12
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$100.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$100.93
|
| 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 |
$131.21
|
| 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
|
| Rate for Payer: Wellcare Medicare Advantage |
$100.93
|
|
