|
TELETHERAPY COMPLEX(P
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 77307
|
| Hospital Charge Code |
333P0009
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$449.82 |
| Rate for Payer: Ambetter Exchange |
$267.16
|
| Rate for Payer: Anthem Medicaid |
$216.83
|
| Rate for Payer: Buckeye Individual/Medicaid |
$267.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$267.16
|
| Rate for Payer: CareSource Just4Me Medicare |
$320.59
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$449.82
|
| Rate for Payer: Humana Medicaid |
$216.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$187.68
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$267.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$267.16
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$221.17
|
| Rate for Payer: Molina Healthcare Passport |
$216.83
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$347.31
|
| Rate for Payer: UHCCP Medicaid |
$105.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$219.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$267.16
|
|
|
TELETHERAPY COMPLEX(T
|
Facility
|
OP
|
$1,029.00
|
|
|
Service Code
|
HCPCS 77307
|
| Hospital Charge Code |
333T0009
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$338.24 |
| Max. Negotiated Rate |
$987.84 |
| Rate for Payer: Aetna Commercial |
$792.33
|
| Rate for Payer: Anthem Medicaid |
$353.87
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$338.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$802.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$473.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$456.62
|
| Rate for Payer: Cash Price |
$514.50
|
| Rate for Payer: Cash Price |
$514.50
|
| Rate for Payer: Cigna Commercial |
$854.07
|
| Rate for Payer: First Health Commercial |
$977.55
|
| Rate for Payer: Humana Commercial |
$874.65
|
| Rate for Payer: Humana KY Medicaid |
$353.87
|
| Rate for Payer: Humana Medicare Advantage |
$338.24
|
| Rate for Payer: Kentucky WC Medicaid |
$357.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$843.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$759.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$405.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$360.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$905.52
|
| Rate for Payer: Ohio Health Group HMO |
$771.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$823.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$895.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$710.01
|
| Rate for Payer: PHCS Commercial |
$987.84
|
| Rate for Payer: United Healthcare All Payer |
$905.52
|
|
|
TELETHERAPY COMPLEX(T
|
Facility
|
IP
|
$1,029.00
|
|
|
Service Code
|
HCPCS 77307
|
| Hospital Charge Code |
333T0009
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$308.70 |
| Max. Negotiated Rate |
$987.84 |
| Rate for Payer: Aetna Commercial |
$792.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$802.62
|
| Rate for Payer: Cash Price |
$514.50
|
| Rate for Payer: Cigna Commercial |
$854.07
|
| Rate for Payer: First Health Commercial |
$977.55
|
| Rate for Payer: Humana Commercial |
$874.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$843.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$759.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$308.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$905.52
|
| Rate for Payer: Ohio Health Group HMO |
$771.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$823.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$895.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$710.01
|
| Rate for Payer: PHCS Commercial |
$987.84
|
| Rate for Payer: United Healthcare All Payer |
$905.52
|
|
|
TELETHX ISODOSE PLAN SIMPLE
|
Professional
|
Both
|
$586.00
|
|
|
Service Code
|
HCPCS 77306
|
| Hospital Charge Code |
33300008
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$90.06 |
| Max. Negotiated Rate |
$351.60 |
| Rate for Payer: Ambetter Exchange |
$136.91
|
| Rate for Payer: Anthem Medicaid |
$110.46
|
| Rate for Payer: Buckeye Individual/Medicaid |
$136.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$136.91
|
| Rate for Payer: CareSource Just4Me Medicare |
$164.29
|
| Rate for Payer: Cash Price |
$293.00
|
| Rate for Payer: Cash Price |
$293.00
|
| Rate for Payer: Cigna Commercial |
$229.38
|
| Rate for Payer: Humana Medicaid |
$110.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$90.06
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$136.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$136.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$112.67
|
| Rate for Payer: Molina Healthcare Passport |
$110.46
|
| Rate for Payer: Multiplan PHCS |
$351.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$177.98
|
| Rate for Payer: UHCCP Medicaid |
$205.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$111.56
|
| Rate for Payer: Wellcare Medicare Advantage |
$136.91
|
|
|
TELETHX ISODOSE PLAN SIMPLE
|
Facility
|
OP
|
$586.00
|
|
|
Service Code
|
HCPCS 77306
|
| Hospital Charge Code |
33300008
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$201.53 |
| Max. Negotiated Rate |
$562.56 |
| Rate for Payer: Aetna Commercial |
$451.22
|
| Rate for Payer: Anthem Medicaid |
$201.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$338.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$457.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$473.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$456.62
|
| Rate for Payer: Cash Price |
$293.00
|
| Rate for Payer: Cash Price |
$293.00
|
| Rate for Payer: Cigna Commercial |
$486.38
|
| Rate for Payer: First Health Commercial |
$556.70
|
| Rate for Payer: Humana Commercial |
$498.10
|
| Rate for Payer: Humana KY Medicaid |
$201.53
|
| Rate for Payer: Humana Medicare Advantage |
$338.24
|
| Rate for Payer: Kentucky WC Medicaid |
$203.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$480.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$432.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$405.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$205.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$515.68
|
| Rate for Payer: Ohio Health Group HMO |
$439.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$468.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$509.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$404.34
|
| Rate for Payer: PHCS Commercial |
$562.56
|
| Rate for Payer: United Healthcare All Payer |
$515.68
|
|
|
TELETHX ISODOSE PLAN SIMPLE
|
Facility
|
IP
|
$586.00
|
|
|
Service Code
|
HCPCS 77306
|
| Hospital Charge Code |
33300008
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$175.80 |
| Max. Negotiated Rate |
$562.56 |
| Rate for Payer: Aetna Commercial |
$451.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$457.08
|
| Rate for Payer: Cash Price |
$293.00
|
| Rate for Payer: Cigna Commercial |
$486.38
|
| Rate for Payer: First Health Commercial |
$556.70
|
| Rate for Payer: Humana Commercial |
$498.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$480.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$432.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$175.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$515.68
|
| Rate for Payer: Ohio Health Group HMO |
$439.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$468.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$509.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$404.34
|
| Rate for Payer: PHCS Commercial |
$562.56
|
| Rate for Payer: United Healthcare All Payer |
$515.68
|
|
|
TELETHX ISODOSE PLAN SIMPLE(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 77306
|
| Hospital Charge Code |
333P0008
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$229.38 |
| Rate for Payer: Ambetter Exchange |
$136.91
|
| Rate for Payer: Anthem Medicaid |
$110.46
|
| Rate for Payer: Buckeye Individual/Medicaid |
$136.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$136.91
|
| Rate for Payer: CareSource Just4Me Medicare |
$164.29
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$229.38
|
| Rate for Payer: Humana Medicaid |
$110.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$90.06
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$136.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$136.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$112.67
|
| Rate for Payer: Molina Healthcare Passport |
$110.46
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$177.98
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$111.56
|
| Rate for Payer: Wellcare Medicare Advantage |
$136.91
|
|
|
TELETHX ISODOSE PLAN SIMPLE(T
|
Facility
|
IP
|
$436.00
|
|
|
Service Code
|
HCPCS 77306
|
| Hospital Charge Code |
333T0008
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$130.80 |
| Max. Negotiated Rate |
$418.56 |
| Rate for Payer: Aetna Commercial |
$335.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$340.08
|
| Rate for Payer: Cash Price |
$218.00
|
| Rate for Payer: Cigna Commercial |
$361.88
|
| Rate for Payer: First Health Commercial |
$414.20
|
| Rate for Payer: Humana Commercial |
$370.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$357.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$321.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$130.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$383.68
|
| Rate for Payer: Ohio Health Group HMO |
$327.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$348.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$379.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$300.84
|
| Rate for Payer: PHCS Commercial |
$418.56
|
| Rate for Payer: United Healthcare All Payer |
$383.68
|
|
|
TELETHX ISODOSE PLAN SIMPLE(T
|
Facility
|
OP
|
$436.00
|
|
|
Service Code
|
HCPCS 77306
|
| Hospital Charge Code |
333T0008
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$149.94 |
| Max. Negotiated Rate |
$473.54 |
| Rate for Payer: Aetna Commercial |
$335.72
|
| Rate for Payer: Anthem Medicaid |
$149.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$338.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$340.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$473.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$456.62
|
| Rate for Payer: Cash Price |
$218.00
|
| Rate for Payer: Cash Price |
$218.00
|
| Rate for Payer: Cigna Commercial |
$361.88
|
| Rate for Payer: First Health Commercial |
$414.20
|
| Rate for Payer: Humana Commercial |
$370.60
|
| Rate for Payer: Humana KY Medicaid |
$149.94
|
| Rate for Payer: Humana Medicare Advantage |
$338.24
|
| Rate for Payer: Kentucky WC Medicaid |
$151.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$357.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$321.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$405.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$152.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$383.68
|
| Rate for Payer: Ohio Health Group HMO |
$327.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$348.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$379.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$300.84
|
| Rate for Payer: PHCS Commercial |
$418.56
|
| Rate for Payer: United Healthcare All Payer |
$383.68
|
|
|
TEMODAR 1MG (100 MG VL)
|
Facility
|
OP
|
$5,466.95
|
|
|
Service Code
|
HCPCS J9328
|
| Hospital Charge Code |
25002681
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.39 |
| Max. Negotiated Rate |
$5,248.27 |
| Rate for Payer: Aetna Commercial |
$4,209.55
|
| Rate for Payer: Anthem Medicaid |
$1,880.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$10.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,264.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$14.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$14.03
|
| Rate for Payer: Cash Price |
$2,733.48
|
| Rate for Payer: Cash Price |
$2,733.48
|
| Rate for Payer: Cigna Commercial |
$4,537.57
|
| Rate for Payer: First Health Commercial |
$5,193.60
|
| Rate for Payer: Humana Commercial |
$4,646.91
|
| Rate for Payer: Humana KY Medicaid |
$1,880.08
|
| Rate for Payer: Humana Medicare Advantage |
$10.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,899.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,482.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,034.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,917.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,810.92
|
| Rate for Payer: Ohio Health Group HMO |
$4,100.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,373.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,756.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,772.20
|
| Rate for Payer: PHCS Commercial |
$5,248.27
|
| Rate for Payer: United Healthcare All Payer |
$4,810.92
|
|
|
TEMODAR 1MG (100 MG VL)
|
Facility
|
IP
|
$5,466.95
|
|
|
Service Code
|
HCPCS J9328
|
| Hospital Charge Code |
25002681
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,640.09 |
| Max. Negotiated Rate |
$5,248.27 |
| Rate for Payer: Aetna Commercial |
$4,209.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,264.22
|
| Rate for Payer: Cash Price |
$2,733.48
|
| Rate for Payer: Cigna Commercial |
$4,537.57
|
| Rate for Payer: First Health Commercial |
$5,193.60
|
| Rate for Payer: Humana Commercial |
$4,646.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,482.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,034.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,640.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,810.92
|
| Rate for Payer: Ohio Health Group HMO |
$4,100.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,373.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,756.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,772.20
|
| Rate for Payer: PHCS Commercial |
$5,248.27
|
| Rate for Payer: United Healthcare All Payer |
$4,810.92
|
|
|
TEMOVATE 0.05% CREAM 30GM
|
Facility
|
IP
|
$3.17
|
|
|
Service Code
|
NDC 51672125802
|
| Hospital Charge Code |
25001505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$3.04 |
| Rate for Payer: Aetna Commercial |
$2.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.47
|
| Rate for Payer: Cash Price |
$1.58
|
| Rate for Payer: Cigna Commercial |
$2.63
|
| Rate for Payer: First Health Commercial |
$3.01
|
| Rate for Payer: Humana Commercial |
$2.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.79
|
| Rate for Payer: Ohio Health Group HMO |
$2.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.19
|
| Rate for Payer: PHCS Commercial |
$3.04
|
| Rate for Payer: United Healthcare All Payer |
$2.79
|
|
|
TEMOVATE 0.05% CREAM 30GM
|
Facility
|
OP
|
$3.17
|
|
|
Service Code
|
NDC 51672125802
|
| Hospital Charge Code |
25001505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$3.04 |
| Rate for Payer: Aetna Commercial |
$2.44
|
| Rate for Payer: Anthem Medicaid |
$1.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.47
|
| Rate for Payer: Cash Price |
$1.58
|
| Rate for Payer: Cigna Commercial |
$2.63
|
| Rate for Payer: First Health Commercial |
$3.01
|
| Rate for Payer: Humana Commercial |
$2.69
|
| Rate for Payer: Humana KY Medicaid |
$1.09
|
| Rate for Payer: Kentucky WC Medicaid |
$1.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.79
|
| Rate for Payer: Ohio Health Group HMO |
$2.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.19
|
| Rate for Payer: PHCS Commercial |
$3.04
|
| Rate for Payer: United Healthcare All Payer |
$2.79
|
|
|
TEMOVATE 0.05% OINTMENT 30GM
|
Facility
|
IP
|
$2.83
|
|
|
Service Code
|
NDC 21922001705
|
| Hospital Charge Code |
25001504
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Aetna Commercial |
$2.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.21
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Cigna Commercial |
$2.35
|
| Rate for Payer: First Health Commercial |
$2.69
|
| Rate for Payer: Humana Commercial |
$2.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.49
|
| Rate for Payer: Ohio Health Group HMO |
$2.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.95
|
| Rate for Payer: PHCS Commercial |
$2.72
|
| Rate for Payer: United Healthcare All Payer |
$2.49
|
|
|
TEMOVATE 0.05% OINTMENT 30GM
|
Facility
|
OP
|
$2.83
|
|
|
Service Code
|
NDC 21922001705
|
| Hospital Charge Code |
25001504
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Aetna Commercial |
$2.18
|
| Rate for Payer: Anthem Medicaid |
$0.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.21
|
| Rate for Payer: Cash Price |
$1.42
|
| Rate for Payer: Cigna Commercial |
$2.35
|
| Rate for Payer: First Health Commercial |
$2.69
|
| Rate for Payer: Humana Commercial |
$2.41
|
| Rate for Payer: Humana KY Medicaid |
$0.97
|
| Rate for Payer: Kentucky WC Medicaid |
$0.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.49
|
| Rate for Payer: Ohio Health Group HMO |
$2.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.95
|
| Rate for Payer: PHCS Commercial |
$2.72
|
| Rate for Payer: United Healthcare All Payer |
$2.49
|
|
|
TEMPO ST. 5F 65CM
|
Facility
|
OP
|
$1,513.50
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$454.05 |
| Max. Negotiated Rate |
$1,452.96 |
| Rate for Payer: Aetna Commercial |
$1,165.39
|
| Rate for Payer: Anthem Medicaid |
$520.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,180.53
|
| Rate for Payer: Cash Price |
$756.75
|
| Rate for Payer: Cigna Commercial |
$1,256.20
|
| Rate for Payer: First Health Commercial |
$1,437.83
|
| Rate for Payer: Humana Commercial |
$1,286.47
|
| Rate for Payer: Humana KY Medicaid |
$520.49
|
| Rate for Payer: Kentucky WC Medicaid |
$525.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,241.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,116.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$454.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$530.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,331.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,135.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,210.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,316.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,044.32
|
| Rate for Payer: PHCS Commercial |
$1,452.96
|
| Rate for Payer: United Healthcare All Payer |
$1,331.88
|
|
|
TEMPO ST. 5F 65CM
|
Facility
|
IP
|
$1,513.50
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$454.05 |
| Max. Negotiated Rate |
$1,452.96 |
| Rate for Payer: Aetna Commercial |
$1,165.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,180.53
|
| Rate for Payer: Cash Price |
$756.75
|
| Rate for Payer: Cigna Commercial |
$1,256.20
|
| Rate for Payer: First Health Commercial |
$1,437.83
|
| Rate for Payer: Humana Commercial |
$1,286.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,241.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,116.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$454.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,331.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,135.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,210.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,316.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,044.32
|
| Rate for Payer: PHCS Commercial |
$1,452.96
|
| Rate for Payer: United Healthcare All Payer |
$1,331.88
|
|
|
TEMP TRANSCUTANEOUS PACING
|
Facility
|
OP
|
$1,218.49
|
|
|
Service Code
|
HCPCS 92953
|
| Hospital Charge Code |
76102466
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$419.04 |
| Max. Negotiated Rate |
$1,169.75 |
| Rate for Payer: Aetna Commercial |
$938.24
|
| Rate for Payer: Anthem Medicaid |
$419.04
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$604.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$950.42
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$846.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$816.25
|
| Rate for Payer: Cash Price |
$609.24
|
| Rate for Payer: Cash Price |
$609.24
|
| Rate for Payer: Cigna Commercial |
$1,011.35
|
| Rate for Payer: First Health Commercial |
$1,157.57
|
| Rate for Payer: Humana Commercial |
$1,035.72
|
| Rate for Payer: Humana KY Medicaid |
$419.04
|
| Rate for Payer: Humana Medicare Advantage |
$604.63
|
| Rate for Payer: Kentucky WC Medicaid |
$423.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$999.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$899.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$725.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$427.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,072.27
|
| Rate for Payer: Ohio Health Group HMO |
$913.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$974.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,060.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$840.76
|
| Rate for Payer: PHCS Commercial |
$1,169.75
|
| Rate for Payer: United Healthcare All Payer |
$1,072.27
|
|
|
TEMP TRANSCUTANEOUS PACING
|
Professional
|
Both
|
$1,218.49
|
|
|
Service Code
|
HCPCS 92953
|
| Hospital Charge Code |
76102466
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$731.09 |
| Rate for Payer: Aetna Commercial |
$19.93
|
| Rate for Payer: Ambetter Exchange |
$0.95
|
| Rate for Payer: Anthem Medicaid |
$28.10
|
| Rate for Payer: Buckeye Individual/Medicaid |
$0.95
|
| Rate for Payer: Buckeye Medicare Advantage |
$0.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$1.14
|
| Rate for Payer: Cash Price |
$609.24
|
| Rate for Payer: Cash Price |
$609.24
|
| Rate for Payer: Cigna Commercial |
$18.15
|
| Rate for Payer: Healthspan PPO |
$18.74
|
| Rate for Payer: Humana Medicaid |
$28.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$14.88
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$0.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.95
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$28.66
|
| Rate for Payer: Molina Healthcare Passport |
$28.10
|
| Rate for Payer: Multiplan PHCS |
$731.09
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1.24
|
| Rate for Payer: UHCCP Medicaid |
$426.47
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$28.38
|
| Rate for Payer: Wellcare Medicare Advantage |
$0.95
|
|
|
TEMP TRANSCUTANEOUS PACING
|
Facility
|
IP
|
$1,218.49
|
|
|
Service Code
|
HCPCS 92953
|
| Hospital Charge Code |
76102466
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$365.55 |
| Max. Negotiated Rate |
$1,169.75 |
| Rate for Payer: Aetna Commercial |
$938.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$950.42
|
| Rate for Payer: Cash Price |
$609.24
|
| Rate for Payer: Cigna Commercial |
$1,011.35
|
| Rate for Payer: First Health Commercial |
$1,157.57
|
| Rate for Payer: Humana Commercial |
$1,035.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$999.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$899.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$365.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,072.27
|
| Rate for Payer: Ohio Health Group HMO |
$913.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$974.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,060.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$840.76
|
| Rate for Payer: PHCS Commercial |
$1,169.75
|
| Rate for Payer: United Healthcare All Payer |
$1,072.27
|
|
|
TEMP TRANSCUTANEOUS PACING(P
|
Professional
|
Both
|
$320.00
|
|
|
Service Code
|
HCPCS 92953
|
| Hospital Charge Code |
761P2466
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial |
$19.93
|
| Rate for Payer: Ambetter Exchange |
$0.95
|
| Rate for Payer: Anthem Medicaid |
$28.10
|
| Rate for Payer: Buckeye Individual/Medicaid |
$0.95
|
| Rate for Payer: Buckeye Medicare Advantage |
$0.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$1.14
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cigna Commercial |
$18.15
|
| Rate for Payer: Healthspan PPO |
$18.74
|
| Rate for Payer: Humana Medicaid |
$28.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$14.88
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$0.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.95
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$28.66
|
| Rate for Payer: Molina Healthcare Passport |
$28.10
|
| Rate for Payer: Multiplan PHCS |
$192.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1.24
|
| Rate for Payer: UHCCP Medicaid |
$112.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$28.38
|
| Rate for Payer: Wellcare Medicare Advantage |
$0.95
|
|
|
TEMP TRANSCUTANEOUS PACING(T
|
Facility
|
OP
|
$898.49
|
|
|
Service Code
|
HCPCS 92953
|
| Hospital Charge Code |
761T2466
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$308.99 |
| Max. Negotiated Rate |
$862.55 |
| Rate for Payer: Aetna Commercial |
$691.84
|
| Rate for Payer: Anthem Medicaid |
$308.99
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$604.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$700.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$846.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$816.25
|
| Rate for Payer: Cash Price |
$449.24
|
| Rate for Payer: Cash Price |
$449.24
|
| Rate for Payer: Cigna Commercial |
$745.75
|
| Rate for Payer: First Health Commercial |
$853.57
|
| Rate for Payer: Humana Commercial |
$763.72
|
| Rate for Payer: Humana KY Medicaid |
$308.99
|
| Rate for Payer: Humana Medicare Advantage |
$604.63
|
| Rate for Payer: Kentucky WC Medicaid |
$312.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$736.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$663.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$725.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$315.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$790.67
|
| Rate for Payer: Ohio Health Group HMO |
$673.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$718.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$781.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$619.96
|
| Rate for Payer: PHCS Commercial |
$862.55
|
| Rate for Payer: United Healthcare All Payer |
$790.67
|
|
|
TEMP TRANSCUTANEOUS PACING(T
|
Facility
|
IP
|
$898.49
|
|
|
Service Code
|
HCPCS 92953
|
| Hospital Charge Code |
761T2466
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$269.55 |
| Max. Negotiated Rate |
$862.55 |
| Rate for Payer: Aetna Commercial |
$691.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$700.82
|
| Rate for Payer: Cash Price |
$449.24
|
| Rate for Payer: Cigna Commercial |
$745.75
|
| Rate for Payer: First Health Commercial |
$853.57
|
| Rate for Payer: Humana Commercial |
$763.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$736.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$663.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$269.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$790.67
|
| Rate for Payer: Ohio Health Group HMO |
$673.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$718.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$781.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$619.96
|
| Rate for Payer: PHCS Commercial |
$862.55
|
| Rate for Payer: United Healthcare All Payer |
$790.67
|
|
|
TENDON EXCISION PALM/FINGER
|
Facility
|
IP
|
$1,450.00
|
|
|
Service Code
|
HCPCS 26145
|
| Hospital Charge Code |
76100677
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$435.00 |
| Max. Negotiated Rate |
$1,392.00 |
| Rate for Payer: Aetna Commercial |
$1,116.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,131.00
|
| Rate for Payer: Cash Price |
$725.00
|
| Rate for Payer: Cigna Commercial |
$1,203.50
|
| Rate for Payer: First Health Commercial |
$1,377.50
|
| Rate for Payer: Humana Commercial |
$1,232.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,189.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,070.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$435.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,276.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,160.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,261.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,000.50
|
| Rate for Payer: PHCS Commercial |
$1,392.00
|
| Rate for Payer: United Healthcare All Payer |
$1,276.00
|
|
|
TENDON EXCISION PALM/FINGER
|
Facility
|
OP
|
$1,450.00
|
|
|
Service Code
|
HCPCS 26145
|
| Hospital Charge Code |
76100677
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$498.65 |
| Max. Negotiated Rate |
$2,070.25 |
| Rate for Payer: Aetna Commercial |
$1,116.50
|
| Rate for Payer: Anthem Medicaid |
$498.65
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,478.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,131.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,070.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,996.31
|
| Rate for Payer: Cash Price |
$725.00
|
| Rate for Payer: Cash Price |
$725.00
|
| Rate for Payer: Cigna Commercial |
$1,203.50
|
| Rate for Payer: First Health Commercial |
$1,377.50
|
| Rate for Payer: Humana Commercial |
$1,232.50
|
| Rate for Payer: Humana KY Medicaid |
$498.65
|
| Rate for Payer: Humana Medicare Advantage |
$1,478.75
|
| Rate for Payer: Kentucky WC Medicaid |
$503.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,189.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,070.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,774.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$508.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,276.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,160.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,261.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,000.50
|
| Rate for Payer: PHCS Commercial |
$1,392.00
|
| Rate for Payer: United Healthcare All Payer |
$1,276.00
|
|
