|
TENOTOMY PERCUTAN, SING TEND(T
|
Facility
|
OP
|
$2,540.00
|
|
|
Service Code
|
HCPCS 28010
|
| Hospital Charge Code |
761T2678
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$873.51 |
| Max. Negotiated Rate |
$2,438.40 |
| Rate for Payer: Aetna Commercial |
$1,955.80
|
| Rate for Payer: Anthem Medicaid |
$873.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,478.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,981.20
|
| 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 |
$1,270.00
|
| Rate for Payer: Cash Price |
$1,270.00
|
| Rate for Payer: Cigna Commercial |
$2,108.20
|
| Rate for Payer: First Health Commercial |
$2,413.00
|
| Rate for Payer: Humana Commercial |
$2,159.00
|
| Rate for Payer: Humana KY Medicaid |
$873.51
|
| Rate for Payer: Humana Medicare Advantage |
$1,478.75
|
| Rate for Payer: Kentucky WC Medicaid |
$882.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,082.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,874.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,774.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$891.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,235.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,905.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,032.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,209.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,752.60
|
| Rate for Payer: PHCS Commercial |
$2,438.40
|
| Rate for Payer: United Healthcare All Payer |
$2,235.20
|
|
|
TEPEZZA 10 MG (500mg VIAL)
|
Facility
|
IP
|
$98,203.28
|
|
|
Service Code
|
HCPCS J3241
|
| Hospital Charge Code |
25004115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29,460.98 |
| Max. Negotiated Rate |
$94,275.15 |
| Rate for Payer: Aetna Commercial |
$75,616.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76,598.56
|
| Rate for Payer: Cash Price |
$49,101.64
|
| Rate for Payer: Cigna Commercial |
$81,508.72
|
| Rate for Payer: First Health Commercial |
$93,293.12
|
| Rate for Payer: Humana Commercial |
$83,472.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80,526.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72,474.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29,460.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$86,418.89
|
| Rate for Payer: Ohio Health Group HMO |
$73,652.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78,562.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85,436.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67,760.26
|
| Rate for Payer: PHCS Commercial |
$94,275.15
|
| Rate for Payer: United Healthcare All Payer |
$86,418.89
|
|
|
TEPEZZA 10 MG (500mg VIAL)
|
Facility
|
OP
|
$98,203.28
|
|
|
Service Code
|
HCPCS J3241
|
| Hospital Charge Code |
25004115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$359.09 |
| Max. Negotiated Rate |
$94,275.15 |
| Rate for Payer: Aetna Commercial |
$75,616.53
|
| Rate for Payer: Anthem Medicaid |
$33,772.11
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$359.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76,598.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$502.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$484.77
|
| Rate for Payer: Cash Price |
$49,101.64
|
| Rate for Payer: Cash Price |
$49,101.64
|
| Rate for Payer: Cigna Commercial |
$81,508.72
|
| Rate for Payer: First Health Commercial |
$93,293.12
|
| Rate for Payer: Humana Commercial |
$83,472.79
|
| Rate for Payer: Humana KY Medicaid |
$33,772.11
|
| Rate for Payer: Humana Medicare Advantage |
$359.09
|
| Rate for Payer: Kentucky WC Medicaid |
$34,115.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80,526.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72,474.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$430.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$34,449.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$86,418.89
|
| Rate for Payer: Ohio Health Group HMO |
$73,652.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78,562.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85,436.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67,760.26
|
| Rate for Payer: PHCS Commercial |
$94,275.15
|
| Rate for Payer: United Healthcare All Payer |
$86,418.89
|
|
|
TERAZOL 3 (0.8%) VAG CREAM
|
Facility
|
OP
|
$62.34
|
|
|
Service Code
|
NDC 51672130200
|
| Hospital Charge Code |
25001509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.70 |
| Max. Negotiated Rate |
$59.85 |
| Rate for Payer: Aetna Commercial |
$48.00
|
| Rate for Payer: Anthem Medicaid |
$21.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.63
|
| Rate for Payer: Cash Price |
$31.17
|
| Rate for Payer: Cigna Commercial |
$51.74
|
| Rate for Payer: First Health Commercial |
$59.22
|
| Rate for Payer: Humana Commercial |
$52.99
|
| Rate for Payer: Humana KY Medicaid |
$21.44
|
| Rate for Payer: Kentucky WC Medicaid |
$21.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$54.86
|
| Rate for Payer: Ohio Health Group HMO |
$46.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.01
|
| Rate for Payer: PHCS Commercial |
$59.85
|
| Rate for Payer: United Healthcare All Payer |
$54.86
|
|
|
TERAZOL 3 (0.8%) VAG CREAM
|
Facility
|
IP
|
$62.34
|
|
|
Service Code
|
NDC 51672130200
|
| Hospital Charge Code |
25001509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.70 |
| Max. Negotiated Rate |
$59.85 |
| Rate for Payer: Aetna Commercial |
$48.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.63
|
| Rate for Payer: Cash Price |
$31.17
|
| Rate for Payer: Cigna Commercial |
$51.74
|
| Rate for Payer: First Health Commercial |
$59.22
|
| Rate for Payer: Humana Commercial |
$52.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$54.86
|
| Rate for Payer: Ohio Health Group HMO |
$46.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.01
|
| Rate for Payer: PHCS Commercial |
$59.85
|
| Rate for Payer: United Healthcare All Payer |
$54.86
|
|
|
TERAZOL 3 (TERCONAZOL 80MG/1EA
|
Facility
|
OP
|
$65.21
|
|
|
Service Code
|
NDC 713055273
|
| Hospital Charge Code |
25001510
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.56 |
| Max. Negotiated Rate |
$62.60 |
| Rate for Payer: Aetna Commercial |
$50.21
|
| Rate for Payer: Anthem Medicaid |
$22.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.86
|
| Rate for Payer: Cash Price |
$32.60
|
| Rate for Payer: Cigna Commercial |
$54.12
|
| Rate for Payer: First Health Commercial |
$61.95
|
| Rate for Payer: Humana Commercial |
$55.43
|
| Rate for Payer: Humana KY Medicaid |
$22.43
|
| Rate for Payer: Kentucky WC Medicaid |
$22.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.38
|
| Rate for Payer: Ohio Health Group HMO |
$48.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$56.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.99
|
| Rate for Payer: PHCS Commercial |
$62.60
|
| Rate for Payer: United Healthcare All Payer |
$57.38
|
|
|
TERAZOL 3 (TERCONAZOL 80MG/1EA
|
Facility
|
IP
|
$65.21
|
|
|
Service Code
|
NDC 713055273
|
| Hospital Charge Code |
25001510
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.56 |
| Max. Negotiated Rate |
$62.60 |
| Rate for Payer: Aetna Commercial |
$50.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.86
|
| Rate for Payer: Cash Price |
$32.60
|
| Rate for Payer: Cigna Commercial |
$54.12
|
| Rate for Payer: First Health Commercial |
$61.95
|
| Rate for Payer: Humana Commercial |
$55.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.38
|
| Rate for Payer: Ohio Health Group HMO |
$48.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$56.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.99
|
| Rate for Payer: PHCS Commercial |
$62.60
|
| Rate for Payer: United Healthcare All Payer |
$57.38
|
|
|
TERAZOL 7(TERCONAZOLE)VAG 45GM
|
Facility
|
OP
|
$26.72
|
|
|
Service Code
|
NDC 51672130406
|
| Hospital Charge Code |
25001511
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.02 |
| Max. Negotiated Rate |
$25.65 |
| Rate for Payer: Aetna Commercial |
$20.57
|
| Rate for Payer: Anthem Medicaid |
$9.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.84
|
| Rate for Payer: Cash Price |
$13.36
|
| Rate for Payer: Cigna Commercial |
$22.18
|
| Rate for Payer: First Health Commercial |
$25.38
|
| Rate for Payer: Humana Commercial |
$22.71
|
| Rate for Payer: Humana KY Medicaid |
$9.19
|
| Rate for Payer: Kentucky WC Medicaid |
$9.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.51
|
| Rate for Payer: Ohio Health Group HMO |
$20.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.44
|
| Rate for Payer: PHCS Commercial |
$25.65
|
| Rate for Payer: United Healthcare All Payer |
$23.51
|
|
|
TERAZOL 7(TERCONAZOLE)VAG 45GM
|
Facility
|
IP
|
$26.72
|
|
|
Service Code
|
NDC 51672130406
|
| Hospital Charge Code |
25001511
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.02 |
| Max. Negotiated Rate |
$25.65 |
| Rate for Payer: Aetna Commercial |
$20.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.84
|
| Rate for Payer: Cash Price |
$13.36
|
| Rate for Payer: Cigna Commercial |
$22.18
|
| Rate for Payer: First Health Commercial |
$25.38
|
| Rate for Payer: Humana Commercial |
$22.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.51
|
| Rate for Payer: Ohio Health Group HMO |
$20.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.44
|
| Rate for Payer: PHCS Commercial |
$25.65
|
| Rate for Payer: United Healthcare All Payer |
$23.51
|
|
|
TESSALON PERLES (BE 100MG/1CAP
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
NDC 69452014320
|
| Hospital Charge Code |
25001512
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.73
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.10
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
TESSALON PERLES (BE 100MG/1CAP
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
NDC 69452014320
|
| Hospital Charge Code |
25001512
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.73
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.10
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
TESTICLES ULTRASOUND
|
Facility
|
OP
|
$997.00
|
|
|
Service Code
|
HCPCS 76870
|
| Hospital Charge Code |
40200051
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$957.12 |
| Rate for Payer: Aetna Commercial |
$767.69
|
| Rate for Payer: Anthem Medicaid |
$342.87
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$777.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$498.50
|
| Rate for Payer: Cash Price |
$498.50
|
| Rate for Payer: Cigna Commercial |
$827.51
|
| Rate for Payer: First Health Commercial |
$947.15
|
| Rate for Payer: Humana Commercial |
$847.45
|
| Rate for Payer: Humana KY Medicaid |
$342.87
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$346.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$817.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$735.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$349.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$877.36
|
| Rate for Payer: Ohio Health Group HMO |
$747.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$797.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$867.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$687.93
|
| Rate for Payer: PHCS Commercial |
$957.12
|
| Rate for Payer: United Healthcare All Payer |
$877.36
|
|
|
TESTICLES ULTRASOUND
|
Facility
|
IP
|
$997.00
|
|
|
Service Code
|
HCPCS 76870
|
| Hospital Charge Code |
40200051
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$299.10 |
| Max. Negotiated Rate |
$957.12 |
| Rate for Payer: Aetna Commercial |
$767.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$777.66
|
| Rate for Payer: Cash Price |
$498.50
|
| Rate for Payer: Cigna Commercial |
$827.51
|
| Rate for Payer: First Health Commercial |
$947.15
|
| Rate for Payer: Humana Commercial |
$847.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$817.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$735.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$299.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$877.36
|
| Rate for Payer: Ohio Health Group HMO |
$747.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$797.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$867.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$687.93
|
| Rate for Payer: PHCS Commercial |
$957.12
|
| Rate for Payer: United Healthcare All Payer |
$877.36
|
|
|
TESTICLES ULTRASOUND
|
Professional
|
Both
|
$997.00
|
|
|
Service Code
|
HCPCS 76870
|
| Hospital Charge Code |
40200051
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$41.12 |
| Max. Negotiated Rate |
$598.20 |
| Rate for Payer: Aetna Commercial |
$181.61
|
| Rate for Payer: Ambetter Exchange |
$90.15
|
| Rate for Payer: Anthem Medicaid |
$68.85
|
| Rate for Payer: Buckeye Individual/Medicaid |
$90.15
|
| Rate for Payer: Buckeye Medicare Advantage |
$90.15
|
| Rate for Payer: CareSource Just4Me Medicare |
$108.18
|
| Rate for Payer: Cash Price |
$498.50
|
| Rate for Payer: Cash Price |
$498.50
|
| Rate for Payer: Cigna Commercial |
$150.23
|
| Rate for Payer: Healthspan PPO |
$170.18
|
| Rate for Payer: Humana Medicaid |
$68.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$41.12
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$90.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$90.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$70.23
|
| Rate for Payer: Molina Healthcare Passport |
$68.85
|
| Rate for Payer: Multiplan PHCS |
$598.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$117.19
|
| Rate for Payer: UHCCP Medicaid |
$348.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$69.54
|
| Rate for Payer: Wellcare Medicare Advantage |
$90.15
|
|
|
TESTICLES ULTRASOUND(P
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 76870
|
| Hospital Charge Code |
402P0051
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$41.12 |
| Max. Negotiated Rate |
$181.61 |
| Rate for Payer: Aetna Commercial |
$181.61
|
| Rate for Payer: Ambetter Exchange |
$90.15
|
| Rate for Payer: Anthem Medicaid |
$68.85
|
| Rate for Payer: Buckeye Individual/Medicaid |
$90.15
|
| Rate for Payer: Buckeye Medicare Advantage |
$90.15
|
| Rate for Payer: CareSource Just4Me Medicare |
$108.18
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$150.23
|
| Rate for Payer: Healthspan PPO |
$170.18
|
| Rate for Payer: Humana Medicaid |
$68.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$41.12
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$90.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$90.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$70.23
|
| Rate for Payer: Molina Healthcare Passport |
$68.85
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$117.19
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$69.54
|
| Rate for Payer: Wellcare Medicare Advantage |
$90.15
|
|
|
TESTICLES ULTRASOUND(T
|
Facility
|
OP
|
$872.00
|
|
|
Service Code
|
HCPCS 76870
|
| Hospital Charge Code |
402T0051
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$98.26 |
| Max. Negotiated Rate |
$837.12 |
| Rate for Payer: Aetna Commercial |
$671.44
|
| Rate for Payer: Anthem Medicaid |
$299.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$98.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$680.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$137.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$132.65
|
| Rate for Payer: Cash Price |
$436.00
|
| Rate for Payer: Cash Price |
$436.00
|
| Rate for Payer: Cigna Commercial |
$723.76
|
| Rate for Payer: First Health Commercial |
$828.40
|
| Rate for Payer: Humana Commercial |
$741.20
|
| Rate for Payer: Humana KY Medicaid |
$299.88
|
| Rate for Payer: Humana Medicare Advantage |
$98.26
|
| Rate for Payer: Kentucky WC Medicaid |
$302.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$715.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$643.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$305.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$767.36
|
| Rate for Payer: Ohio Health Group HMO |
$654.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$697.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$758.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$601.68
|
| Rate for Payer: PHCS Commercial |
$837.12
|
| Rate for Payer: United Healthcare All Payer |
$767.36
|
|
|
TESTICLES ULTRASOUND(T
|
Facility
|
IP
|
$872.00
|
|
|
Service Code
|
HCPCS 76870
|
| Hospital Charge Code |
402T0051
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$261.60 |
| Max. Negotiated Rate |
$837.12 |
| Rate for Payer: Aetna Commercial |
$671.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$680.16
|
| Rate for Payer: Cash Price |
$436.00
|
| Rate for Payer: Cigna Commercial |
$723.76
|
| Rate for Payer: First Health Commercial |
$828.40
|
| Rate for Payer: Humana Commercial |
$741.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$715.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$643.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$261.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$767.36
|
| Rate for Payer: Ohio Health Group HMO |
$654.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$697.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$758.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$601.68
|
| Rate for Payer: PHCS Commercial |
$837.12
|
| Rate for Payer: United Healthcare All Payer |
$767.36
|
|
|
TESTOSTERONE 100MG PELLET
|
Facility
|
OP
|
$129.05
|
|
|
Service Code
|
HCPCS J7999
|
| Hospital Charge Code |
636T0225
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.72 |
| Max. Negotiated Rate |
$123.89 |
| Rate for Payer: Aetna Commercial |
$99.37
|
| Rate for Payer: Anthem Medicaid |
$44.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$100.66
|
| Rate for Payer: Cash Price |
$64.53
|
| Rate for Payer: Cigna Commercial |
$107.11
|
| Rate for Payer: First Health Commercial |
$122.60
|
| Rate for Payer: Humana Commercial |
$109.69
|
| Rate for Payer: Humana KY Medicaid |
$44.38
|
| Rate for Payer: Kentucky WC Medicaid |
$44.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$105.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$45.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$113.56
|
| Rate for Payer: Ohio Health Group HMO |
$96.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$112.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$89.04
|
| Rate for Payer: PHCS Commercial |
$123.89
|
| Rate for Payer: United Healthcare All Payer |
$113.56
|
|
|
TESTOSTERONE 100MG PELLET
|
Facility
|
OP
|
$129.05
|
|
|
Service Code
|
HCPCS J7999
|
| Hospital Charge Code |
63600225
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.72 |
| Max. Negotiated Rate |
$123.89 |
| Rate for Payer: Aetna Commercial |
$99.37
|
| Rate for Payer: Anthem Medicaid |
$44.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$100.66
|
| Rate for Payer: Cash Price |
$64.53
|
| Rate for Payer: Cigna Commercial |
$107.11
|
| Rate for Payer: First Health Commercial |
$122.60
|
| Rate for Payer: Humana Commercial |
$109.69
|
| Rate for Payer: Humana KY Medicaid |
$44.38
|
| Rate for Payer: Kentucky WC Medicaid |
$44.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$105.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$45.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$113.56
|
| Rate for Payer: Ohio Health Group HMO |
$96.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$112.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$89.04
|
| Rate for Payer: PHCS Commercial |
$123.89
|
| Rate for Payer: United Healthcare All Payer |
$113.56
|
|
|
TESTOSTERONE 100MG PELLET
|
Facility
|
IP
|
$129.05
|
|
|
Service Code
|
HCPCS J7999
|
| Hospital Charge Code |
63600225
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.72 |
| Max. Negotiated Rate |
$123.89 |
| Rate for Payer: Aetna Commercial |
$99.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$100.66
|
| Rate for Payer: Cash Price |
$64.53
|
| Rate for Payer: Cigna Commercial |
$107.11
|
| Rate for Payer: First Health Commercial |
$122.60
|
| Rate for Payer: Humana Commercial |
$109.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$105.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$113.56
|
| Rate for Payer: Ohio Health Group HMO |
$96.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$112.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$89.04
|
| Rate for Payer: PHCS Commercial |
$123.89
|
| Rate for Payer: United Healthcare All Payer |
$113.56
|
|
|
TESTOSTERONE 100MG PELLET
|
Facility
|
IP
|
$129.05
|
|
|
Service Code
|
HCPCS J7999
|
| Hospital Charge Code |
636T0225
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.72 |
| Max. Negotiated Rate |
$123.89 |
| Rate for Payer: Aetna Commercial |
$99.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$100.66
|
| Rate for Payer: Cash Price |
$64.53
|
| Rate for Payer: Cigna Commercial |
$107.11
|
| Rate for Payer: First Health Commercial |
$122.60
|
| Rate for Payer: Humana Commercial |
$109.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$105.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$113.56
|
| Rate for Payer: Ohio Health Group HMO |
$96.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$112.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$89.04
|
| Rate for Payer: PHCS Commercial |
$123.89
|
| Rate for Payer: United Healthcare All Payer |
$113.56
|
|
|
TESTOSTERONE 100MG PELLET
|
Professional
|
Both
|
$129.05
|
|
|
Service Code
|
HCPCS J7999
|
| Hospital Charge Code |
63600225
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.17 |
| Max. Negotiated Rate |
$90.33 |
| Rate for Payer: Cash Price |
$64.53
|
| Rate for Payer: Multiplan PHCS |
$77.43
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$90.33
|
| Rate for Payer: UHCCP Medicaid |
$45.17
|
|
|
TESTOSTERONE CYP 1mg(200mgSDV)
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
63600028
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Aetna Commercial |
$0.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.37
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna Commercial |
$0.40
|
| Rate for Payer: First Health Commercial |
$0.46
|
| Rate for Payer: Humana Commercial |
$0.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.42
|
| Rate for Payer: Ohio Health Group HMO |
$0.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.33
|
| Rate for Payer: PHCS Commercial |
$0.46
|
| Rate for Payer: United Healthcare All Payer |
$0.42
|
|
|
TESTOSTERONE CYP 1mg(200mgSDV)
|
Professional
|
Both
|
$0.48
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
63600028
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna Commercial |
$0.04
|
| Rate for Payer: Ambetter Exchange |
$0.03
|
| Rate for Payer: Buckeye Individual/Medicaid |
$0.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$0.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.04
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$0.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.03
|
| Rate for Payer: Multiplan PHCS |
$0.29
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$0.04
|
| Rate for Payer: UHCCP Medicaid |
$0.17
|
| Rate for Payer: Wellcare Medicare Advantage |
$0.03
|
|
|
TESTOSTERONE CYP 1mg(200mgSDV)
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
63600028
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Aetna Commercial |
$0.37
|
| Rate for Payer: Anthem Medicaid |
$0.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.37
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna Commercial |
$0.40
|
| Rate for Payer: First Health Commercial |
$0.46
|
| Rate for Payer: Humana Commercial |
$0.41
|
| Rate for Payer: Humana KY Medicaid |
$0.17
|
| Rate for Payer: Kentucky WC Medicaid |
$0.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.42
|
| Rate for Payer: Ohio Health Group HMO |
$0.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.33
|
| Rate for Payer: PHCS Commercial |
$0.46
|
| Rate for Payer: United Healthcare All Payer |
$0.42
|
|
