|
TIMOPTIC(TIMOLOL).25% OP 5ML
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 64980051305
|
| Hospital Charge Code |
25001551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Aetna Commercial |
$0.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.62
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna Commercial |
$0.66
|
| Rate for Payer: First Health Commercial |
$0.76
|
| Rate for Payer: Humana Commercial |
$0.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.70
|
| Rate for Payer: Ohio Health Group HMO |
$0.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.25
|
| Rate for Payer: PHCS Commercial |
$0.77
|
| Rate for Payer: United Healthcare All Payer |
$0.70
|
|
|
TIMOPTIC(TIMOLOL).25% OP 5ML
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 64980051305
|
| Hospital Charge Code |
25001551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Aetna Commercial |
$0.62
|
| Rate for Payer: Anthem Medicaid |
$0.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.62
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: Cigna Commercial |
$0.66
|
| Rate for Payer: First Health Commercial |
$0.76
|
| Rate for Payer: Humana Commercial |
$0.68
|
| Rate for Payer: Humana KY Medicaid |
$0.28
|
| Rate for Payer: Kentucky WC Medicaid |
$0.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.70
|
| Rate for Payer: Ohio Health Group HMO |
$0.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.25
|
| Rate for Payer: PHCS Commercial |
$0.77
|
| Rate for Payer: United Healthcare All Payer |
$0.70
|
|
|
TIMOPTIC(TIMOLOL)SOL-GEL5 ML
|
Facility
|
IP
|
$5.77
|
|
|
Service Code
|
NDC 61314022405
|
| Hospital Charge Code |
25001552
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$5.54 |
| Rate for Payer: Aetna Commercial |
$4.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.50
|
| Rate for Payer: Cash Price |
$2.88
|
| Rate for Payer: Cigna Commercial |
$4.79
|
| Rate for Payer: First Health Commercial |
$5.48
|
| Rate for Payer: Humana Commercial |
$4.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.08
|
| Rate for Payer: Ohio Health Group HMO |
$4.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.79
|
| Rate for Payer: PHCS Commercial |
$5.54
|
| Rate for Payer: United Healthcare All Payer |
$5.08
|
|
|
TIMOPTIC(TIMOLOL)SOL-GEL5 ML
|
Facility
|
OP
|
$5.77
|
|
|
Service Code
|
NDC 61314022405
|
| Hospital Charge Code |
25001552
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$5.54 |
| Rate for Payer: Aetna Commercial |
$4.44
|
| Rate for Payer: Anthem Medicaid |
$1.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.50
|
| Rate for Payer: Cash Price |
$2.88
|
| Rate for Payer: Cigna Commercial |
$4.79
|
| Rate for Payer: First Health Commercial |
$5.48
|
| Rate for Payer: Humana Commercial |
$4.90
|
| Rate for Payer: Humana KY Medicaid |
$1.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.08
|
| Rate for Payer: Ohio Health Group HMO |
$4.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.79
|
| Rate for Payer: PHCS Commercial |
$5.54
|
| Rate for Payer: United Healthcare All Payer |
$5.08
|
|
|
TIMOPTIC-XE (TIMOLOL) 2.5%/5ML
|
Facility
|
OP
|
$5.92
|
|
|
Service Code
|
NDC 61314022505
|
| Hospital Charge Code |
25001553
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$5.68 |
| Rate for Payer: Aetna Commercial |
$4.56
|
| Rate for Payer: Anthem Medicaid |
$2.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.62
|
| Rate for Payer: Cash Price |
$2.96
|
| Rate for Payer: Cigna Commercial |
$4.91
|
| Rate for Payer: First Health Commercial |
$5.62
|
| Rate for Payer: Humana Commercial |
$5.03
|
| Rate for Payer: Humana KY Medicaid |
$2.04
|
| Rate for Payer: Kentucky WC Medicaid |
$2.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.21
|
| Rate for Payer: Ohio Health Group HMO |
$4.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.84
|
| Rate for Payer: PHCS Commercial |
$5.68
|
| Rate for Payer: United Healthcare All Payer |
$5.21
|
|
|
TIMOPTIC-XE (TIMOLOL) 2.5%/5ML
|
Facility
|
IP
|
$5.92
|
|
|
Service Code
|
NDC 61314022505
|
| Hospital Charge Code |
25001553
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$5.68 |
| Rate for Payer: Aetna Commercial |
$4.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.62
|
| Rate for Payer: Cash Price |
$2.96
|
| Rate for Payer: Cigna Commercial |
$4.91
|
| Rate for Payer: First Health Commercial |
$5.62
|
| Rate for Payer: Humana Commercial |
$5.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.21
|
| Rate for Payer: Ohio Health Group HMO |
$4.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.84
|
| Rate for Payer: PHCS Commercial |
$5.68
|
| Rate for Payer: United Healthcare All Payer |
$5.21
|
|
|
TIMOTHY GRASS IGE
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000722
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
TIMOTHY GRASS IGE
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000722
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem Medicaid |
$22.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Humana KY Medicaid |
$22.35
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Kentucky WC Medicaid |
$22.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
TINACTIN(TOLNAFTATE) 1% C 15GM
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 51672202001
|
| Hospital Charge Code |
25001554
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna Commercial |
$0.16
|
| Rate for Payer: Anthem Medicaid |
$0.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.16
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna Commercial |
$0.17
|
| Rate for Payer: First Health Commercial |
$0.20
|
| Rate for Payer: Humana Commercial |
$0.18
|
| Rate for Payer: Humana KY Medicaid |
$0.07
|
| Rate for Payer: Kentucky WC Medicaid |
$0.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.18
|
| Rate for Payer: Ohio Health Group HMO |
$0.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.07
|
| Rate for Payer: PHCS Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Payer |
$0.18
|
|
|
TINACTIN(TOLNAFTATE) 1% C 15GM
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 51672202001
|
| Hospital Charge Code |
25001554
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna Commercial |
$0.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.16
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna Commercial |
$0.17
|
| Rate for Payer: First Health Commercial |
$0.20
|
| Rate for Payer: Humana Commercial |
$0.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.18
|
| Rate for Payer: Ohio Health Group HMO |
$0.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.07
|
| Rate for Payer: PHCS Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Payer |
$0.18
|
|
|
TINCTURE OF BENZOIN SPRAY 4OZ
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25001555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna Commercial |
$0.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.20
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna Commercial |
$0.22
|
| Rate for Payer: First Health Commercial |
$0.25
|
| Rate for Payer: Humana Commercial |
$0.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.23
|
| Rate for Payer: Ohio Health Group HMO |
$0.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.08
|
| Rate for Payer: PHCS Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Payer |
$0.23
|
|
|
TINCTURE OF BENZOIN SPRAY 4OZ
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25001555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna Commercial |
$0.20
|
| Rate for Payer: Anthem Medicaid |
$0.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.20
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna Commercial |
$0.22
|
| Rate for Payer: First Health Commercial |
$0.25
|
| Rate for Payer: Humana Commercial |
$0.22
|
| Rate for Payer: Humana KY Medicaid |
$0.09
|
| Rate for Payer: Kentucky WC Medicaid |
$0.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.23
|
| Rate for Payer: Ohio Health Group HMO |
$0.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.08
|
| Rate for Payer: PHCS Commercial |
$0.25
|
| Rate for Payer: United Healthcare All Payer |
$0.23
|
|
|
TIROFIBAN 0.25mg (5mg SDBag)
|
Facility
|
IP
|
$476.33
|
|
|
Service Code
|
HCPCS J3246
|
| Hospital Charge Code |
25004465
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.92 |
| Max. Negotiated Rate |
$457.28 |
| Rate for Payer: Aetna Commercial |
$366.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$371.54
|
| Rate for Payer: Cash Price |
$238.16
|
| Rate for Payer: Cigna Commercial |
$395.35
|
| Rate for Payer: First Health Commercial |
$452.51
|
| Rate for Payer: Humana Commercial |
$404.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$390.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$351.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$419.17
|
| Rate for Payer: Ohio Health Group HMO |
$357.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$95.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$61.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$147.66
|
| Rate for Payer: PHCS Commercial |
$457.28
|
| Rate for Payer: United Healthcare All Payer |
$419.17
|
|
|
TIROFIBAN 0.25mg (5mg SDBag)
|
Facility
|
OP
|
$476.33
|
|
|
Service Code
|
HCPCS J3246
|
| Hospital Charge Code |
25004465
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.32 |
| Max. Negotiated Rate |
$457.28 |
| Rate for Payer: Aetna Commercial |
$366.77
|
| Rate for Payer: Anthem Medicaid |
$163.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$371.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.83
|
| Rate for Payer: Cash Price |
$238.16
|
| Rate for Payer: Cash Price |
$238.16
|
| Rate for Payer: Cigna Commercial |
$395.35
|
| Rate for Payer: First Health Commercial |
$452.51
|
| Rate for Payer: Humana Commercial |
$404.88
|
| Rate for Payer: Humana KY Medicaid |
$163.81
|
| Rate for Payer: Humana Medicare Advantage |
$4.32
|
| Rate for Payer: Kentucky WC Medicaid |
$165.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$390.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$351.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$167.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$419.17
|
| Rate for Payer: Ohio Health Group HMO |
$357.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$95.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$61.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$147.66
|
| Rate for Payer: PHCS Commercial |
$457.28
|
| Rate for Payer: United Healthcare All Payer |
$419.17
|
|
|
TISSUE EXAM BY PATHOLOGIST
|
Facility
|
OP
|
$420.00
|
|
|
Service Code
|
HCPCS 88307
|
| Hospital Charge Code |
30001508
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$435.16 |
| Rate for Payer: Aetna Commercial |
$323.40
|
| Rate for Payer: Anthem Medicaid |
$144.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$310.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$337.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$435.16
|
| Rate for Payer: CareSource Just4Me Medicare |
$419.62
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cigna Commercial |
$348.60
|
| Rate for Payer: First Health Commercial |
$399.00
|
| Rate for Payer: Humana Commercial |
$357.00
|
| Rate for Payer: Humana KY Medicaid |
$144.44
|
| Rate for Payer: Humana Medicare Advantage |
$310.83
|
| Rate for Payer: Kentucky WC Medicaid |
$145.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$344.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$309.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$373.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$147.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$369.60
|
| Rate for Payer: Ohio Health Group HMO |
$315.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$84.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$130.20
|
| Rate for Payer: PHCS Commercial |
$403.20
|
| Rate for Payer: United Healthcare All Payer |
$369.60
|
|
|
TISSUE EXAM BY PATHOLOGIST
|
Facility
|
IP
|
$420.00
|
|
|
Service Code
|
HCPCS 88307
|
| Hospital Charge Code |
30001508
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$403.20 |
| Rate for Payer: Aetna Commercial |
$323.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$337.26
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cigna Commercial |
$348.60
|
| Rate for Payer: First Health Commercial |
$399.00
|
| Rate for Payer: Humana Commercial |
$357.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$344.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$309.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$126.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$369.60
|
| Rate for Payer: Ohio Health Group HMO |
$315.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$84.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$130.20
|
| Rate for Payer: PHCS Commercial |
$403.20
|
| Rate for Payer: United Healthcare All Payer |
$369.60
|
|
|
TISSUE EXAM BY PATHOLOGIST
|
Professional
|
Both
|
$420.00
|
|
|
Service Code
|
HCPCS 88307
|
| Hospital Charge Code |
30001508
|
|
Hospital Revenue Code
|
312
|
| Min. Negotiated Rate |
$42.50 |
| Max. Negotiated Rate |
$420.00 |
| Rate for Payer: Aetna Commercial |
$317.09
|
| Rate for Payer: Anthem Medicaid |
$152.38
|
| Rate for Payer: Buckeye Medicare Advantage |
$420.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cigna Commercial |
$123.11
|
| Rate for Payer: Healthspan PPO |
$301.08
|
| Rate for Payer: Humana Medicaid |
$152.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$42.50
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$155.43
|
| Rate for Payer: Molina Healthcare Passport |
$152.38
|
| Rate for Payer: Multiplan PHCS |
$252.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$294.00
|
| Rate for Payer: UHCCP Medicaid |
$147.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$153.90
|
|
|
TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)
|
Facility
|
OP
|
$21,334.05
|
|
|
Service Code
|
CPT 19357
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$15,238.61 |
| Max. Negotiated Rate |
$21,334.05 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$15,238.61
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$21,334.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$20,572.12
|
| Rate for Payer: Humana Medicare Advantage |
$15,238.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18,286.33
|
|
|
TISSUE EXPANDER RECTANGLE
|
Facility
|
OP
|
$4,650.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$604.50 |
| Max. Negotiated Rate |
$4,464.00 |
| Rate for Payer: Aetna Commercial |
$3,580.50
|
| Rate for Payer: Anthem Medicaid |
$1,599.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,627.00
|
| Rate for Payer: Cash Price |
$2,325.00
|
| Rate for Payer: Cigna Commercial |
$3,859.50
|
| Rate for Payer: First Health Commercial |
$4,417.50
|
| Rate for Payer: Humana Commercial |
$3,952.50
|
| Rate for Payer: Humana KY Medicaid |
$1,599.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,615.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,813.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,431.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,395.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,631.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,092.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$930.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$604.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,441.50
|
| Rate for Payer: PHCS Commercial |
$4,464.00
|
| Rate for Payer: United Healthcare All Payer |
$4,092.00
|
|
|
TISSUE EXPANDER RECTANGLE
|
Facility
|
IP
|
$4,650.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$604.50 |
| Max. Negotiated Rate |
$4,464.00 |
| Rate for Payer: Aetna Commercial |
$3,580.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,627.00
|
| Rate for Payer: Cash Price |
$2,325.00
|
| Rate for Payer: Cigna Commercial |
$3,859.50
|
| Rate for Payer: First Health Commercial |
$4,417.50
|
| Rate for Payer: Humana Commercial |
$3,952.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,813.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,431.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,395.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,092.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$930.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$604.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,441.50
|
| Rate for Payer: PHCS Commercial |
$4,464.00
|
| Rate for Payer: United Healthcare All Payer |
$4,092.00
|
|
|
TISSUE HOMOGENIZATION
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
HCPCS 87176
|
| Hospital Charge Code |
30001315
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.42 |
| Max. Negotiated Rate |
$32.64 |
| Rate for Payer: Aetna Commercial |
$26.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.30
|
| Rate for Payer: Cash Price |
$17.00
|
| Rate for Payer: Cigna Commercial |
$28.22
|
| Rate for Payer: First Health Commercial |
$32.30
|
| Rate for Payer: Humana Commercial |
$28.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$29.92
|
| Rate for Payer: Ohio Health Group HMO |
$25.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.54
|
| Rate for Payer: PHCS Commercial |
$32.64
|
| Rate for Payer: United Healthcare All Payer |
$29.92
|
|
|
TISSUE HOMOGENIZATION
|
Facility
|
OP
|
$34.00
|
|
|
Service Code
|
HCPCS 87176
|
| Hospital Charge Code |
30001315
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.42 |
| Max. Negotiated Rate |
$32.64 |
| Rate for Payer: Aetna Commercial |
$26.18
|
| Rate for Payer: Anthem Medicaid |
$11.69
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.88
|
| Rate for Payer: Cash Price |
$17.00
|
| Rate for Payer: Cash Price |
$17.00
|
| Rate for Payer: Cigna Commercial |
$28.22
|
| Rate for Payer: First Health Commercial |
$32.30
|
| Rate for Payer: Humana Commercial |
$28.90
|
| Rate for Payer: Humana KY Medicaid |
$11.69
|
| Rate for Payer: Humana Medicare Advantage |
$5.88
|
| Rate for Payer: Kentucky WC Medicaid |
$11.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$29.92
|
| Rate for Payer: Ohio Health Group HMO |
$25.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.54
|
| Rate for Payer: PHCS Commercial |
$32.64
|
| Rate for Payer: United Healthcare All Payer |
$29.92
|
|
|
TISSUE IMMUNOPEROX 1STAB SLIDE
|
Facility
|
IP
|
$442.00
|
|
|
Service Code
|
HCPCS 88342
|
| Hospital Charge Code |
30001527
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$57.46 |
| Max. Negotiated Rate |
$424.32 |
| Rate for Payer: Aetna Commercial |
$340.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$354.93
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cigna Commercial |
$366.86
|
| Rate for Payer: First Health Commercial |
$419.90
|
| Rate for Payer: Humana Commercial |
$375.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$362.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$326.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$388.96
|
| Rate for Payer: Ohio Health Group HMO |
$331.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$88.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$57.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$137.02
|
| Rate for Payer: PHCS Commercial |
$424.32
|
| Rate for Payer: United Healthcare All Payer |
$388.96
|
|
|
TISSUE IMMUNOPEROX 1STAB SLIDE
|
Facility
|
OP
|
$442.00
|
|
|
Service Code
|
HCPCS 88342
|
| Hospital Charge Code |
30001527
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$57.46 |
| Max. Negotiated Rate |
$424.32 |
| Rate for Payer: Aetna Commercial |
$340.34
|
| Rate for Payer: Anthem Medicaid |
$152.00
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$147.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$354.93
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$206.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$199.40
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cigna Commercial |
$366.86
|
| Rate for Payer: First Health Commercial |
$419.90
|
| Rate for Payer: Humana Commercial |
$375.70
|
| Rate for Payer: Humana KY Medicaid |
$152.00
|
| Rate for Payer: Humana Medicare Advantage |
$147.70
|
| Rate for Payer: Kentucky WC Medicaid |
$153.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$362.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$326.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$177.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$155.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$388.96
|
| Rate for Payer: Ohio Health Group HMO |
$331.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$88.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$57.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$137.02
|
| Rate for Payer: PHCS Commercial |
$424.32
|
| Rate for Payer: United Healthcare All Payer |
$388.96
|
|
|
TISSUE IMMUNOPEROX 1STAB SLIDE
|
Professional
|
Both
|
$442.00
|
|
|
Service Code
|
HCPCS 88342
|
| Hospital Charge Code |
30001527
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$22.04 |
| Max. Negotiated Rate |
$442.00 |
| Rate for Payer: Aetna Commercial |
$150.04
|
| Rate for Payer: Anthem Medicaid |
$71.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$442.00
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cash Price |
$221.00
|
| Rate for Payer: Cigna Commercial |
$59.11
|
| Rate for Payer: Healthspan PPO |
$142.47
|
| Rate for Payer: Humana Medicaid |
$71.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$22.04
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$73.41
|
| Rate for Payer: Molina Healthcare Passport |
$71.97
|
| Rate for Payer: Multiplan PHCS |
$265.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$309.40
|
| Rate for Payer: UHCCP Medicaid |
$154.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.69
|
|
