|
TH PREVENT VISIT - UNDER 1
|
Professional
|
Both
|
$205.00
|
|
|
Service Code
|
HCPCS 99391
|
| Hospital Charge Code |
51000312
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$34.78 |
| Max. Negotiated Rate |
$143.50 |
| Rate for Payer: Aetna Commercial |
$80.47
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$34.78
|
| Rate for Payer: Anthem Medicaid |
$67.57
|
| Rate for Payer: Cash Price |
$102.50
|
| Rate for Payer: Cash Price |
$102.50
|
| Rate for Payer: Cigna Commercial |
$110.62
|
| Rate for Payer: Healthspan PPO |
$91.25
|
| Rate for Payer: Humana Medicaid |
$67.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$68.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$68.92
|
| Rate for Payer: Molina Healthcare Passport |
$67.57
|
| Rate for Payer: Multiplan PHCS |
$123.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$143.50
|
| Rate for Payer: UHCCP Medicaid |
$36.52
|
| Rate for Payer: United Healthcare Non-Options |
$55.42
|
| Rate for Payer: United Healthcare Options |
$45.37
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$68.25
|
|
|
TH PREVENT VIS NEW 65 & OLDER
|
Professional
|
Both
|
$509.00
|
|
|
Service Code
|
HCPCS 99387
|
| Hospital Charge Code |
51000316
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$66.93 |
| Max. Negotiated Rate |
$356.30 |
| Rate for Payer: Aetna Commercial |
$162.45
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$66.93
|
| Rate for Payer: Anthem Medicaid |
$127.74
|
| Rate for Payer: Cash Price |
$254.50
|
| Rate for Payer: Cash Price |
$254.50
|
| Rate for Payer: Cigna Commercial |
$208.03
|
| Rate for Payer: Healthspan PPO |
$162.38
|
| Rate for Payer: Humana Medicaid |
$127.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$138.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$130.29
|
| Rate for Payer: Molina Healthcare Passport |
$127.74
|
| Rate for Payer: Multiplan PHCS |
$305.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$356.30
|
| Rate for Payer: UHCCP Medicaid |
$70.28
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$129.02
|
|
|
TH PREVENT VIS NEW PT AGE 1-4
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
HCPCS 99382
|
| Hospital Charge Code |
51000318
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.74 |
| Max. Negotiated Rate |
$164.50 |
| Rate for Payer: Aetna Commercial |
$107.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$42.74
|
| Rate for Payer: Anthem Medicaid |
$89.90
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$152.62
|
| Rate for Payer: Healthspan PPO |
$116.33
|
| Rate for Payer: Humana Medicaid |
$89.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$90.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$91.70
|
| Rate for Payer: Molina Healthcare Passport |
$89.90
|
| Rate for Payer: Multiplan PHCS |
$141.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$164.50
|
| Rate for Payer: UHCCP Medicaid |
$44.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$90.80
|
|
|
TH PREV VISIT NEW AGE 12-17
|
Professional
|
Both
|
$275.00
|
|
|
Service Code
|
HCPCS 99384
|
| Hospital Charge Code |
51000319
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$51.05 |
| Max. Negotiated Rate |
$192.50 |
| Rate for Payer: Aetna Commercial |
$120.97
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$51.05
|
| Rate for Payer: Anthem Medicaid |
$101.22
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$163.72
|
| Rate for Payer: Healthspan PPO |
$126.64
|
| Rate for Payer: Humana Medicaid |
$101.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$102.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.24
|
| Rate for Payer: Molina Healthcare Passport |
$101.22
|
| Rate for Payer: Multiplan PHCS |
$165.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$192.50
|
| Rate for Payer: UHCCP Medicaid |
$53.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.23
|
|
|
TH PREV VISIT NEW AGE 40-64
|
Professional
|
Both
|
$269.50
|
|
|
Service Code
|
HCPCS 99386
|
| Hospital Charge Code |
51000295
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$62.29 |
| Max. Negotiated Rate |
$191.42 |
| Rate for Payer: Aetna Commercial |
$148.32
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$62.29
|
| Rate for Payer: Anthem Medicaid |
$116.70
|
| Rate for Payer: Cash Price |
$134.75
|
| Rate for Payer: Cash Price |
$134.75
|
| Rate for Payer: Cigna Commercial |
$191.42
|
| Rate for Payer: Healthspan PPO |
$147.57
|
| Rate for Payer: Humana Medicaid |
$116.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$125.67
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$119.03
|
| Rate for Payer: Molina Healthcare Passport |
$116.70
|
| Rate for Payer: Multiplan PHCS |
$161.70
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$188.65
|
| Rate for Payer: UHCCP Medicaid |
$65.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$117.87
|
|
|
TH PSYCH DIAG EVAL W/MED SRVCS
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 90792
|
| Hospital Charge Code |
51000186
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$87.90 |
| Max. Negotiated Rate |
$213.04 |
| Rate for Payer: Aetna Commercial |
$213.04
|
| Rate for Payer: Ambetter Exchange |
$161.71
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$87.90
|
| Rate for Payer: Anthem Medicaid |
$105.30
|
| Rate for Payer: Buckeye Individual/Medicaid |
$161.71
|
| Rate for Payer: Buckeye Medicare Advantage |
$161.71
|
| Rate for Payer: CareSource Just4Me Medicare |
$194.05
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$184.98
|
| Rate for Payer: Healthspan PPO |
$110.67
|
| Rate for Payer: Humana Medicaid |
$105.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$177.47
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$161.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$161.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$107.41
|
| Rate for Payer: Molina Healthcare Passport |
$105.30
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$210.22
|
| Rate for Payer: UHCCP Medicaid |
$92.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$106.35
|
| Rate for Payer: Wellcare Medicare Advantage |
$161.71
|
|
|
THP-VISTARIL 50 MG CAPS #2
|
Facility
|
IP
|
$5.09
|
|
|
Service Code
|
NDC 185067601
|
| Hospital Charge Code |
25001542
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$4.89 |
| Rate for Payer: Aetna Commercial |
$3.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.97
|
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Cigna Commercial |
$4.22
|
| Rate for Payer: First Health Commercial |
$4.84
|
| Rate for Payer: Humana Commercial |
$4.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.48
|
| Rate for Payer: Ohio Health Group HMO |
$3.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.51
|
| Rate for Payer: PHCS Commercial |
$4.89
|
| Rate for Payer: United Healthcare All Payer |
$4.48
|
|
|
THP-VISTARIL 50 MG CAPS #2
|
Facility
|
OP
|
$5.09
|
|
|
Service Code
|
NDC 185067601
|
| Hospital Charge Code |
25001542
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$4.89 |
| Rate for Payer: Aetna Commercial |
$3.92
|
| Rate for Payer: Anthem Medicaid |
$1.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.97
|
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Cigna Commercial |
$4.22
|
| Rate for Payer: First Health Commercial |
$4.84
|
| Rate for Payer: Humana Commercial |
$4.33
|
| Rate for Payer: Humana KY Medicaid |
$1.75
|
| Rate for Payer: Kentucky WC Medicaid |
$1.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.48
|
| Rate for Payer: Ohio Health Group HMO |
$3.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.51
|
| Rate for Payer: PHCS Commercial |
$4.89
|
| Rate for Payer: United Healthcare All Payer |
$4.48
|
|
|
THP-ZOFRAN-ODT 4MG TABLET
|
Facility
|
IP
|
$4.56
|
|
|
Service Code
|
NDC 57237007530
|
| Hospital Charge Code |
25001543
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.38 |
| Rate for Payer: Aetna Commercial |
$3.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.33
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.01
|
| Rate for Payer: Ohio Health Group HMO |
$3.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Payer |
$4.01
|
|
|
THP-ZOFRAN-ODT 4MG TABLET
|
Facility
|
OP
|
$4.56
|
|
|
Service Code
|
NDC 57237007530
|
| Hospital Charge Code |
25001543
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.38 |
| Rate for Payer: Aetna Commercial |
$3.51
|
| Rate for Payer: Anthem Medicaid |
$1.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.33
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Humana KY Medicaid |
$1.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.01
|
| Rate for Payer: Ohio Health Group HMO |
$3.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Payer |
$4.01
|
|
|
THREADED ROD 6*250MM
|
Facility
|
OP
|
$1,496.40
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$448.92 |
| Max. Negotiated Rate |
$1,436.54 |
| Rate for Payer: Aetna Commercial |
$1,152.23
|
| Rate for Payer: Anthem Medicaid |
$514.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,167.19
|
| Rate for Payer: Cash Price |
$748.20
|
| Rate for Payer: Cigna Commercial |
$1,242.01
|
| Rate for Payer: First Health Commercial |
$1,421.58
|
| Rate for Payer: Humana Commercial |
$1,271.94
|
| Rate for Payer: Humana KY Medicaid |
$514.61
|
| Rate for Payer: Kentucky WC Medicaid |
$519.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,227.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,104.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$448.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$524.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,316.83
|
| Rate for Payer: Ohio Health Group HMO |
$1,122.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,197.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,301.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,032.52
|
| Rate for Payer: PHCS Commercial |
$1,436.54
|
| Rate for Payer: United Healthcare All Payer |
$1,316.83
|
|
|
THREADED ROD 6*250MM
|
Facility
|
IP
|
$1,496.40
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$448.92 |
| Max. Negotiated Rate |
$1,436.54 |
| Rate for Payer: Aetna Commercial |
$1,152.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,167.19
|
| Rate for Payer: Cash Price |
$748.20
|
| Rate for Payer: Cigna Commercial |
$1,242.01
|
| Rate for Payer: First Health Commercial |
$1,421.58
|
| Rate for Payer: Humana Commercial |
$1,271.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,227.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,104.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$448.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,316.83
|
| Rate for Payer: Ohio Health Group HMO |
$1,122.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,197.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,301.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,032.52
|
| Rate for Payer: PHCS Commercial |
$1,436.54
|
| Rate for Payer: United Healthcare All Payer |
$1,316.83
|
|
|
THREADER
|
Facility
|
OP
|
$3,500.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$3,360.00 |
| Rate for Payer: Aetna Commercial |
$2,695.00
|
| Rate for Payer: Anthem Medicaid |
$1,203.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,730.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$2,905.00
|
| Rate for Payer: First Health Commercial |
$3,325.00
|
| Rate for Payer: Humana Commercial |
$2,975.00
|
| Rate for Payer: Humana KY Medicaid |
$1,203.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1,215.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,870.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,583.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,050.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,227.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,080.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,045.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,415.00
|
| Rate for Payer: PHCS Commercial |
$3,360.00
|
| Rate for Payer: United Healthcare All Payer |
$3,080.00
|
|
|
THREADER
|
Facility
|
IP
|
$3,500.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$3,360.00 |
| Rate for Payer: Aetna Commercial |
$2,695.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,730.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$2,905.00
|
| Rate for Payer: First Health Commercial |
$3,325.00
|
| Rate for Payer: Humana Commercial |
$2,975.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,870.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,583.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,050.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,080.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,045.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,415.00
|
| Rate for Payer: PHCS Commercial |
$3,360.00
|
| Rate for Payer: United Healthcare All Payer |
$3,080.00
|
|
|
THRMBC/NFS DIALYSIS CIRCUIT
|
Facility
|
IP
|
$730.00
|
|
|
Service Code
|
HCPCS 36906
|
| Hospital Charge Code |
76101519
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$219.00 |
| Max. Negotiated Rate |
$700.80 |
| Rate for Payer: Aetna Commercial |
$562.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$569.40
|
| Rate for Payer: Cash Price |
$365.00
|
| Rate for Payer: Cigna Commercial |
$605.90
|
| Rate for Payer: First Health Commercial |
$693.50
|
| Rate for Payer: Humana Commercial |
$620.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$598.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$538.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$219.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$642.40
|
| Rate for Payer: Ohio Health Group HMO |
$547.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$584.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$635.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$503.70
|
| Rate for Payer: PHCS Commercial |
$700.80
|
| Rate for Payer: United Healthcare All Payer |
$642.40
|
|
|
THRMBC/NFS DIALYSIS CIRCUIT
|
Facility
|
OP
|
$580.00
|
|
|
Service Code
|
HCPCS 36904
|
| Hospital Charge Code |
76101517
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$199.46 |
| Max. Negotiated Rate |
$7,375.33 |
| Rate for Payer: Aetna Commercial |
$446.60
|
| Rate for Payer: Anthem Medicaid |
$199.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,268.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$452.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,375.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,111.92
|
| Rate for Payer: Cash Price |
$290.00
|
| Rate for Payer: Cash Price |
$290.00
|
| Rate for Payer: Cigna Commercial |
$481.40
|
| Rate for Payer: First Health Commercial |
$551.00
|
| Rate for Payer: Humana Commercial |
$493.00
|
| Rate for Payer: Humana KY Medicaid |
$199.46
|
| Rate for Payer: Humana Medicare Advantage |
$5,268.09
|
| Rate for Payer: Kentucky WC Medicaid |
$201.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$475.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$428.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,321.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$203.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$510.40
|
| Rate for Payer: Ohio Health Group HMO |
$435.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$464.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$504.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$400.20
|
| Rate for Payer: PHCS Commercial |
$556.80
|
| Rate for Payer: United Healthcare All Payer |
$510.40
|
|
|
THRMBC/NFS DIALYSIS CIRCUIT
|
Facility
|
OP
|
$635.00
|
|
|
Service Code
|
HCPCS 36905
|
| Hospital Charge Code |
76101518
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$218.38 |
| Max. Negotiated Rate |
$14,669.84 |
| Rate for Payer: Aetna Commercial |
$488.95
|
| Rate for Payer: Anthem Medicaid |
$218.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$10,478.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$495.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$14,669.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$14,145.92
|
| Rate for Payer: Cash Price |
$317.50
|
| Rate for Payer: Cash Price |
$317.50
|
| Rate for Payer: Cigna Commercial |
$527.05
|
| Rate for Payer: First Health Commercial |
$603.25
|
| Rate for Payer: Humana Commercial |
$539.75
|
| Rate for Payer: Humana KY Medicaid |
$218.38
|
| Rate for Payer: Humana Medicare Advantage |
$10,478.46
|
| Rate for Payer: Kentucky WC Medicaid |
$220.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$520.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$468.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,574.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$222.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$558.80
|
| Rate for Payer: Ohio Health Group HMO |
$476.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$508.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$552.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$438.15
|
| Rate for Payer: PHCS Commercial |
$609.60
|
| Rate for Payer: United Healthcare All Payer |
$558.80
|
|
|
THRMBC/NFS DIALYSIS CIRCUIT
|
Facility
|
OP
|
$730.00
|
|
|
Service Code
|
HCPCS 36906
|
| Hospital Charge Code |
76101519
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$251.05 |
| Max. Negotiated Rate |
$23,228.31 |
| Rate for Payer: Aetna Commercial |
$562.10
|
| Rate for Payer: Anthem Medicaid |
$251.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$16,591.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$569.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$23,228.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$22,398.73
|
| Rate for Payer: Cash Price |
$365.00
|
| Rate for Payer: Cash Price |
$365.00
|
| Rate for Payer: Cigna Commercial |
$605.90
|
| Rate for Payer: First Health Commercial |
$693.50
|
| Rate for Payer: Humana Commercial |
$620.50
|
| Rate for Payer: Humana KY Medicaid |
$251.05
|
| Rate for Payer: Humana Medicare Advantage |
$16,591.65
|
| Rate for Payer: Kentucky WC Medicaid |
$253.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$598.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$538.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19,909.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$256.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$642.40
|
| Rate for Payer: Ohio Health Group HMO |
$547.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$584.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$635.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$503.70
|
| Rate for Payer: PHCS Commercial |
$700.80
|
| Rate for Payer: United Healthcare All Payer |
$642.40
|
|
|
THRMBC/NFS DIALYSIS CIRCUIT
|
Professional
|
Both
|
$730.00
|
|
|
Service Code
|
HCPCS 36906
|
| Hospital Charge Code |
76101519
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$408.46 |
| Max. Negotiated Rate |
$5,106.48 |
| Rate for Payer: Ambetter Exchange |
$475.28
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$408.46
|
| Rate for Payer: Anthem Medicaid |
$5,006.35
|
| Rate for Payer: Buckeye Individual/Medicaid |
$475.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$475.28
|
| Rate for Payer: CareSource Just4Me Medicare |
$570.34
|
| Rate for Payer: Cash Price |
$365.00
|
| Rate for Payer: Cash Price |
$365.00
|
| Rate for Payer: Cigna Commercial |
$836.65
|
| Rate for Payer: Humana Medicaid |
$5,006.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$649.24
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$475.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$475.28
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$5,106.48
|
| Rate for Payer: Molina Healthcare Passport |
$5,006.35
|
| Rate for Payer: Multiplan PHCS |
$438.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$617.86
|
| Rate for Payer: UHCCP Medicaid |
$428.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$5,056.41
|
| Rate for Payer: Wellcare Medicare Advantage |
$475.28
|
|
|
THRMBC/NFS DIALYSIS CIRCUIT
|
Professional
|
Both
|
$635.00
|
|
|
Service Code
|
HCPCS 36905
|
| Hospital Charge Code |
76101518
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$350.00 |
| Max. Negotiated Rate |
$1,730.82 |
| Rate for Payer: Ambetter Exchange |
$412.49
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$350.00
|
| Rate for Payer: Anthem Medicaid |
$1,696.88
|
| Rate for Payer: Buckeye Individual/Medicaid |
$412.49
|
| Rate for Payer: Buckeye Medicare Advantage |
$412.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$494.99
|
| Rate for Payer: Cash Price |
$317.50
|
| Rate for Payer: Cash Price |
$317.50
|
| Rate for Payer: Cigna Commercial |
$716.93
|
| Rate for Payer: Humana Medicaid |
$1,696.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$556.32
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$412.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$412.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,730.82
|
| Rate for Payer: Molina Healthcare Passport |
$1,696.88
|
| Rate for Payer: Multiplan PHCS |
$381.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$536.24
|
| Rate for Payer: UHCCP Medicaid |
$367.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,713.85
|
| Rate for Payer: Wellcare Medicare Advantage |
$412.49
|
|
|
THRMBC/NFS DIALYSIS CIRCUIT
|
Professional
|
Both
|
$580.00
|
|
|
Service Code
|
HCPCS 36904
|
| Hospital Charge Code |
76101517
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$278.83 |
| Max. Negotiated Rate |
$1,352.98 |
| Rate for Payer: Ambetter Exchange |
$343.00
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$278.83
|
| Rate for Payer: Anthem Medicaid |
$1,326.45
|
| Rate for Payer: Buckeye Individual/Medicaid |
$343.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$343.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$411.60
|
| Rate for Payer: Cash Price |
$290.00
|
| Rate for Payer: Cash Price |
$290.00
|
| Rate for Payer: Cigna Commercial |
$571.18
|
| Rate for Payer: Humana Medicaid |
$1,326.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$443.21
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$343.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$343.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,352.98
|
| Rate for Payer: Molina Healthcare Passport |
$1,326.45
|
| Rate for Payer: Multiplan PHCS |
$348.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$445.90
|
| Rate for Payer: UHCCP Medicaid |
$292.77
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,339.71
|
| Rate for Payer: Wellcare Medicare Advantage |
$343.00
|
|
|
THRMBC/NFS DIALYSIS CIRCUIT
|
Facility
|
IP
|
$580.00
|
|
|
Service Code
|
HCPCS 36904
|
| Hospital Charge Code |
76101517
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$174.00 |
| Max. Negotiated Rate |
$556.80 |
| Rate for Payer: Aetna Commercial |
$446.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$452.40
|
| Rate for Payer: Cash Price |
$290.00
|
| Rate for Payer: Cigna Commercial |
$481.40
|
| Rate for Payer: First Health Commercial |
$551.00
|
| Rate for Payer: Humana Commercial |
$493.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$475.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$428.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$174.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$510.40
|
| Rate for Payer: Ohio Health Group HMO |
$435.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$464.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$504.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$400.20
|
| Rate for Payer: PHCS Commercial |
$556.80
|
| Rate for Payer: United Healthcare All Payer |
$510.40
|
|
|
THRMBC/NFS DIALYSIS CIRCUIT
|
Facility
|
IP
|
$635.00
|
|
|
Service Code
|
HCPCS 36905
|
| Hospital Charge Code |
76101518
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$190.50 |
| Max. Negotiated Rate |
$609.60 |
| Rate for Payer: Aetna Commercial |
$488.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$495.30
|
| Rate for Payer: Cash Price |
$317.50
|
| Rate for Payer: Cigna Commercial |
$527.05
|
| Rate for Payer: First Health Commercial |
$603.25
|
| Rate for Payer: Humana Commercial |
$539.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$520.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$468.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$558.80
|
| Rate for Payer: Ohio Health Group HMO |
$476.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$508.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$552.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$438.15
|
| Rate for Payer: PHCS Commercial |
$609.60
|
| Rate for Payer: United Healthcare All Payer |
$558.80
|
|
|
THRMBC/NFS DIALYSIS CIRCUIT(P
|
Professional
|
Both
|
$730.00
|
|
|
Service Code
|
HCPCS 36906
|
| Hospital Charge Code |
761P1519
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$408.46 |
| Max. Negotiated Rate |
$5,106.48 |
| Rate for Payer: Ambetter Exchange |
$475.28
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$408.46
|
| Rate for Payer: Anthem Medicaid |
$5,006.35
|
| Rate for Payer: Buckeye Individual/Medicaid |
$475.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$475.28
|
| Rate for Payer: CareSource Just4Me Medicare |
$570.34
|
| Rate for Payer: Cash Price |
$365.00
|
| Rate for Payer: Cash Price |
$365.00
|
| Rate for Payer: Cigna Commercial |
$836.65
|
| Rate for Payer: Humana Medicaid |
$5,006.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$649.24
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$475.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$475.28
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$5,106.48
|
| Rate for Payer: Molina Healthcare Passport |
$5,006.35
|
| Rate for Payer: Multiplan PHCS |
$438.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$617.86
|
| Rate for Payer: UHCCP Medicaid |
$428.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$5,056.41
|
| Rate for Payer: Wellcare Medicare Advantage |
$475.28
|
|
|
THRMBC/NFS DIALYSIS CIRCUIT(P
|
Professional
|
Both
|
$635.00
|
|
|
Service Code
|
HCPCS 36905
|
| Hospital Charge Code |
761P1518
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$350.00 |
| Max. Negotiated Rate |
$1,730.82 |
| Rate for Payer: Ambetter Exchange |
$412.49
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$350.00
|
| Rate for Payer: Anthem Medicaid |
$1,696.88
|
| Rate for Payer: Buckeye Individual/Medicaid |
$412.49
|
| Rate for Payer: Buckeye Medicare Advantage |
$412.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$494.99
|
| Rate for Payer: Cash Price |
$317.50
|
| Rate for Payer: Cash Price |
$317.50
|
| Rate for Payer: Cigna Commercial |
$716.93
|
| Rate for Payer: Humana Medicaid |
$1,696.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$556.32
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$412.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$412.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,730.82
|
| Rate for Payer: Molina Healthcare Passport |
$1,696.88
|
| Rate for Payer: Multiplan PHCS |
$381.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$536.24
|
| Rate for Payer: UHCCP Medicaid |
$367.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,713.85
|
| Rate for Payer: Wellcare Medicare Advantage |
$412.49
|
|
