|
HEP A VACCINE
|
Facility
|
OP
|
$255.00
|
|
|
Service Code
|
HCPCS 90632
|
| Hospital Charge Code |
77000010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.15 |
| Max. Negotiated Rate |
$244.80 |
| Rate for Payer: Aetna Commercial |
$196.35
|
| Rate for Payer: Anthem Medicaid |
$87.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$198.90
|
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Cigna Commercial |
$211.65
|
| Rate for Payer: First Health Commercial |
$242.25
|
| Rate for Payer: Humana Commercial |
$216.75
|
| Rate for Payer: Humana KY Medicaid |
$87.69
|
| Rate for Payer: Kentucky WC Medicaid |
$88.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$209.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$188.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$76.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$89.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$224.40
|
| Rate for Payer: Ohio Health Group HMO |
$191.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$51.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.05
|
| Rate for Payer: PHCS Commercial |
$244.80
|
| Rate for Payer: United Healthcare All Payer |
$224.40
|
|
|
HEP A VACCINE(T
|
Facility
|
OP
|
$255.00
|
|
|
Service Code
|
HCPCS 90632
|
| Hospital Charge Code |
770T0010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.15 |
| Max. Negotiated Rate |
$244.80 |
| Rate for Payer: Aetna Commercial |
$196.35
|
| Rate for Payer: Anthem Medicaid |
$87.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$198.90
|
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Cigna Commercial |
$211.65
|
| Rate for Payer: First Health Commercial |
$242.25
|
| Rate for Payer: Humana Commercial |
$216.75
|
| Rate for Payer: Humana KY Medicaid |
$87.69
|
| Rate for Payer: Kentucky WC Medicaid |
$88.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$209.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$188.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$76.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$89.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$224.40
|
| Rate for Payer: Ohio Health Group HMO |
$191.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$51.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.05
|
| Rate for Payer: PHCS Commercial |
$244.80
|
| Rate for Payer: United Healthcare All Payer |
$224.40
|
|
|
HEP A VACCINE(T
|
Facility
|
IP
|
$255.00
|
|
|
Service Code
|
HCPCS 90632
|
| Hospital Charge Code |
770T0010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.15 |
| Max. Negotiated Rate |
$244.80 |
| Rate for Payer: Aetna Commercial |
$196.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$198.90
|
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Cigna Commercial |
$211.65
|
| Rate for Payer: First Health Commercial |
$242.25
|
| Rate for Payer: Humana Commercial |
$216.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$209.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$188.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$76.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$224.40
|
| Rate for Payer: Ohio Health Group HMO |
$191.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$51.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.05
|
| Rate for Payer: PHCS Commercial |
$244.80
|
| Rate for Payer: United Healthcare All Payer |
$224.40
|
|
|
HEPB-HIB
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
HCPCS 90748
|
| Hospital Charge Code |
77000053
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$115.50
|
| Rate for Payer: Anthem Medicaid |
$51.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$124.50
|
| Rate for Payer: First Health Commercial |
$142.50
|
| Rate for Payer: Humana Commercial |
$127.50
|
| Rate for Payer: Humana KY Medicaid |
$51.58
|
| Rate for Payer: Kentucky WC Medicaid |
$52.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$52.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.00
|
| Rate for Payer: Ohio Health Group HMO |
$112.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.50
|
| Rate for Payer: PHCS Commercial |
$144.00
|
| Rate for Payer: United Healthcare All Payer |
$132.00
|
|
|
HEPB-HIB
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
HCPCS 90748
|
| Hospital Charge Code |
77000053
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$115.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$124.50
|
| Rate for Payer: First Health Commercial |
$142.50
|
| Rate for Payer: Humana Commercial |
$127.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.00
|
| Rate for Payer: Ohio Health Group HMO |
$112.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.50
|
| Rate for Payer: PHCS Commercial |
$144.00
|
| Rate for Payer: United Healthcare All Payer |
$132.00
|
|
|
HEPB-HIB
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 90748
|
| Hospital Charge Code |
77000053
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.58 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$150.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Healthspan PPO |
$48.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$73.70
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
|
|
HEPB-HIB(T
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
HCPCS 90748
|
| Hospital Charge Code |
770T0053
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$115.50
|
| Rate for Payer: Anthem Medicaid |
$51.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$124.50
|
| Rate for Payer: First Health Commercial |
$142.50
|
| Rate for Payer: Humana Commercial |
$127.50
|
| Rate for Payer: Humana KY Medicaid |
$51.58
|
| Rate for Payer: Kentucky WC Medicaid |
$52.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$52.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.00
|
| Rate for Payer: Ohio Health Group HMO |
$112.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.50
|
| Rate for Payer: PHCS Commercial |
$144.00
|
| Rate for Payer: United Healthcare All Payer |
$132.00
|
|
|
HEPB-HIB(T
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
HCPCS 90748
|
| Hospital Charge Code |
770T0053
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$115.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$124.50
|
| Rate for Payer: First Health Commercial |
$142.50
|
| Rate for Payer: Humana Commercial |
$127.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.00
|
| Rate for Payer: Ohio Health Group HMO |
$112.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.50
|
| Rate for Payer: PHCS Commercial |
$144.00
|
| Rate for Payer: United Healthcare All Payer |
$132.00
|
|
|
HEP B IG IM
|
Facility
|
IP
|
$795.18
|
|
|
Service Code
|
HCPCS 90371
|
| Hospital Charge Code |
77000005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$103.37 |
| Max. Negotiated Rate |
$763.37 |
| Rate for Payer: Aetna Commercial |
$612.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$620.24
|
| Rate for Payer: Cash Price |
$397.59
|
| Rate for Payer: Cigna Commercial |
$660.00
|
| Rate for Payer: First Health Commercial |
$755.42
|
| Rate for Payer: Humana Commercial |
$675.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$652.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$586.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$699.76
|
| Rate for Payer: Ohio Health Group HMO |
$596.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$246.51
|
| Rate for Payer: PHCS Commercial |
$763.37
|
| Rate for Payer: United Healthcare All Payer |
$699.76
|
|
|
HEP B IG IM
|
Facility
|
OP
|
$795.18
|
|
|
Service Code
|
HCPCS 90371
|
| Hospital Charge Code |
77000005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$103.37 |
| Max. Negotiated Rate |
$763.37 |
| Rate for Payer: Aetna Commercial |
$612.29
|
| Rate for Payer: Anthem Medicaid |
$273.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$137.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$620.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$193.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$186.15
|
| Rate for Payer: Cash Price |
$397.59
|
| Rate for Payer: Cash Price |
$397.59
|
| Rate for Payer: Cigna Commercial |
$660.00
|
| Rate for Payer: First Health Commercial |
$755.42
|
| Rate for Payer: Humana Commercial |
$675.90
|
| Rate for Payer: Humana KY Medicaid |
$273.46
|
| Rate for Payer: Humana Medicare Advantage |
$137.89
|
| Rate for Payer: Kentucky WC Medicaid |
$276.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$652.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$586.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$165.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$278.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$699.76
|
| Rate for Payer: Ohio Health Group HMO |
$596.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$246.51
|
| Rate for Payer: PHCS Commercial |
$763.37
|
| Rate for Payer: United Healthcare All Payer |
$699.76
|
|
|
HEP B IG IM
|
Professional
|
Both
|
$795.18
|
|
|
Service Code
|
HCPCS 90371
|
| Hospital Charge Code |
77000005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$133.70 |
| Max. Negotiated Rate |
$795.18 |
| Rate for Payer: Buckeye Medicare Advantage |
$795.18
|
| Rate for Payer: Cash Price |
$397.59
|
| Rate for Payer: Cash Price |
$397.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$133.70
|
| Rate for Payer: Multiplan PHCS |
$477.11
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$556.63
|
| Rate for Payer: UHCCP Medicaid |
$278.31
|
|
|
HEP B IG IM(T
|
Facility
|
IP
|
$795.18
|
|
|
Service Code
|
HCPCS 90371
|
| Hospital Charge Code |
770T0005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$103.37 |
| Max. Negotiated Rate |
$763.37 |
| Rate for Payer: Aetna Commercial |
$612.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$620.24
|
| Rate for Payer: Cash Price |
$397.59
|
| Rate for Payer: Cigna Commercial |
$660.00
|
| Rate for Payer: First Health Commercial |
$755.42
|
| Rate for Payer: Humana Commercial |
$675.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$652.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$586.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$699.76
|
| Rate for Payer: Ohio Health Group HMO |
$596.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$246.51
|
| Rate for Payer: PHCS Commercial |
$763.37
|
| Rate for Payer: United Healthcare All Payer |
$699.76
|
|
|
HEP B IG IM(T
|
Facility
|
OP
|
$795.18
|
|
|
Service Code
|
HCPCS 90371
|
| Hospital Charge Code |
770T0005
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$103.37 |
| Max. Negotiated Rate |
$763.37 |
| Rate for Payer: Aetna Commercial |
$612.29
|
| Rate for Payer: Anthem Medicaid |
$273.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$137.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$620.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$193.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$186.15
|
| Rate for Payer: Cash Price |
$397.59
|
| Rate for Payer: Cash Price |
$397.59
|
| Rate for Payer: Cigna Commercial |
$660.00
|
| Rate for Payer: First Health Commercial |
$755.42
|
| Rate for Payer: Humana Commercial |
$675.90
|
| Rate for Payer: Humana KY Medicaid |
$273.46
|
| Rate for Payer: Humana Medicare Advantage |
$137.89
|
| Rate for Payer: Kentucky WC Medicaid |
$276.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$652.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$586.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$165.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$278.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$699.76
|
| Rate for Payer: Ohio Health Group HMO |
$596.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$246.51
|
| Rate for Payer: PHCS Commercial |
$763.37
|
| Rate for Payer: United Healthcare All Payer |
$699.76
|
|
|
HEP B IMMGLOBULIN 1ML (5ML VL)
|
Facility
|
IP
|
$1,651.52
|
|
|
Service Code
|
HCPCS 90371
|
| Hospital Charge Code |
25000004
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$214.70 |
| Max. Negotiated Rate |
$1,585.46 |
| Rate for Payer: Aetna Commercial |
$1,271.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,288.19
|
| Rate for Payer: Cash Price |
$825.76
|
| Rate for Payer: Cigna Commercial |
$1,370.76
|
| Rate for Payer: First Health Commercial |
$1,568.94
|
| Rate for Payer: Humana Commercial |
$1,403.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,354.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,218.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$495.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,453.34
|
| Rate for Payer: Ohio Health Group HMO |
$1,238.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$330.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$214.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$511.97
|
| Rate for Payer: PHCS Commercial |
$1,585.46
|
| Rate for Payer: United Healthcare All Payer |
$1,453.34
|
|
|
HEP B IMMGLOBULIN 1ML (5ML VL)
|
Facility
|
OP
|
$1,651.52
|
|
|
Service Code
|
HCPCS 90371
|
| Hospital Charge Code |
25000004
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.89 |
| Max. Negotiated Rate |
$1,585.46 |
| Rate for Payer: Aetna Commercial |
$1,271.67
|
| Rate for Payer: Anthem Medicaid |
$567.96
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$137.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,288.19
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$193.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$186.15
|
| Rate for Payer: Cash Price |
$825.76
|
| Rate for Payer: Cash Price |
$825.76
|
| Rate for Payer: Cigna Commercial |
$1,370.76
|
| Rate for Payer: First Health Commercial |
$1,568.94
|
| Rate for Payer: Humana Commercial |
$1,403.79
|
| Rate for Payer: Humana KY Medicaid |
$567.96
|
| Rate for Payer: Humana Medicare Advantage |
$137.89
|
| Rate for Payer: Kentucky WC Medicaid |
$573.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,354.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,218.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$165.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$579.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,453.34
|
| Rate for Payer: Ohio Health Group HMO |
$1,238.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$330.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$214.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$511.97
|
| Rate for Payer: PHCS Commercial |
$1,585.46
|
| Rate for Payer: United Healthcare All Payer |
$1,453.34
|
|
|
HEPB VAC TEEN(2DOSESCHED)OHMCD
|
Facility
|
IP
|
$199.50
|
|
|
Service Code
|
HCPCS 90743
|
| Hospital Charge Code |
77000050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.94 |
| Max. Negotiated Rate |
$191.52 |
| Rate for Payer: Aetna Commercial |
$153.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$155.61
|
| Rate for Payer: Cash Price |
$99.75
|
| Rate for Payer: Cigna Commercial |
$165.58
|
| Rate for Payer: First Health Commercial |
$189.52
|
| Rate for Payer: Humana Commercial |
$169.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$163.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$147.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$175.56
|
| Rate for Payer: Ohio Health Group HMO |
$149.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$39.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$61.84
|
| Rate for Payer: PHCS Commercial |
$191.52
|
| Rate for Payer: United Healthcare All Payer |
$175.56
|
|
|
HEPB VAC TEEN(2DOSESCHED)OHMCD
|
Professional
|
Both
|
$199.50
|
|
|
Service Code
|
HCPCS 90743
|
| Hospital Charge Code |
77000050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.89 |
| Max. Negotiated Rate |
$199.50 |
| Rate for Payer: Buckeye Medicare Advantage |
$199.50
|
| Rate for Payer: Cash Price |
$99.75
|
| Rate for Payer: Cash Price |
$99.75
|
| Rate for Payer: Healthspan PPO |
$32.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$104.70
|
| Rate for Payer: Multiplan PHCS |
$119.70
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$139.65
|
| Rate for Payer: UHCCP Medicaid |
$69.82
|
|
|
HEPB VAC TEEN(2DOSESCHED)OHMCD
|
Facility
|
OP
|
$199.50
|
|
|
Service Code
|
HCPCS 90743
|
| Hospital Charge Code |
77000050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.94 |
| Max. Negotiated Rate |
$191.52 |
| Rate for Payer: Aetna Commercial |
$153.62
|
| Rate for Payer: Anthem Medicaid |
$68.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$155.61
|
| Rate for Payer: Cash Price |
$99.75
|
| Rate for Payer: Cigna Commercial |
$165.58
|
| Rate for Payer: First Health Commercial |
$189.52
|
| Rate for Payer: Humana Commercial |
$169.58
|
| Rate for Payer: Humana KY Medicaid |
$68.61
|
| Rate for Payer: Kentucky WC Medicaid |
$69.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$163.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$147.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$69.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$175.56
|
| Rate for Payer: Ohio Health Group HMO |
$149.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$39.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$61.84
|
| Rate for Payer: PHCS Commercial |
$191.52
|
| Rate for Payer: United Healthcare All Payer |
$175.56
|
|
|
HEPB VAC TEEN(2DOSESCHED)OHMCD
|
Facility
|
OP
|
$199.50
|
|
|
Service Code
|
HCPCS 90743
|
| Hospital Charge Code |
770T0050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.94 |
| Max. Negotiated Rate |
$191.52 |
| Rate for Payer: Aetna Commercial |
$153.62
|
| Rate for Payer: Anthem Medicaid |
$68.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$155.61
|
| Rate for Payer: Cash Price |
$99.75
|
| Rate for Payer: Cigna Commercial |
$165.58
|
| Rate for Payer: First Health Commercial |
$189.52
|
| Rate for Payer: Humana Commercial |
$169.58
|
| Rate for Payer: Humana KY Medicaid |
$68.61
|
| Rate for Payer: Kentucky WC Medicaid |
$69.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$163.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$147.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$69.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$175.56
|
| Rate for Payer: Ohio Health Group HMO |
$149.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$39.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$61.84
|
| Rate for Payer: PHCS Commercial |
$191.52
|
| Rate for Payer: United Healthcare All Payer |
$175.56
|
|
|
HEPB VAC TEEN(2DOSESCHED)OHMCD
|
Facility
|
IP
|
$199.50
|
|
|
Service Code
|
HCPCS 90743
|
| Hospital Charge Code |
770T0050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.94 |
| Max. Negotiated Rate |
$191.52 |
| Rate for Payer: Aetna Commercial |
$153.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$155.61
|
| Rate for Payer: Cash Price |
$99.75
|
| Rate for Payer: Cigna Commercial |
$165.58
|
| Rate for Payer: First Health Commercial |
$189.52
|
| Rate for Payer: Humana Commercial |
$169.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$163.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$147.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$175.56
|
| Rate for Payer: Ohio Health Group HMO |
$149.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$39.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$61.84
|
| Rate for Payer: PHCS Commercial |
$191.52
|
| Rate for Payer: United Healthcare All Payer |
$175.56
|
|
|
HEP VENOGRAPHY WEDG/FREE WHEMO
|
Facility
|
IP
|
$4,970.00
|
|
|
Service Code
|
HCPCS 75889
|
| Hospital Charge Code |
320T0175
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$646.10 |
| Max. Negotiated Rate |
$4,771.20 |
| Rate for Payer: Aetna Commercial |
$3,826.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,876.60
|
| Rate for Payer: Cash Price |
$2,485.00
|
| Rate for Payer: Cigna Commercial |
$4,125.10
|
| Rate for Payer: First Health Commercial |
$4,721.50
|
| Rate for Payer: Humana Commercial |
$4,224.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,075.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,667.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,491.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,373.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,727.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$994.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$646.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,540.70
|
| Rate for Payer: PHCS Commercial |
$4,771.20
|
| Rate for Payer: United Healthcare All Payer |
$4,373.60
|
|
|
HEP VENOGRAPHY WEDG/FREE WHEMO
|
Facility
|
OP
|
$5,225.00
|
|
|
Service Code
|
HCPCS 75889
|
| Hospital Charge Code |
32000175
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$679.25 |
| Max. Negotiated Rate |
$5,016.00 |
| Rate for Payer: Aetna Commercial |
$4,023.25
|
| Rate for Payer: Anthem Medicaid |
$1,796.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,756.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,075.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,858.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,721.13
|
| Rate for Payer: Cash Price |
$2,612.50
|
| Rate for Payer: Cash Price |
$2,612.50
|
| Rate for Payer: Cigna Commercial |
$4,336.75
|
| Rate for Payer: First Health Commercial |
$4,963.75
|
| Rate for Payer: Humana Commercial |
$4,441.25
|
| Rate for Payer: Humana KY Medicaid |
$1,796.88
|
| Rate for Payer: Humana Medicare Advantage |
$2,756.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,815.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,284.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,856.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,307.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,832.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,598.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,918.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,045.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$679.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,619.75
|
| Rate for Payer: PHCS Commercial |
$5,016.00
|
| Rate for Payer: United Healthcare All Payer |
$4,598.00
|
|
|
HEP VENOGRAPHY WEDG/FREE WHEMO
|
Professional
|
Both
|
$5,225.00
|
|
|
Service Code
|
HCPCS 75889
|
| Hospital Charge Code |
32000175
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$72.75 |
| Max. Negotiated Rate |
$5,225.00 |
| Rate for Payer: Aetna Commercial |
$414.26
|
| Rate for Payer: Anthem Medicaid |
$389.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,225.00
|
| Rate for Payer: Cash Price |
$2,612.50
|
| Rate for Payer: Cash Price |
$2,612.50
|
| Rate for Payer: Cigna Commercial |
$676.17
|
| Rate for Payer: Healthspan PPO |
$388.17
|
| Rate for Payer: Humana Medicaid |
$389.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$72.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$396.94
|
| Rate for Payer: Molina Healthcare Passport |
$389.16
|
| Rate for Payer: Multiplan PHCS |
$3,135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,657.50
|
| Rate for Payer: UHCCP Medicaid |
$1,828.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$393.05
|
|
|
HEP VENOGRAPHY WEDG/FREE WHEMO
|
Professional
|
Both
|
$255.00
|
|
|
Service Code
|
HCPCS 75889
|
| Hospital Charge Code |
320P0175
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$72.75 |
| Max. Negotiated Rate |
$676.17 |
| Rate for Payer: Aetna Commercial |
$414.26
|
| Rate for Payer: Anthem Medicaid |
$389.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$255.00
|
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Cigna Commercial |
$676.17
|
| Rate for Payer: Healthspan PPO |
$388.17
|
| Rate for Payer: Humana Medicaid |
$389.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$72.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$396.94
|
| Rate for Payer: Molina Healthcare Passport |
$389.16
|
| Rate for Payer: Multiplan PHCS |
$153.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$178.50
|
| Rate for Payer: UHCCP Medicaid |
$89.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$393.05
|
|
|
HEP VENOGRAPHY WEDG/FREE WHEMO
|
Facility
|
OP
|
$4,970.00
|
|
|
Service Code
|
HCPCS 75889
|
| Hospital Charge Code |
320T0175
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$646.10 |
| Max. Negotiated Rate |
$4,771.20 |
| Rate for Payer: Aetna Commercial |
$3,826.90
|
| Rate for Payer: Anthem Medicaid |
$1,709.18
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,756.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,876.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,858.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,721.13
|
| Rate for Payer: Cash Price |
$2,485.00
|
| Rate for Payer: Cash Price |
$2,485.00
|
| Rate for Payer: Cigna Commercial |
$4,125.10
|
| Rate for Payer: First Health Commercial |
$4,721.50
|
| Rate for Payer: Humana Commercial |
$4,224.50
|
| Rate for Payer: Humana KY Medicaid |
$1,709.18
|
| Rate for Payer: Humana Medicare Advantage |
$2,756.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,726.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,075.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,667.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,307.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,743.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,373.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,727.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$994.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$646.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,540.70
|
| Rate for Payer: PHCS Commercial |
$4,771.20
|
| Rate for Payer: United Healthcare All Payer |
$4,373.60
|
|
