|
IIV3 VACC NO PRSV 0.25 ML I(T
|
Facility
|
IP
|
$93.00
|
|
|
Service Code
|
HCPCS 90655
|
| Hospital Charge Code |
770T0019
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.09 |
| Max. Negotiated Rate |
$89.28 |
| Rate for Payer: Aetna Commercial |
$71.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$72.54
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cigna Commercial |
$77.19
|
| Rate for Payer: First Health Commercial |
$88.35
|
| Rate for Payer: Humana Commercial |
$79.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$76.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$68.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$81.84
|
| Rate for Payer: Ohio Health Group HMO |
$69.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.83
|
| Rate for Payer: PHCS Commercial |
$89.28
|
| Rate for Payer: United Healthcare All Payer |
$81.84
|
|
|
IIV3 VACC NO PRSV 0.5 ML IM
|
Professional
|
Both
|
$80.70
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
77000020
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.44 |
| Max. Negotiated Rate |
$80.70 |
| Rate for Payer: Buckeye Medicare Advantage |
$80.70
|
| Rate for Payer: Cash Price |
$40.35
|
| Rate for Payer: Cash Price |
$40.35
|
| Rate for Payer: Healthspan PPO |
$23.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$28.99
|
| Rate for Payer: Multiplan PHCS |
$48.42
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$56.49
|
| Rate for Payer: UHCCP Medicaid |
$28.24
|
|
|
IIV3 VACC NO PRSV 0.5 ML IM
|
Facility
|
OP
|
$80.70
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
77000020
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.49 |
| Max. Negotiated Rate |
$77.47 |
| Rate for Payer: Aetna Commercial |
$62.14
|
| Rate for Payer: Anthem Medicaid |
$27.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.95
|
| Rate for Payer: Cash Price |
$40.35
|
| Rate for Payer: Cigna Commercial |
$66.98
|
| Rate for Payer: First Health Commercial |
$76.66
|
| Rate for Payer: Humana Commercial |
$68.60
|
| Rate for Payer: Humana KY Medicaid |
$27.75
|
| Rate for Payer: Kentucky WC Medicaid |
$28.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.02
|
| Rate for Payer: Ohio Health Group HMO |
$60.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.02
|
| Rate for Payer: PHCS Commercial |
$77.47
|
| Rate for Payer: United Healthcare All Payer |
$71.02
|
|
|
IIV3 VACC NO PRSV 0.5 ML IM
|
Facility
|
IP
|
$80.70
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
77000020
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.49 |
| Max. Negotiated Rate |
$77.47 |
| Rate for Payer: Aetna Commercial |
$62.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.95
|
| Rate for Payer: Cash Price |
$40.35
|
| Rate for Payer: Cigna Commercial |
$66.98
|
| Rate for Payer: First Health Commercial |
$76.66
|
| Rate for Payer: Humana Commercial |
$68.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.02
|
| Rate for Payer: Ohio Health Group HMO |
$60.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.02
|
| Rate for Payer: PHCS Commercial |
$77.47
|
| Rate for Payer: United Healthcare All Payer |
$71.02
|
|
|
IIV3 VACC NO PRSV 0.5 ML IM(T
|
Facility
|
OP
|
$80.70
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
770T0020
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.49 |
| Max. Negotiated Rate |
$77.47 |
| Rate for Payer: Aetna Commercial |
$62.14
|
| Rate for Payer: Anthem Medicaid |
$27.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.95
|
| Rate for Payer: Cash Price |
$40.35
|
| Rate for Payer: Cigna Commercial |
$66.98
|
| Rate for Payer: First Health Commercial |
$76.66
|
| Rate for Payer: Humana Commercial |
$68.60
|
| Rate for Payer: Humana KY Medicaid |
$27.75
|
| Rate for Payer: Kentucky WC Medicaid |
$28.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.02
|
| Rate for Payer: Ohio Health Group HMO |
$60.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.02
|
| Rate for Payer: PHCS Commercial |
$77.47
|
| Rate for Payer: United Healthcare All Payer |
$71.02
|
|
|
IIV3 VACC NO PRSV 0.5 ML IM(T
|
Facility
|
IP
|
$80.70
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
770T0020
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.49 |
| Max. Negotiated Rate |
$77.47 |
| Rate for Payer: Aetna Commercial |
$62.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.95
|
| Rate for Payer: Cash Price |
$40.35
|
| Rate for Payer: Cigna Commercial |
$66.98
|
| Rate for Payer: First Health Commercial |
$76.66
|
| Rate for Payer: Humana Commercial |
$68.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.02
|
| Rate for Payer: Ohio Health Group HMO |
$60.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.02
|
| Rate for Payer: PHCS Commercial |
$77.47
|
| Rate for Payer: United Healthcare All Payer |
$71.02
|
|
|
IIV4 VACCINE SPLT 0.5 ML IM
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
HCPCS 90688
|
| Hospital Charge Code |
77000034
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.71 |
| Max. Negotiated Rate |
$64.32 |
| Rate for Payer: Aetna Commercial |
$51.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.26
|
| Rate for Payer: Cash Price |
$33.50
|
| Rate for Payer: Cigna Commercial |
$55.61
|
| Rate for Payer: First Health Commercial |
$63.65
|
| Rate for Payer: Humana Commercial |
$56.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.96
|
| Rate for Payer: Ohio Health Group HMO |
$50.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.77
|
| Rate for Payer: PHCS Commercial |
$64.32
|
| Rate for Payer: United Healthcare All Payer |
$58.96
|
|
|
IIV4 VACCINE SPLT 0.5 ML IM
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
HCPCS 90688
|
| Hospital Charge Code |
77000034
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.71 |
| Max. Negotiated Rate |
$64.32 |
| Rate for Payer: Aetna Commercial |
$51.59
|
| Rate for Payer: Anthem Medicaid |
$23.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.26
|
| Rate for Payer: Cash Price |
$33.50
|
| Rate for Payer: Cigna Commercial |
$55.61
|
| Rate for Payer: First Health Commercial |
$63.65
|
| Rate for Payer: Humana Commercial |
$56.95
|
| Rate for Payer: Humana KY Medicaid |
$23.04
|
| Rate for Payer: Kentucky WC Medicaid |
$23.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.96
|
| Rate for Payer: Ohio Health Group HMO |
$50.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.77
|
| Rate for Payer: PHCS Commercial |
$64.32
|
| Rate for Payer: United Healthcare All Payer |
$58.96
|
|
|
IIV4 VACCINE SPLT 0.5 ML IM
|
Professional
|
Both
|
$67.00
|
|
|
Service Code
|
HCPCS 90688
|
| Hospital Charge Code |
77000034
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$67.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$67.00
|
| Rate for Payer: Cash Price |
$33.50
|
| Rate for Payer: Cash Price |
$33.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$28.89
|
| Rate for Payer: Multiplan PHCS |
$40.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$46.90
|
| Rate for Payer: UHCCP Medicaid |
$23.45
|
|
|
IIV4 VACCINE SPLT 0.5 ML IM(T
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
HCPCS 90688
|
| Hospital Charge Code |
770T0034
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.71 |
| Max. Negotiated Rate |
$64.32 |
| Rate for Payer: Aetna Commercial |
$51.59
|
| Rate for Payer: Anthem Medicaid |
$23.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.26
|
| Rate for Payer: Cash Price |
$33.50
|
| Rate for Payer: Cigna Commercial |
$55.61
|
| Rate for Payer: First Health Commercial |
$63.65
|
| Rate for Payer: Humana Commercial |
$56.95
|
| Rate for Payer: Humana KY Medicaid |
$23.04
|
| Rate for Payer: Kentucky WC Medicaid |
$23.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.96
|
| Rate for Payer: Ohio Health Group HMO |
$50.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.77
|
| Rate for Payer: PHCS Commercial |
$64.32
|
| Rate for Payer: United Healthcare All Payer |
$58.96
|
|
|
IIV4 VACCINE SPLT 0.5 ML IM(T
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
HCPCS 90688
|
| Hospital Charge Code |
770T0034
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.71 |
| Max. Negotiated Rate |
$64.32 |
| Rate for Payer: Aetna Commercial |
$51.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.26
|
| Rate for Payer: Cash Price |
$33.50
|
| Rate for Payer: Cigna Commercial |
$55.61
|
| Rate for Payer: First Health Commercial |
$63.65
|
| Rate for Payer: Humana Commercial |
$56.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.96
|
| Rate for Payer: Ohio Health Group HMO |
$50.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.77
|
| Rate for Payer: PHCS Commercial |
$64.32
|
| Rate for Payer: United Healthcare All Payer |
$58.96
|
|
|
IIV4 VACC NO PRSV 0.25 ML IM
|
Facility
|
OP
|
$76.00
|
|
|
Service Code
|
HCPCS 90685
|
| Hospital Charge Code |
77000032
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.88 |
| Max. Negotiated Rate |
$72.96 |
| Rate for Payer: Aetna Commercial |
$58.52
|
| Rate for Payer: Anthem Medicaid |
$26.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.28
|
| Rate for Payer: Cash Price |
$38.00
|
| Rate for Payer: Cigna Commercial |
$63.08
|
| Rate for Payer: First Health Commercial |
$72.20
|
| Rate for Payer: Humana Commercial |
$64.60
|
| Rate for Payer: Humana KY Medicaid |
$26.14
|
| Rate for Payer: Kentucky WC Medicaid |
$26.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.88
|
| Rate for Payer: Ohio Health Group HMO |
$57.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.56
|
| Rate for Payer: PHCS Commercial |
$72.96
|
| Rate for Payer: United Healthcare All Payer |
$66.88
|
|
|
IIV4 VACC NO PRSV 0.25 ML IM
|
Facility
|
IP
|
$76.00
|
|
|
Service Code
|
HCPCS 90685
|
| Hospital Charge Code |
77000032
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.88 |
| Max. Negotiated Rate |
$72.96 |
| Rate for Payer: Aetna Commercial |
$58.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.28
|
| Rate for Payer: Cash Price |
$38.00
|
| Rate for Payer: Cigna Commercial |
$63.08
|
| Rate for Payer: First Health Commercial |
$72.20
|
| Rate for Payer: Humana Commercial |
$64.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.88
|
| Rate for Payer: Ohio Health Group HMO |
$57.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.56
|
| Rate for Payer: PHCS Commercial |
$72.96
|
| Rate for Payer: United Healthcare All Payer |
$66.88
|
|
|
IIV4 VACC NO PRSV 0.25 ML IM
|
Professional
|
Both
|
$76.00
|
|
|
Service Code
|
HCPCS 90685
|
| Hospital Charge Code |
77000032
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$76.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$76.00
|
| Rate for Payer: Cash Price |
$38.00
|
| Rate for Payer: Cash Price |
$38.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$31.54
|
| Rate for Payer: Multiplan PHCS |
$45.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$53.20
|
| Rate for Payer: UHCCP Medicaid |
$26.60
|
|
|
IIV4 VACC NO PRSV 0.25 ML I(T
|
Facility
|
OP
|
$76.00
|
|
|
Service Code
|
HCPCS 90685
|
| Hospital Charge Code |
770T0032
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.88 |
| Max. Negotiated Rate |
$72.96 |
| Rate for Payer: Aetna Commercial |
$58.52
|
| Rate for Payer: Anthem Medicaid |
$26.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.28
|
| Rate for Payer: Cash Price |
$38.00
|
| Rate for Payer: Cigna Commercial |
$63.08
|
| Rate for Payer: First Health Commercial |
$72.20
|
| Rate for Payer: Humana Commercial |
$64.60
|
| Rate for Payer: Humana KY Medicaid |
$26.14
|
| Rate for Payer: Kentucky WC Medicaid |
$26.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.88
|
| Rate for Payer: Ohio Health Group HMO |
$57.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.56
|
| Rate for Payer: PHCS Commercial |
$72.96
|
| Rate for Payer: United Healthcare All Payer |
$66.88
|
|
|
IIV4 VACC NO PRSV 0.25 ML I(T
|
Facility
|
IP
|
$76.00
|
|
|
Service Code
|
HCPCS 90685
|
| Hospital Charge Code |
770T0032
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.88 |
| Max. Negotiated Rate |
$72.96 |
| Rate for Payer: Aetna Commercial |
$58.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.28
|
| Rate for Payer: Cash Price |
$38.00
|
| Rate for Payer: Cigna Commercial |
$63.08
|
| Rate for Payer: First Health Commercial |
$72.20
|
| Rate for Payer: Humana Commercial |
$64.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.88
|
| Rate for Payer: Ohio Health Group HMO |
$57.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.56
|
| Rate for Payer: PHCS Commercial |
$72.96
|
| Rate for Payer: United Healthcare All Payer |
$66.88
|
|
|
IIV NO PRSV INCREASED AG IM
|
Facility
|
OP
|
$181.00
|
|
|
Service Code
|
HCPCS 90662
|
| Hospital Charge Code |
77000024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.53 |
| Max. Negotiated Rate |
$173.76 |
| Rate for Payer: Aetna Commercial |
$139.37
|
| Rate for Payer: Anthem Medicaid |
$62.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.18
|
| Rate for Payer: Cash Price |
$90.50
|
| Rate for Payer: Cigna Commercial |
$150.23
|
| Rate for Payer: First Health Commercial |
$171.95
|
| Rate for Payer: Humana Commercial |
$153.85
|
| Rate for Payer: Humana KY Medicaid |
$62.25
|
| Rate for Payer: Kentucky WC Medicaid |
$62.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$148.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$63.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$159.28
|
| Rate for Payer: Ohio Health Group HMO |
$135.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.11
|
| Rate for Payer: PHCS Commercial |
$173.76
|
| Rate for Payer: United Healthcare All Payer |
$159.28
|
|
|
IIV NO PRSV INCREASED AG IM
|
Facility
|
IP
|
$181.00
|
|
|
Service Code
|
HCPCS 90662
|
| Hospital Charge Code |
77000024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.53 |
| Max. Negotiated Rate |
$173.76 |
| Rate for Payer: Aetna Commercial |
$139.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.18
|
| Rate for Payer: Cash Price |
$90.50
|
| Rate for Payer: Cigna Commercial |
$150.23
|
| Rate for Payer: First Health Commercial |
$171.95
|
| Rate for Payer: Humana Commercial |
$153.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$148.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$159.28
|
| Rate for Payer: Ohio Health Group HMO |
$135.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.11
|
| Rate for Payer: PHCS Commercial |
$173.76
|
| Rate for Payer: United Healthcare All Payer |
$159.28
|
|
|
IIV NO PRSV INCREASED AG IM
|
Professional
|
Both
|
$181.00
|
|
|
Service Code
|
HCPCS 90662
|
| Hospital Charge Code |
77000024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$181.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$181.00
|
| Rate for Payer: Cash Price |
$90.50
|
| Rate for Payer: Cash Price |
$90.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$91.03
|
| Rate for Payer: Multiplan PHCS |
$108.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$126.70
|
| Rate for Payer: UHCCP Medicaid |
$63.35
|
|
|
IIV NO PRSV INCREASED AG IM(T
|
Facility
|
OP
|
$181.00
|
|
|
Service Code
|
HCPCS 90662
|
| Hospital Charge Code |
770T0024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.53 |
| Max. Negotiated Rate |
$173.76 |
| Rate for Payer: Aetna Commercial |
$139.37
|
| Rate for Payer: Anthem Medicaid |
$62.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.18
|
| Rate for Payer: Cash Price |
$90.50
|
| Rate for Payer: Cigna Commercial |
$150.23
|
| Rate for Payer: First Health Commercial |
$171.95
|
| Rate for Payer: Humana Commercial |
$153.85
|
| Rate for Payer: Humana KY Medicaid |
$62.25
|
| Rate for Payer: Kentucky WC Medicaid |
$62.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$148.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$63.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$159.28
|
| Rate for Payer: Ohio Health Group HMO |
$135.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.11
|
| Rate for Payer: PHCS Commercial |
$173.76
|
| Rate for Payer: United Healthcare All Payer |
$159.28
|
|
|
IIV NO PRSV INCREASED AG IM(T
|
Facility
|
IP
|
$181.00
|
|
|
Service Code
|
HCPCS 90662
|
| Hospital Charge Code |
770T0024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.53 |
| Max. Negotiated Rate |
$173.76 |
| Rate for Payer: Aetna Commercial |
$139.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.18
|
| Rate for Payer: Cash Price |
$90.50
|
| Rate for Payer: Cigna Commercial |
$150.23
|
| Rate for Payer: First Health Commercial |
$171.95
|
| Rate for Payer: Humana Commercial |
$153.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$148.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$159.28
|
| Rate for Payer: Ohio Health Group HMO |
$135.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.11
|
| Rate for Payer: PHCS Commercial |
$173.76
|
| Rate for Payer: United Healthcare All Payer |
$159.28
|
|
|
IKARI 5FR LEFT 3.5
|
Facility
|
OP
|
$1,151.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$149.63 |
| Max. Negotiated Rate |
$1,104.96 |
| Rate for Payer: Aetna Commercial |
$886.27
|
| Rate for Payer: Anthem Medicaid |
$395.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$897.78
|
| Rate for Payer: Cash Price |
$575.50
|
| Rate for Payer: Cigna Commercial |
$955.33
|
| Rate for Payer: First Health Commercial |
$1,093.45
|
| Rate for Payer: Humana Commercial |
$978.35
|
| Rate for Payer: Humana KY Medicaid |
$395.83
|
| Rate for Payer: Kentucky WC Medicaid |
$399.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$943.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$849.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$403.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,012.88
|
| Rate for Payer: Ohio Health Group HMO |
$863.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$230.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$149.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$356.81
|
| Rate for Payer: PHCS Commercial |
$1,104.96
|
| Rate for Payer: United Healthcare All Payer |
$1,012.88
|
|
|
IKARI 5FR LEFT 3.5
|
Facility
|
IP
|
$1,151.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$149.63 |
| Max. Negotiated Rate |
$1,104.96 |
| Rate for Payer: Aetna Commercial |
$886.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$897.78
|
| Rate for Payer: Cash Price |
$575.50
|
| Rate for Payer: Cigna Commercial |
$955.33
|
| Rate for Payer: First Health Commercial |
$1,093.45
|
| Rate for Payer: Humana Commercial |
$978.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$943.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$849.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,012.88
|
| Rate for Payer: Ohio Health Group HMO |
$863.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$230.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$149.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$356.81
|
| Rate for Payer: PHCS Commercial |
$1,104.96
|
| Rate for Payer: United Healthcare All Payer |
$1,012.88
|
|
|
IKARI 5FR LEFT 3.75
|
Facility
|
OP
|
$1,151.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$149.63 |
| Max. Negotiated Rate |
$1,104.96 |
| Rate for Payer: Aetna Commercial |
$886.27
|
| Rate for Payer: Anthem Medicaid |
$395.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$897.78
|
| Rate for Payer: Cash Price |
$575.50
|
| Rate for Payer: Cigna Commercial |
$955.33
|
| Rate for Payer: First Health Commercial |
$1,093.45
|
| Rate for Payer: Humana Commercial |
$978.35
|
| Rate for Payer: Humana KY Medicaid |
$395.83
|
| Rate for Payer: Kentucky WC Medicaid |
$399.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$943.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$849.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$403.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,012.88
|
| Rate for Payer: Ohio Health Group HMO |
$863.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$230.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$149.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$356.81
|
| Rate for Payer: PHCS Commercial |
$1,104.96
|
| Rate for Payer: United Healthcare All Payer |
$1,012.88
|
|
|
IKARI 5FR LEFT 3.75
|
Facility
|
IP
|
$1,151.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$149.63 |
| Max. Negotiated Rate |
$1,104.96 |
| Rate for Payer: Aetna Commercial |
$886.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$897.78
|
| Rate for Payer: Cash Price |
$575.50
|
| Rate for Payer: Cigna Commercial |
$955.33
|
| Rate for Payer: First Health Commercial |
$1,093.45
|
| Rate for Payer: Humana Commercial |
$978.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$943.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$849.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,012.88
|
| Rate for Payer: Ohio Health Group HMO |
$863.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$230.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$149.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$356.81
|
| Rate for Payer: PHCS Commercial |
$1,104.96
|
| Rate for Payer: United Healthcare All Payer |
$1,012.88
|
|
